Gundersen Senior Preferred MEDICARE 2018 PART D Updates
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- Harold Parrish
- 5 years ago
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1 Gundersen Senior MEDICARE 2018 PART D Updates January, /01/2018 okebo doxycycline monohydrate ADD TO FORMULARY 01/01/2018 roweepra xr levetiracetam Non- 01/01/2018 VISTOGARD uridine triacetate ADD TO FORMULARY 01/01/2018 norethin-eth estra-ferrous fum norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY 01/01/2018 anodyne lpt lidocaine/prilocaine ADD TO FORMULARY 01/01/2018 doxorubicin hcl liposome 01/01/2018 lithium carbonate er doxorubicin hcl pegylated liposomal ADD TO FORMULARY lithium carbonate ADD TO FORMULARY 01/01/2018 cefepime hcl cefepime hcl ADD TO FORMULARY 01/01/2018 lido-prilo caine pack lidocaine/prilocaine ADD TO FORMULARY 01/01/2018 EPINEPHRINE epinephrine ADD UM: QUANTITY 2 / 30 DAYS 01/01/2018 doxycycline monohydrate doxycycline monohydrate ADD TO FORMULARY 01/01/2018 erythromycin erythromycin base ADD TO FORMULARY 01/01/2018 hydroxychloroqui ne sulfate hydroxychloroquine sulfate ADD TO FORMULARY 01/01/2018 pfizerpen penicillin g potassium ADD TO FORMULARY 01/01/2018 roweepra xr levetiracetam REMOVE UM: QUANTITY 180 / 30 DAYS 01/01/2018 vigabatrin vigabatrin ADD TO FORMULARY 01/01/2018 ezetimibe ezetimibe ADD TO FORMULARY PAGE 1 UPDATED 09/2018
2 Gundersen Senior MEDICARE 2018 PART D Updates 01/01/2018 oxycodone hcl oxycodone hcl ADD TO FORMULARY 01/01/2018 LEVO-T levothyroxine sodium ADD TO FORMULARY Brands 01/01/2018 onetouch ultra blue test strp 01/01/2018 methylphenidate er blood sugar diagnostic Non- methylphenidate hcl ADD TO FORMULARY 01/01/2018 leva set lidocaine/prilocaine ADD TO FORMULARY 01/01/2018 niacin er niacin ADD TO FORMULARY 01/01/2018 XURIDEN uridine triacetate ADD TO FORMULARY 01/01/2018 tiagabine hcl tiagabine hcl ADD TO FORMULARY 01/01/2018 clindamycin-0.9% nacl 01/01/2018 sodium polystyrene sulfonate clindamycin phosphate in 0.9 % sodium chloride sodium polystyrene sulfonate ADD TO FORMULARY ADD TO FORMULARY 01/01/2018 DALIRESP roflumilast ADD TO FORMULARY 01/01/2018 oxacillin sodium oxacillin sodium ADD TO FORMULARY 01/02/2018 TYPHIM VI typhoid vaccine vi capsular polysaccharide ADD TO FORMULARY 01/05/2018 atazanavir sulfate atazanavir sulfate 01/06/2018 plenamine parenteral amino acid 15% combination no.1 01/08/2018 LATUDA lurasidone hcl ADD TO FORMULARY 01/08/2018 LATUDA lurasidone hcl ADD UM: QUANTITY 30 / 30 DAYS 01/08/2018 nafcillin sodium nafcillin sodium ADD UM: 01/08/2018 nafcillin sodium nafcillin sodium ADD TO FORMULARY Non- PAGE 2 UPDATED 09/2018
