Medicare Part D 2015 Formulary Changes Desert Preferred Choice
|
|
|
- Johnathan King
- 5 years ago
- Views:
Transcription
1 Medicare Part D 2015 Formulary s Desert Preferred Choice Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity limits and/or step therapy restrictions or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the U.S. Food and Drug Administration (FDA) determines a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. The table below outlines changes made to our formulary throughout VERSION: FORMULARY ADDITIONS UPDATE AS OF NOVEMBER 1, 2015: FORMULARY ID: Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of to an existing formulary drug SOMATULINE INJ120/.5ML SOMATULINE INJ60/0.2ML SOMATULINE INJ90/0.3ML LANREOTIDE LANREOTIDE LANREOTIDE Tier Removed prior authorization 11/1/15 5 Removed prior authorization 11/1/15 5 Removed prior authorization 11/1/15 5 OTREXUP INJ10MG METHOTREXATE Addition 11/1/15 4 OTREXUP INJ15MG METHOTREXATE Addition 11/1/15 4 OTREXUP INJ20MG METHOTREXATE Addition 11/1/15 4 1
2 OTREXUP INJ25MG METHOTREXATE Addition 11/1/15 4 OTREXUP INJ7.5/0.4MG METHOTREXATE Addition 11/1/15 4 THIOTEPA INJ15MG THIOTEPA Addition 11/1/15 5 Tier ARIPIPRAZOLE TAB 10MG ABILIFY Addition 10/1/15 2 QL (90 per 30 days) ARIPIPRAZOLE TAB 15MG ABILIFY Addition 10/1/15 2 QL (60 per 30 days) ARIPIPRAZOLE TAB 20MG ABILIFY Addition 10/1/15 2 QL (60 per 30 days) ARIPIPRAZOLE TAB 2MG ABILIFY Addition 10/1/15 2 QL (450 per 30 days) ARIPIPRAZOLE TAB 30MG ABILIFY Addition 10/1/15 2 QL (30 per 30 days) ARIPIPRAZOLE TAB 5MG ABILIFY Addition 10/1/15 2 QL (180 per 30 days) AVASTIN INJ 400/16ML BEVACIZUMAB Addition 10/1/15 5 BEXAROTENE CAP 75MG TARGRETIN Addition 10/1/15 5 CYRAMZA INJ 100/10ML RAMUCIRUMAB Addition 10/1/15 5 CYRAMZA INJ 500/50ML RAMUCIRUMAB Addition 10/1/15 5 ERBITUX INJ 100MG CETUXIMAB Deletion 10/1/15 4 FOSCARNET INJ 24MG/ML FOSCARNET Deletion 10/1/15 4 HYPERRAB S/D INJ 150/ML RABIES IMMUNE GLOBULIN Addition 10/1/15 4 KADCYLA INJ 100MG ADO-TRASTUZUMAB EMTANSINE Deletion 10/1/15 5 2
3 Tier KEYTRUDA INJ 100MG/4M PEMBROLIZUMAB Addition 10/1/15 5 OFLOXACIN TAB 300MG FLOXIN Deletion 10/1/15 2 REXULTI TAB 0.25MG BREXPIPRAZOLE Addition 10/1/15 4 QL (480 per 30 days) REXULTI TAB 0.5MG BREXPIPRAZOLE Addition 10/1/15 4 QL (240 per 30 days) REXULTI TAB 1MG BREXPIPRAZOLE Addition 10/1/15 4 QL (120 per 30 days) REXULTI TAB 2MG BREXPIPRAZOLE Addition 10/1/15 4 QL (60 per 30 days) REXULTI TAB 3MG BREXPIPRAZOLE Addition 10/1/15 4 QL (30 per 30 days) REXULTI TAB 4MG BREXPIPRAZOLE Addition 10/1/15 4 QL (30 per 30 days) TEKAMLO TAB MG ALISKIREN AND AMOLODIPINE Deletion 10/1/15 3 QL (30 per 30 days) TEKAMLO TAB 150-5MG ALISKIREN AND AMOLODIPINE Deletion 10/1/15 3 QL (30 per 30 days) TEKAMLO TAB MG ALISKIREN AND AMOLODIPINE Deletion 10/1/15 3 QL (30 per 30 days) TEKAMLO TAB 300-5MG ALISKIREN AND AMOLODIPINE Deletion 10/1/15 3 QL (30 per 30 days) TETANUS TOX INJ 5LF ADS TETANUS TOXOID Deletion 10/1/15 3 U-CORT CRE 1% HYDROCORTISONE AND UREA Deletion 10/1/15 2 VECTIBIX INJ 100MG PANITUMUMAB Deletion 10/1/15 4 YERVOY INJ 50MG IPILIMUMAB Deletion 10/1/15 5 ABILIFY DISC TAB 10MG ARIPIPRAZOLE Deletion 9/1/ QL (90 per 30 days) ABILIFY DISC TAB 15MG ARIPIPRAZOLE Deletion 9/1/ QL (60 per 30 days) 3