3 Gundersen Senior MEDICARE 2018 PART D Updates 01/12/2018 BYETTA exenatide Non- 01/12/2018 estradiol estradiol Non- 01/12/2018 OPDIVO nivolumab 01/12/2018 PROLASTIN C alpha-1-proteinase inhibitor 01/15/2018 CIALIS tadalafil ADD TO FORMULARY Brands 01/15/2018 linezolid linezolid QUANTITY 60 / 30 DAYS 01/15/2018 sertraline hcl sertraline hcl ADD TO FORMULARY 01/15/2018 sertraline hcl sertraline hcl ADD UM: STEP ANTIDEPRESSA NT THERAPY 01/15/2018 CIALIS tadalafil ADD UM: QUANTITY 30 / 30 DAYS 01/18/2018 BYETTA exenatide Brands 01/19/2018 romidepsin romidepsin 01/19/2018 bortezomib bortezomib 01/19/2018 gemcitabine hcl gemcitabine hcl Non- 01/19/2018 CINVANTI aprepitant Non- 01/19/2018 ALUNBRIG brigatinib 01/23/2018 GAMMAPLEX immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml ADD TO FORMULARY 01/23/2018 SAPHRIS asenapine maleate ADD TO FORMULARY Non- 01/23/2018 BYSTOLIC nebivolol hcl ADD UM: QUANTITY 90 / 30 DAYS PAGE 3 UPDATED 09/2018
4 Gundersen Senior MEDICARE 2018 PART D Updates 01/23/2018 GAMMAPLEX immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml ADD UM: 01/23/2018 BYSTOLIC nebivolol hcl ADD TO FORMULARY Brands 01/23/2018 SAPHRIS asenapine maleate ADD UM: QUANTITY 60 / 30 DAYS 01/26/2018 heparin sodium in 0.45% nacl heparin sodium,porcine in 0.45 % sodium chloride 01/26/2018 cefepime cefepime hcl in iso-osmotic dextrose 01/26/2018 nafcillin nafcillin in dextrose, isoosmotic 01/26/2018 tobramycin tobramycin/nebulizer QUANTITY 01/26/2018 heparin sodiumd5w 01/26/2018 heparin sodiumd5w 01/26/2018 litetouch insulin syringe heparin sodium,porcine/dextrose 5 % in water heparin sodium,porcine/dextrose 5 % in water syringe with needle,insulin,0.5 ml 01/26/2018 SPS sodium polystyrene sulfonate/sorbitol solution IVIG 280 / 56 DAYS ADD TO FORMULARY Non- ADD UM: Non- 01/26/2018 morphine sulfate morphine sulfate Non- 01/26/2018 NEUAC clindamycin phosphate/benzoyl peroxide/emollient comb no.94 01/26/2018 heparin sodium in 0.45% nacl heparin sodium,porcine in 0.45 % sodium chloride REMOVE FROM FORMULARY Non- Non- PAGE 4 UPDATED 09/2018
5 Gundersen Senior MEDICARE 2018 PART D Updates 01/26/2018 lidocaine hcl lidocaine hcl/pf Non- 01/26/2018 ZOSYN piperacillin sodium/tazobactam sodium 01/26/2018 METRO IV metronidazole in sodium chloride 01/26/2018 heparin sodium in 0.45% nacl heparin sodium,porcine in 0.45 % sodium chloride Non- Non- ADD TO FORMULARY Non- 01/26/2018 AZACTAM aztreonam Non- 01/26/2018 CLINDACIN ETZ clindamycin phosphate/skin cleanser comb no.19 01/26/2018 cefepimedextrose 01/26/2018 cefazolin sodiumdextrose 01/26/2018 heparin sodium- 0.45% nacl cefepime hcl in dextrose 5 % in water cefazolin sodium/dextrose, iso-osmotic heparin sodium,porcine in 0.45 % sodium chloride Non- 01/26/2018 timolol maleate timolol maleate 01/26/2018 ceftriaxone ceftriaxone sodium in isoosmotic dextrose 01/26/2018 cefoxitin sodium cefoxitin sodium/dextrose, iso-osmotic 01/26/2018 heparin sodiumd5w heparin sodium,porcine/dextrose 5 % in water REMOVE FROM FORMULARY Non- Non- PAGE 5 UPDATED 09/2018
6 Gundersen Senior MEDICARE 2018 PART D Updates February, /01/2018 heparin sodium- 0.9% nacl heparin sodium,porcine in 0.9 % sodium chloride/pf 02/01/2018 timolol maleate timolol maleate 02/01/2018 bortezomib bortezomib TERM AUTO RULE 02/01/2018 CALQUENCE acalabrutinib 02/01/2018 bortezomib bortezomib 02/01/2018 levocarnitine levocarnitine 02/01/2018 heparin sodium in 0.45% nacl heparin sodium,porcine in 0.45 % sodium chloride Bortezomib 02/01/2018 TRISENOX arsenic trioxide 