4 Tier AVONEX PEN KIT 30MCG INTERFERON BETA-1A Addition 9/1/ QL (4 per 28 days), BREO ELLIPTA INH FLUTICASONE AND VILANTEROL Addition 9/1/ QL (60 per 30 days) DULOXETINE CAP 40MG CYMBALTA Addition 9/1/ QL (90 per 30 days) ENBREL SRCLK INJ 50MG/ML ETANERCEPT Addition 9/1/ QL (8 per 28 days), HUMALOG KWIK INJ 100/ML INSULIN LISPRO Addition 9/1/ HUMALOG KWIK INJ 200/ML INSULIN LISPRO Addition 9/1/ HUMALOG INJ 100/ML INSULIN LISPRO Addition 9/1/ HYPERRAB S/D INJ 150/ML RABIES IMMUNE GLOBULIN Addition 9/1/ IRENKA CAP 40MG DULOXETINE Addition 9/1/ QL (90 per 30 days) NOVOLOG INJ PENFILL INSULIN ASPART Addition 9/1/ QL (30 per 30 days) PEGASYS INJ PROCLICK VARIZIG INJ 125 UNIT PEGINTERFERON ALFA- 2A Addition 9/1/ VARICELLA ZOSTER IMMUNE GLOBULIN Addition 9/1/ QL (2 per 28 days), ABILIFY 9.75MG INJ ARIPIPAZOLE Deletion 8/1/ ABILIFY SOL 1MG/ML ARIPIPAZOLE Deletion 8/1/ QL (900 per 30 days) AMTURNIDE TABLETS ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE Deletion 8/1/ QL (30 per 30 days) 4
5 Tier AMTURNIDE TABLETS AMTURNIDE MG TABLETS ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE Deletion 8/1/ QL (30 per 30 days) Deletion 8/1/ QL (30 per 30 days) AMTURNIDE TABLETS ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE Deletion 8/1/ QL (30 per 30 days) AMTURNIDE MG TABLETS ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE Deletion 8/1/ QL (30 per 30 days) ANDROXY 10MG TABLETS FLUOXYMESTERONE Deletion 8/1/ GAMUNEX-C 1GM/10ML INJ IMMUNE GLOBULIN Addition 8/1/ HARVONI MG TABLETS LEDIPASVIR AND SOFOSBUVIR Addition 8/1/ HYDROXYZINE HCL 25MG/ML HYDROXYZINE Deletion 8/1/ HYDROXYZINE HCL 50MG/ML HYDROXYZINE Deletion 8/1/ LUFYLLIN 200MG TABLETS DYPHYLLINE Deletion 8/1/ PANTOPRAZOLE 40MG INJ PROTONIX Deletion 8/1/2015 4, QL (28 per 28 days) 5
6 Tier PEDI-DRI POW NYSTATIN Deletion 8/1/ PRISTIQ 25MG TABLETS DESVENLAFAXINE Addition 8/1/ QL (480 per 30 days) QUADRACEL INJ DIPTHERIA,TETANUS TOXOIDS,ACELLULAR PERTUSSIS AND Addition 8/1/ POLIOVIRUS VACCINE QUINIDINE SULF 300MG ER TABLETS QUINIDINE Deletion 8/1/ ADRUCIL INJ 500/10ML FLUOROURACIL Addition 6/1/ Prior AMP-SULBACTA INJ 1.5GM UNASYN Addition 6/1/ Prior BEXSERO INJ MENINGOCOCCAL GROUP B VACCINE Addition 6/1/ DAUNOXOME INJ 2MG/ML DAUNORUBICIN Addition 6/1/ Prior FARYDAK CAP 20MG PANOBINOSTAT Addition 6/1/ QL (6 per 21 days) FARYDAK CAP 10MG PANOBINOSTAT Addition 6/1/ QL (6 per 21 days) FARYDAK CAP 15MG PANOBINOSTAT Addition 6/1/ QL (6 per 21 days) FENTANYL DIS 37.5MCG FENTANYL Addition 6/1/ QL (30 per 30 days) FENTANYL DIS 62.5MCG FENTANYL Addition 6/1/ QL (30 per 30 days) FENTANYL DIS 87.5MCG FENTANYL Addition 6/1/ QL (30 per 30 days) FRAGMIN INJ 7500/0.3 DALTEPARIN Deletion 6/1/ QL (20 per 30 days), Prior ICLUSIG TAB 45MG PONATINIB Addition 6/1/ QL (30 per 30 days) LENVIMA CAP 10MG LENVATINIB Addition 6/1/ QL (30 per 30 days) LENVIMA CAP 14MG LENVATINIB Addition 6/1/ QL (60 per 30 days) LENVIMA CAP 20MG LENVATINIB Addition 6/1/ QL (60 per 30 days) LENVIMA CAP 24MG LENVATINIB Addition 6/1/ QL (90 per 30 days) LEVETIRACETAM INJ 10MG/ML LEVETIRACETAM Addition 6/1/
7 Tier LEVETIRACETAM INJ 15MG/ML LEVETIRACETAM Addition 6/1/ LEVETIRACETAM INJ 5MG/ML LEVETIRACETAM Addition 6/1/ MOVANTIK TAB 12.5MG NALOXEGOL OXALATE Addition 6/1/ QL (30 per 30 days) MOVANTIK TAB 25MG NALOXEGOL OXALATE Addition 6/1/ QL (30 per 30 days) OTEZLA TAB 10/20/30 APREMILAST Addition 6/1/ QL (60 per 30 days) RELISTOR INJ 8/0.4ML METHYLNALTREXONE Addition 6/1/ Prior RELISTOR INJ 12/0.6ML METHYLNALTREXONE Addition 6/1/ Prior SAIZEN INJ 8.8MG SOMATROPIN Addition 6/1/ Prior SUPRAX TAB 400MG CEFIXIME Deletion 6/1/ TARGRETIN GEL 1% BEXAROTENE Deletion 6/1/ QL (60 per 30 days) TYPHIM VI INJ TYPHOID VI POLYSACCHARIDE VACCINE Addition 6/1/ ZENATANE CAP 30MG ISOTRETINOIN Addition 6/1/ ZYPREXA RELP INJ 210MG OLANZAPINE Addition 6/1/ ABILIFY MAIN INJ 300MG ARIPIPRAZOLE Addition 5/1/ ABILIFY MAIN INJ 400MG ARIPIPRAZOLE Addition 5/1/ COUMADIN INJ 5 MG WARFARIN Deletion 5/1/ Prior ATAZANAVIR AND EVOTAZ TAB MG COBICISTAT Addition 5/1/ QL (30 per 30 days) FRAGMIN INJ 25000/ML DALTEPARIN Deletion 5/1/ Prior, QL (20 per 30 days) GLEOSTINE CAP 100MG LOMUSTINE Addition 5/1/ GLEOSTINE CAP 10MG LOMUSTINE Addition 5/1/ GLEOSTINE CAP 40MG LOMUSTINE Addition 5/1/ IBRANCE CAP 100MG PALBOCICLIB Addition 5/1/ QL (30 per 30 days) IBRANCE CAP 125MG PALBOCICLIB Addition 5/1/ QL (30 per 30 days) 7
8 Tier IBRANCE CAP 75MG PALBOCICLIB Addition 5/1/ QL (30 per 30 days) LAMOTRIGINE TAB ODT 25MG LAMICTAL Addition 5/1/ LAMOTRIGINE TAB ODT 50MG LAMICTAL Addition 5/1/ LAMOTRIGINE TAB ODT/100MG LAMICTAL Addition 5/1/ LAMOTRIGINE TAB ODT/200MG LAMICTAL Addition 5/1/ DARUNAVIR AND PREZCOBIX TAB MG COBICISTAT Addition 5/1/ QL (30 per 30 days) RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/ RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/ RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/ RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/ RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/ VITEKTA TAB 150MG ELVITEGRAVIR Addition 5/1/ QL (30 per 30 days) VITEKTA TAB 85MG ELVITEGRAVIR Addition 5/1/ QL (30 per 30 days) ANDROGEL GEL1.62% TESTOSTERONE Addition 4/1/ QL (300 per 30 days) ANDROGEL GEL1.62% TESTOSTERONE Addition 4/1/ QL (300 per 30 days) AUBRA TAB LEVONORGESTREL and Addition 4/1/ BELEODAQ INJ500MG BELINOSTA Addition 4/1/ Prior BREO ELLIPTAINH FLUTICASONE and VILANTEROL Addition 4/1/ QL (60 per 30 days) CELECOXIB CAP100MG CELEBREX Addition 4/1/ QL (60 per 30 days) CELECOXIB CAP200MG CELEBREX Addition 4/1/ QL (60 per 30 days) CELECOXIB CAP400MG CELEBREX Addition 4/1/ QL (60 per 30 days) 8