02/01/2018 heparin sodium heparin sodium,porcine/pf 02/01/2018 TREANDA bendamustine hcl 02/01/2018 BYDUREON BCISE 02/01/2018 heparin sodiumd5w exenatide microspheres heparin sodium,porcine/dextrose 5 % in water QUANTITY 02/01/2018 heparin sodium heparin sodium,porcine 02/01/2018 VIVITROL naltrexone microspheres TERM AUTO RULE 3.4 / 28 DAYS 02/02/2018 ELIQUIS apixaban Brands 02/02/2018 haloperidol decanoate haloperidol decanoate TERM AUTO RULE PAGE 6 UPDATED 09/2018
7 Gundersen Senior MEDICARE 2018 PART D Updates 02/02/2018 haloperidol decanoate 100 haloperidol decanoate TERM AUTO RULE 02/09/2018 efavirenz efavirenz 02/09/2018 assure id insulin safety syringe with needle, insulin, safety, 0.5 ml 02/09/2018 isotretinoin isotretinoin Non- 02/09/2018 methylphenidate er 02/09/2018 assure id insulin safety methylphenidate hcl Non- syringe with needle, insulin, safety, 1 ml 02/16/2018 vylibra norgestimate-ethinyl estradiol 02/16/2018 haloperidol lactate 02/16/2018 tri-vylibra norgestimate-ethinyl estradiol haloperidol lactate Non- 02/23/2018 trientine hcl trientine hcl 02/25/2018 roweepra xr levetiracetam Non- Non- PAGE 7 UPDATED 09/2018
8 Gundersen Senior MEDICARE 2018 PART D Updates March, /01/2018 BIKTARVY bictegravir sodium/emtricitabine/tenofov ir alafenamide fumar 03/01/2018 estradiol estradiol Non- 03/01/2018 doripenem doripenem Non- 03/09/2018 methylphenidate er 03/09/2018 methylphenidate er 03/09/2018 MAKENA hydroxyprogesterone caproate/pf 03/09/2018 methylphenidate la 03/10/2018 onetouch ultra blue test strp methylphenidate hcl ADD TO FORMULARY Non- methylphenidate hcl Non- methylphenidate hcl Non- blood sugar diagnostic 03/16/2018 kelnor 1-50 ethynodiol diacetate-ethinyl estradiol 03/17/2018 ibu ibuprofen Non- Non- 03/23/2018 tiagabine hcl tiagabine hcl Non- 03/23/2018 ibu ibuprofen 03/23/2018 ritonavir ritonavir Non- 03/31/2018 omnipod insulin pump cartridge Brands PAGE 8 UPDATED 09/2018
9 Gundersen Senior MEDICARE 2018 PART D Updates 03/31/2018 omnipod subcutaneous insulin pump Brands PAGE 9 UPDATED 09/2018
10 Gundersen Senior MEDICARE 2018 PART D Updates April, /01/2018 IMBRUVICA ibrutinib 04/01/2018 lidocaine lidocaine 04/01/2018 methotrexate methotrexate sodium 04/01/2018 HEMLIBRA emicizumab-kxwh 04/01/2018 prochlorperazine maleate prochlorperazine maleate 04/01/2018 DALIRESP roflumilast Non- 04/01/2018 LIDORXKIT lidocaine/skin cleanser combination no.37 04/01/2018 ERLEADA apalutamide 04/01/2018 ENDARI glutamine 04/01/2018 lidocaineprilocaine lidocaine/prilocaine 04/01/2018 VIDEX EC didanosine Non- 04/01/2018 PREVYMIS letermovir 04/01/2018 lidocaine hcl lidocaine hcl 04/01/2018 paricalcitol paricalcitol 04/06/2018 palonosetron hcl palonosetron hcl 04/06/2018 SYMFI LO efavirenz/lamivudine/tenofov ir disoproxil fumarate PAGE 10 UPDATED 09/2018