9 Tier CELECOXIB CAP50MG CELEBREX Addition 4/1/ QL (60 per 30 days) COLY-MYCIN SSUSOTIC NEOMYCIN, COLISTIN, HYDROCORTISONE, and THONZONIUM Deletion 4/1/ CRINONE GEL4% VAG PROGESTERONE Deletion 4/1/ CRINONE GEL8% VAG PROGESTERONE Deletion 4/1/ CYCLOPHOSPH TAB25MG CYCLOPHOSPHAMIDE Deletion 4/1/ Prior CYCLOPHOSPH TAB50MG CYCLOPHOSPHAMIDE Deletion 4/1/ Prior DELYLA TAB LEVONORGESTREL and Addition 4/1/ DOCEFREZ INJ80MG DOCETAXEL Deletion 4/1/ Prior CONJUGATED DUAVEE TAB ESTROGENS and Addition 4/1/ QL (30 per 30 days) BAZEDOXIFENE ELIQUIS TAB2.5MG APIXABAN Addition 4/1/ QL (60 per 30 days) ELIQUIS TAB5MG APIXABAN Addition 4/1/ QL (60 per 30 days) FALMINA TAB LEVONORGESTREL and Addition 4/1/ FYCOMPA TAB10MG PERAMPANEL Addition 4/1/ QL (30 per 30 days) FYCOMPA TAB12MG PERAMPANEL Addition 4/1/ QL (30 per 30 days) HUMAN GARDASIL 9 INJ PAPILLOMAVIRUS (HPV) Addition 4/1/ Prior VACCINE GARDASIL INJ HUMAN PAPILLOMAVIRUS (HPV) VACCINE Addition 4/1/ Prior GILDESS TAB1.5/30 LEVONORGESTREL and Addition 4/1/
10 GRANISOL SOL2MG/10ML GRANISETRON Deletion 4/1/ Tier QL (30 per 30 days), Prior HEP SOD/NACLINJ1000UNIT HEPARIN and SODIUM CHLORIDE Deletion 4/1/ Prior HUMIRA INJ10MG/0.2 ADALIMUMAB Addition 4/1/ QL (6 per 30 days), Prior ICLUSIG TAB15MG PONATINIB Addition 4/1/ QL (90 per 30 days) INCIVEK TAB375MG TELAPREVIR Deletion 4/1/ INTRON A INJ18MU INTERFERON ALFA-2b Addition 4/1/ INTRON A INJ50MU INTERFERON ALFA-2b Addition 4/1/ KEYTRUDA SOL50MG PEMBROLIZUMAB Addition 4/1/ Prior LAMIVUDINE SOL10MG/ML EPIVIR Addition 4/1/ LARIN TAB1.5/30 NORETHINDRONE and Addition 4/1/ LIDOCAINE INJ1% XYLOCAINE Deletion 4/1/ Prior LUFYLLIN TAB400MG DYPHYLLINE Deletion 4/1/ LYNPARZA CAP50MG OLAPARIB Addition 4/1/ QL (480 per 30 days) MYCOPHENOLATSUS200MG/ ML CELLCEPT Addition 4/1/ Prior NAMENDA TAB5-10MG MEMANTINE Addition 4/1/ QL (60 per 30 days) NAMENDA TAB10MG MEMANTINE Addition 4/1/ QL (60 per 30 days) NAMENDA TAB5MG MEMANTINE Addition 4/1/ QL (60 per 30 days) NEVIRAPINE TAB400MG ER VIRAMUNE XR Addition 4/1/ OFLOXACIN TAB200MG FLOXIN Deletion 4/1/ OPDIVO INJ40MG/4ML NIVOLUMAB Addition 4/1/ Prior ORSYTHIA TAB LEVONORGESTREL and Addition 4/1/ ORTHO EVRA DISWEEK NORELGESTROMIN and Deletion 4/1/