11 Gundersen Senior MEDICARE 2018 PART D Updates 04/12/2018 VIDEX EC didanosine Non- 04/13/2018 VIDEX EC didanosine Non- 04/13/2018 TROGARZO ibalizumab-uiyk 04/13/2018 easy glide pen needle 04/13/2018 TOUJEO MAX SOLOSTAR pen needle, diabetic insulin glargine,human recombinant analog Brands 04/15/2018 TASIGNA nilotinib hcl 04/20/2018 ADVAIR DISKUS fluticasone propionate/salmeterol xinafoate 04/20/2018 QTERN dapagliflozin propanediol/saxagliptin hcl STEP TRELEGY Non- 04/20/2018 FASENRA benralizumab 04/20/2018 OZEMPIC semaglutide Non- 04/20/2018 BYDUREON BCISE exenatide microspheres STEP OZEMPIC 04/20/2018 TRULICITY dulaglutide STEP OZEMPIC 04/20/2018 safetyglide insulin syringe syringe with needle, insulin, safety, 0.3 ml 04/20/2018 BREO ELLIPTA fluticasone furoate/vilanterol trifenatate 04/20/2018 FIASP FLEXTOUCH 04/20/2018 safetyglide insulin syringe STEP TRELEGY insulin aspart (niacinamide) Brands syringe with needle, insulin, safety, 1 ml PAGE 11 UPDATED 09/2018
12 Gundersen Senior MEDICARE 2018 PART D Updates 04/20/2018 FIASP insulin aspart (niacinamide) Brands 04/20/2018 easy touch pen needle 04/20/2018 fluticasonesalmeterol 04/20/2018 TRELEGY ELLIPTA pen needle, diabetic fluticasone propionate/salmeterol xinafoate fluticasone furoate/umeclidinium bromide/vilanterol trifenat 04/20/2018 ADVAIR HFA fluticasone propionate/salmeterol xinafoate STEP STEP TRELEGY Non- TRELEGY 04/20/2018 BAXDELA delafloxacin meglumine 04/20/2018 SYMBICORT budesonide/formoterol fumarate STEP TRELEGY 04/20/2018 BYETTA exenatide STEP OZEMPIC 04/20/2018 BYDUREON PEN exenatide microspheres STEP OZEMPIC 04/20/2018 GLYXAMBI empagliflozin/linagliptin STEP QTERN 04/20/2018 BYDUREON exenatide microspheres STEP OZEMPIC 04/20/2018 timolol maleate timolol maleate Non- 04/20/2018 safetyglide insulin syringe syringe with needle, insulin, safety, 0.5 ml 04/27/2018 miglustat miglustat 04/30/2018 SYLVANT siltuximab 04/30/2018 SYLVANT siltuximab TERM AUTO RULE Sylvant PAGE 12 UPDATED 09/2018
13 Gundersen Senior MEDICARE 2018 PART D Updates 04/30/2018 palonosetron hcl palonosetron hcl Non- 04/30/2018 CIMDUO lamivudine/tenofovir disoproxil fumarate 04/30/2018 EPIPEN JR 2- PAK epinephrine Brands 04/30/2018 VIRAMUNE nevirapine 04/30/2018 EPIPEN 2-PAK epinephrine Brands 04/30/2018 SYMFI efavirenz/lamivudine/tenofov ir disoproxil fumarate PAGE 13 UPDATED 09/2018
14 Gundersen Senior MEDICARE 2018 PART D Updates May, /04/2018 insulin syringe syringe with needle,insulin,0.3 ml 05/04/2018 veo insulin syringe 05/04/2018 veo insulin syringe syringe with needle,insulin,0.5 ml syringe with needle,disposable,insulin 1 ml 05/04/2018 insulin syringe syringe with needle,insulin,0.5 ml 05/04/2018 decadron dexamethasone Non- 05/04/2018 veo insulin syringe syringe with needle,insulin,0.3 ml 05/04/2018 insulin syringe syringe with needle,disposable,insulin 1 ml 05/04/2018 ganciclovir sodium ganciclovir sodium Non- 05/04/2018 praziquantel praziquantel Non- 05/04/2018 veo insulin syringe 05/04/2018 techlite insulin syringe syringe with needle,insulin 0.3 ml (half unit mark) syringe with needle,disposable,insulin 1 ml 05/11/2018 HUMIRA adalimumab PAGE 14 UPDATED 09/2018
15 Gundersen Senior MEDICARE 2018 PART D Updates 05/11/2018 HUMIRA PEDIATRIC CROHN'S 05/11/2018 techlite insulin syringe 05/11/2018 techlite insulin syringe adalimumab syringe with needle,insulin 0.3 ml (half unit mark) syringe with needle,insulin 0.5 ml (half unit mark) 05/11/2018 HUMIRA PEN adalimumab 05/11/2018 KYMRIAH tisagenlecleucel 05/25/2018 colesevelam hcl colesevelam hcl Non- 05/25/2018 insulin syringe syringe with needle,insulin,0.5 ml 05/25/2018 NORVIR ritonavir Non- 05/25/2018 baclofen baclofen Non- 05/25/2018 insulin syringe syringe with needle,disposable,insulin 1 ml 05/25/2018 mili norgestimate-ethinyl estradiol 05/25/2018 insulin syringe syringe with needle,insulin,0.3 ml PAGE 15 UPDATED 09/2018
16 Gundersen Senior MEDICARE 2018 PART D Updates June, /01/2018 BENZNIDAZOLE benznidazole Non- 06/01/2018 BAXDELA delafloxacin meglumine TERM AUTO RULE 06/01/2018 tri-mili norgestimate-ethinyl estradiol 06/01/2018 testosterone testosterone Non- 06/08/2018 sodium fluoride fluoride (sodium) 06/08/2018 flura-drops fluoride (sodium) 06/08/2018 FLUOR-A-DAY sodium fluoride/xylitol 06/08/2018 multivitamin with fluoride 06/08/2018 multi-vitamin with fluoride pediatric multivitamins no.17 with sodium fluoride pediatric multivitamins no.17 with sodium fluoride 06/08/2018 fluoritab fluoride (sodium) 06/08/2018 ARNUITY ELLIPTA fluticasone furoate Brands 06/08/2018 ludent fluoride fluoride (sodium) 06/08/2018 TRI-VI-FLOR pediatric multivitamin a,c,and d3 no.38 with sodium fluoride PAGE 16 UPDATED 09/2018
17 Gundersen Senior MEDICARE 2018 PART D Updates 06/08/2018 pro comfort insulin syringe syringe with needle,disposable,insulin 1 ml 06/08/2018 POLY-VI-FLOR pediatric multivitamin no.37 with sodium fluoride 06/08/2018 pro comfort insulin syringe 06/08/2018 POLY-VI-FLOR WITH IRON syringe with needle,insulin,0.5 ml pediatric multivitamin no.33/sodium fluoride/iron carbonyl 06/08/2018 POLY-VI-FLOR pediatric multivitamin no.33 with sodium fluoride 06/08/2018 MYKIDZ IRON FL 06/08/2018 POLY-VI-FLOR WITH IRON ferrous sulfate/sodium fluoride/vit a palm/vit c/vitamin d3 pediatric multivit no.37/sodium fluoride/iron bisglycin.hcl 06/08/2018 fluoride fluoride (sodium) 06/08/2018 tulana norethindrone 06/15/2018 EPIPEN JR 2- PAK epinephrine TERM AUTO RULE 06/15/2018 KEVZARA sarilumab 06/15/2018 subvenite lamotrigine 06/15/2018 EPIPEN 2-PAK epinephrine TERM AUTO RULE 06/15/2018 KIONEX sodium polystyrene sulfonate/sorbitol solution 06/15/2018 EPINEPHRINE epinephrine TERM AUTO RULE Non- Non- PAGE 17 UPDATED 09/2018
18 Gundersen Senior MEDICARE 2018 PART D Updates 06/15/2018 epinephrine epinephrine Non- 06/15/2018 EPINEPHRINE epinephrine REMOVE UM: STEP EPINEPHRINE AUTO- INJECTOR THERAPY 06/29/2018 hydromorphone hcl hydromorphone hcl/pf 06/29/2018 daptomycin daptomycin 06/29/2018 buprenorphinenaloxone 06/29/2018 assure id pen needle buprenorphine hcl/naloxone hcl Non- pen needle, diabetic, safety PAGE 18 UPDATED 09/2018