11 PEG-INTRON KIT120MCG PEGINTERFERON ALFA-2b Addition 4/1/ PEG-INTRON KIT150MCG PEGINTERFERON ALFA-2b Addition 4/1/ PEG-INTRON KIT80MCG PEGINTERFERON ALFA-2b Addition 4/1/ Tier QL (4 per 30 days), Prior QL (4 per 30 days), Prior QL (4 per 30 days), Prior POT CITRATE TAB1620MG UROCIT-K Addition 4/1/ PRIFTIN TAB150MG RIFAPENTINE Deletion 4/1/ PURIXAN SUS20MG/ML MERCAPTOPURINE Addition 4/1/ QVAR AER80MCG BECLOMETHASONE Deletion 4/1/ QL (21.9 per 30 days) RECOMBIVA HBINJ10MCG/ML HEPATITIS B VACCINE RECOMBINANT Addition 4/1/ Prior RECOMBIVA HBINJ5MCG/0.5 HEPATITIS B VACCINE RECOMBINANT Addition 4/1/ Prior REYATAZ POW50MG ATAZANAVIR Addition 4/1/ SIROLIMUS TAB1MG RAPAMUNE Addition 4/1/ Prior SIROLIMUS TAB2MG RAPAMUNE Addition 4/1/ Prior SOMAVERT INJ25MG PEGVISOMANT Addition 4/1/ Prior SOMAVERT INJ30MG PEGVISOMANT Addition 4/1/ Prior SUTENT CAP37.5MG SUNITINIB Addition 4/1/ SYMBICORT AER BUDESONIDE and FORMOTEROL Deletion 4/1/ QL (6.9 per 30 days) TREANDA INJ45/0.5ML BENDAMUSTINE Addition 4/1/ Prior TRIUMEQ TAB ABACAVIR, DOLUTEGRAVIR and LAMIVUDINE Addition 4/1/ QL (30 per 30 days) TRUMENBA INJ MENINGOCOCCAL GROUP B VACCINE Addition 4/1/ TYBOST TAB150MG COBICISTAT Addition 4/1/ QL (30 per 30 days) 11
12 Tier VALACYCLOVIRTAB1GM VALTREX Removed Quantity Limits 4/1/ VALACYCLOVIRTAB500MG VALTREX Removed Quantity Limits 4/1/ VAQTA INJ25/0.5ML HEPATITIS A VACCINE Addition 4/1/ VAQTA INJ50UNT/ML HEPATITIS A VACCINE Addition 4/1/ DASABUVIR,OMBITASVIR VIEKIRA PAK TAB,PARITAPREVIR and Addition 4/1/ RITONAVIR ZENPEP CAP40000UNT PANCRELIPASE Addition 4/1/ ZENZEDI TAB2.5MG DEXTROAMPHETAMINE Addition 4/1/ ZENZEDI TAB7.5MG DEXTROAMPHETAMINE Addition 4/1/ ZYDELIG TAB100MG IDELALISIB Addition 4/1/ QL (90 per 30 days) ZYDELIG TAB150MG IDELALISIB Addition 4/1/ QL (60 per 30 days) VALCHLOR GEL 0.016% MECHLORETHAMINE Addition 3/1/ QL (112 per 30 days), Prior 12
Aetna Better Health Illinois Premier Plan. November 2015 Formulary Updates. October 2015 Formulary Updates
Aetna Better Health Illinois Premier Plan November 2015 Formulary Updates desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg RIVASTIGMINE DIS 13.3/24; QL (30 patches/30 days) RIVASTIGMINE DIS 4.6MG/24;
Medicare Part D 2016 Formulary Changes Desert Preferred Choice
Medicare Part D 2016 Formulary s Desert Preferred Choice Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred
Medicare Part D 2016 Formulary s Service To Senior and OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior
Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred
Medicare Part D 2016 Formulary s Service To Senior and OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior
Medicare Part D 2012 Formulary Changes Service To Senior and Total Fit
Medicare Part D 2012 Formulary s Service To Senior and Total Fit Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 017 Formulary s OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity
Medicare Part D 2017 Formulary Changes Service To Senior
Medicare Part D 2017 Formulary s Service To Senior Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 2017 Formulary Changes OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2017 Formulary Changes Service To Senior