19 Gundersen Senior MEDICARE 2018 PART D Updates July, /06/2018 ertapenem ertapenem sodium Non- 07/06/2018 hydromorphone hcl 07/06/2018 assure id pen needle hydromorphone hcl/pf Non- pen needle, diabetic, safety 07/06/2018 vigadrone vigabatrin 07/13/2018 ARISTADA INITIO 07/13/2018 hydromorphone hcl aripiprazole lauroxil, submicronized hydromorphone hcl/pf Non- 07/13/2018 ritonavir ritonavir Non- 07/13/2018 TROGARZO ibalizumab-uiyk 07/13/2018 SYMDEKO tezacaftor/ivacaftor 07/20/2018 CUPRIMINE penicillamine TERM AUTO RULE 07/20/2018 budesonide er budesonide Non- 07/20/2018 hydroxyprogester one caproate hydroxyprogesterone caproate/pf 07/20/2018 XELJANZ tofacitinib citrate 07/20/2018 DEPEN penicillamine TERM AUTO RULE 07/20/2018 ketoprofen ketoprofen Non- 07/20/2018 SYPRINE trientine hcl TERM AUTO RULE PAGE 19 UPDATED 09/2018
20 Gundersen Senior MEDICARE 2018 PART D Updates 07/20/2018 trientine hcl trientine hcl TERM AUTO RULE 07/27/2018 levobunolol hcl levobunolol hcl STEP RHOPRESSA 07/27/2018 betaxolol hcl betaxolol hcl STEP RHOPRESSA 07/27/2018 latanoprost latanoprost STEP RHOPRESSA 07/27/2018 ALPHAGAN P brimonidine tartrate STEP RHOPRESSA 07/27/2018 bimatoprost bimatoprost STEP RHOPRESSA 07/27/2018 brimonidine tartrate brimonidine tartrate STEP RHOPRESSA 07/27/2018 LUMIGAN bimatoprost STEP RHOPRESSA 07/27/2018 dorzolamide hcl dorzolamide hcl STEP RHOPRESSA 07/27/2018 RHOPRESSA netarsudil mesylate Non- 07/27/2018 carteolol hcl carteolol hcl STEP RHOPRESSA 07/27/2018 colesevelam hcl colesevelam hcl Non- 07/27/2018 dorzolamidetimolol dorzolamide hcl/timolol maleate STEP RHOPRESSA 07/27/2018 timolol maleate timolol maleate STEP RHOPRESSA 07/27/2018 KIONEX sodium polystyrene sulfonate/sorbitol solution Non- 07/27/2018 TRAVATAN Z travoprost STEP RHOPRESSA 07/27/2018 AZOPT brinzolamide STEP RHOPRESSA 07/27/2018 COMBIGAN brimonidine tartrate/timolol maleate STEP RHOPRESSA 07/27/2018 VYZULTA latanoprostene bunod Non- 07/27/2018 SIMBRINZA brinzolamide/brimonidine tartrate STEP RHOPRESSA PAGE 20 UPDATED 09/2018
21 Gundersen Senior MEDICARE 2018 PART D Updates 07/27/2018 incassia norethindrone 07/27/2018 metipranolol metipranolol STEP RHOPRESSA 07/27/2018 travoprost travoprost (benzalkonium) STEP RHOPRESSA 07/27/2018 COSOPT PF dorzolamide hcl/timolol maleate/pf STEP 07/28/2018 ILARIS canakinumab/pf RHOPRESSA PAGE 21 UPDATED 09/2018
22 Gundersen Senior MEDICARE 2018 PART D Updates August, /01/2018 YONSA abiraterone acetate, submicronized 08/03/2018 NUPLAZID pimavanserin tartrate 08/03/2018 ILARIS canakinumab/pf 08/03/2018 crotan crotamiton Non- 08/03/2018 ILARIS canakinumab/pf REMOVE UM: QUANTITY 2 / 28 DAYS 08/03/2018 bendamustine hcl bendamustine hcl 08/03/2018 privigen immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml 08/06/2018 privigen immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml 08/10/2018 HUMIRA PEN CROHN-UC-HS STARTER 08/10/2018 GAMASTAN immune globulin,gamma(igg)/glycine 08/10/2018 HUMIRA PEN PSORIASIS- UVEITIS 08/10/2018 dorzolamidetimolol adalimumab Brands adalimumab dorzolamide hcl/timolol maleate/pf 08/10/2018 HEPLISAV-B hepatitis b vaccine recombinant/vaccine adjuvant cpg 1018/pf Non- PAGE 22 UPDATED 09/2018