Medicare Part D 2017 Formulary Changes Service To Senior Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization,
Medicare Part D 2017 Formulary Changes OC Preferred
Medicare Part D 2017 Formulary s OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity
Rationale for Decision Excluded Generic OTC equivalent available (Flonase Allergy Relief) Medicare status (if differs)
BLUE SHIELD OF CALIFORNIA FIRST QUARTER 2015 FORMULARY AND MEDICATION POLICY UPDATES EFFECTIVE MARCH 19, 2015 The Blue Shield of California (BSC) Pharmacy and Therapeutics (P&T) Committee, consisting of
Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary
Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates July 2018 TRADE NAME (generic name) or generic name ADVAIR DISKUS (fluticasone-salmeterol aer powder ba 100-50 mcg/dose) Brand Addition ADVAIR
How do I request an exception to the Liberty Health Advantage s Formulary?
QUANTITY LIMITATIONS How do I request an exception to the Liberty Health Advantage s Formulary? You can ask Liberty Health Advantage to make an exception to our coverage rules. There are several types
2018 Formulary Notice of Change Prescription Drug Plans
2018 Formulary Notice of Change Prescription Drug Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) WellCare may add or remove drugs from our formulary during the
ELEVATE. Formulary Updates to Elevate Plans (Bronze HDHP/Standard, Silver Select/Standard & Gold Select/Standard)
ELEVATE Formulary Updates to Elevate Plans (Bronze HDHP/Standard, Silver Select/Standard & Gold Select/Standard) P&T/Formulary Committee Actions 4Q 2017 (Effective January 1, 2018) Marketplace Standard
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy
2018 Medicare Part D Formulary Change
2018 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy
Changes to the 2018 BlueCross Secure SM (HMO) & BlueCross Total SM (PPO) Formularies
Changes to the 2018 BlueCross Secure SM (HMO) & BlueCross Total SM (PPO) Formularies BlueCross BlueShield of South Carolina may add or remove drugs from the formulary during the year. If we remove drugs
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs
LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT
LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT The following medications may be covered under your medical benefit if they are provided to you in your doctor s office or outpatient infusion
2019 Drug List Negative Changes
2019 Drug List Negative Changes Updated 03/26/2019 If you are taking a drug that is removed from the formulary (also known as the Drug List), we will tell you. We will also tell you if we add any restrictions
2018 Drug List Negative Changes Updated 10/25/2018 The table below shows changes made to our 2018 List of Covered Drugs (Formulary).