23 Gundersen Senior MEDICARE 2018 PART D Updates 08/17/2018 dropsafe pen needle 08/17/2018 chateal eq levonorgestrel-ethinyl estradiol 08/17/2018 privigen immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml 08/17/2018 aubra eq levonorgestrel-ethinyl estradiol 08/17/2018 PLENVU peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c pen needle, diabetic, safety Brands 08/17/2018 KYPROLIS carfilzomib 08/24/2018 temsirolimus temsirolimus 08/24/2018 metformin hcl metformin hcl Non- 08/24/2018 hydroxyprogester one caproate hydroxyprogesterone caproate 08/24/2018 omnipod dash insulin pump cartridge Brands 08/24/2018 tadalafil tadalafil 08/24/2018 adriamycin doxorubicin hcl Non- 08/31/2018 TIBSOVO ivosidenib 08/31/2018 MEKTOVI binimetinib 08/31/2018 SYMTUZA darunavir eth/cobicistat/emtricitabine/t enofovir alafenamide 08/31/2018 BRAFTOVI encorafenib PAGE 23 UPDATED 09/2018
24 Gundersen Senior MEDICARE 2018 PART D Updates 08/31/2018 imiquimod imiquimod PAGE 24 UPDATED 09/2018
25 Gundersen Senior MEDICARE 2018 PART D Updates September, /14/2018 LENVIMA lenvatinib mesylate 09/14/2018 POTELIGEO mogamulizumab-kpkc 09/15/2018 SAPHRIS asenapine maleate Non- Non- 09/21/2018 SAPHRIS asenapine maleate Non- 09/21/2018 dalfampridine er dalfampridine 09/22/2018 techlite pen needle pen needle, diabetic PAGE 25 UPDATED 09/2018
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TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp
During non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day.
MEICARE AVANTAGE BlueCross BlueShield of Western New York 2018 Formulary Update BlueCross BlueShield of Western New York has updated its formulary (drug list) since its original publication in January
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Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
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Partners Notice of Change March 2017
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ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18351, Version 15 1 ANTIDEPRESSANTS - SCORE Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following
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5-Fluorouracil 5-FU, Fluorouracil Stability Indicating HPLC-UV USP 7-keto DHEA Stability Indicating HPLC-UV Medisca Tier 1 Acetaminophen Stability Indicating HPLC-UV USP Adenosine Alprostadil PGE-1, Prostaglandin
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Blue Shield 65 Plus Choice Plan (HMO) Blue Shield of California is an independent member of the Blue Shield Association. Formulary Updates:
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G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.048 J0285 INJECTION, AMPHOTERICIN B 50 MG $31.668 J0287 INJECTION,
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Riesbeck's Pharmacy Reward Club Generic Medication List February 2018 $4 30 Day Supply
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
Step Therapy Requirements. Effective: 11/01/2018
Effective: 11/01/2018 Updated 10/2018 ANTIDEPRESSANTS Sharp Health Plan (HMO) TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK
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Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
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