2018 Drug List Negative s Updated 10/25/2018 The table below shows changes made to our 2018 List of Covered Drugs (Formulary). Date of 1/1/2018 COLYTE-FLAVOR PACKS SOLR 227.1GM- 21.5GM-5.53GM- 2.82GM-6.36GM
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs
Alprazolam 0.25mg, 0.5mg, 1mg tablets
Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service
2018 Formulary Update
MEDICARE ADVANTAGE BlueShield of Northeastern New York 2018 Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January 2018. This
Exclusion Reasons Presumption of Long- Term Non-Acute Administration C9399 Unclassified Drugs or
Noridian Healthcare Solutions, LLC Jurisdiction F Part B Self-Administered Drug (SAD) Exclusion List (A53033); Effective 8/7/2017 The following medications are considered self-administered and are not
NOTIFICATION OF FORMULARY CHANGES
NOTIFICATION OF CHANGES The following summary describes changes to the 2018 Presbyterian Senior Care (HMO)/(HMO-POS), Presbyterian MediCare PPO and formularies. The formulary may change at any time. You
Partners Notice of Change March 2017
New Added Products: Effective 3/1/2017 Drug Reason Tier Restrictions abacavir 600 mg-lamivudine 300 QL ADRENACLICK 0.15 MG/0.15 ML INJECTION,AUTO- INJECTOR ADRENACLICK 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR
Descriptor Brand Name. Alprostadil, Caverject, Edex, Prostin VR Pediatric. Calcimar, Miacalcin
Self-Administered Drug Exclusion List R2 This article from Medicare A News, Issue 2106 dated January 23, 2013 and Medicare B News, Issue 283 dated January 23, 2013 is being revised to add Acthar ACTH gel
2017 Formulary Changes Year to Date
2017 Formulary Changes Year to Date Health Choice Arizona may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or
Notice of Mid-Year Changes to 2019 Paramount Enhanced Formulary
Notice of Mid-Year s to 2019 Paramount Enhanced Formulary Paramount Elite (HMO) may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the
Aetna Better Health FIDA Plan
Aetna Better Health FIDA Plan May 2016 Formulary Updates ASCOMP/COD - QL; PA FYAVOLV 5MCG; 1MG- PA METOPROLOL TABS 37.5MG, 75MG CIPRODEX LETAIRIS - QL; PA OFEV - QL; PA OTREXUP - ST PRALUENT - QL; PA RASUVO
Health Partners Medicare Special Formulary Updates
March 2018 Effective Date Brand Name Generic Name Type of Change 90 / 30 DAYS tenofovir disoproxil fumarate tenofovir disoproxil fumarate clobetasol propionate tenofovir disoproxil fumarate Previous Value
Coverage of Vaccines Medicaid and Child Health Plus Members
Coverage of Vaccines Medicaid and Child Health Plus Members For children between the ages 0-18, routine recommended vaccinations are covered through Vaccines for Children program [VFC]. Fidelis Care will
Alameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee Decisions
Alameda Alliance for Health FORMULARY UPDATE Effective: October 27, 2017. Drugs notated with an * have an undetermined implementation date Alameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee
ICP Formulary Updates
ICP Formulary Updates July 2017 TRADE NAME (generic name) adapalene cream 0.1% 2017-07-01 Removal adapalene gel 0.3% 2017-07-01 Removal adefovir dipivoxil tab 10 mg 2017-07-01 Removal ADVAIR DISKUS (fluticasone-salmeterol
UPDATE Ohana QUEST Integration Medicaid
UPDATE Ohana QUEST Integration Medicaid Preferred Drug List June 29, 2015 Dear Provider: At the June 04, 2015 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes
HNE Medicare Advantage Plan (HMO and HMO- POS) 2016 Formulary (List of Covered Drugs)
HNE Medicare Advantage Plan (HMO and HMO- POS) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File
August 2016 Formulary Updates
August 2016 Formulary Updates DOXYCYCLINE HYCLATE TABS DR 50MG, 200MG NALOXONE HCL INJ 0.4MG/ML VANCOMYCIN HCL INJ 500MG, 750MG BRIVIACT INJ - PA BRIVIACT ORAL SOLN - QL; PA BRIVIACT TABS - QL; PA LENVIMA
2018 CareOregon Advantage Part D Formulary Changes
2018 CareOregon Advantage Part D Formulary Changes Abbreviations: AGE = Age Restriction; PA = Prior Authorization Required; QL = Quantity Limit; ST = Step Therapy Required; LD = Limited Distribution; BvD
Health Partners Medicare Prime 2019 Formulary Changes
Health Partners Medicare Prime 2019 Formulary Changes Changes occur, for example, because new drugs come on the market, a drug is moved to a different cost-sharing level (tier), or a generic version becomes
2014 Quantity Limits (QL) Criteria
2014 Quantity Limits (QL) Criteria Certain drugs covered through your EmblemHealth Medicare HMO/PPO Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food
ALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
Aetna Better Health of Illinois Medicaid Formulary Updates
October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
Mike Ouellette, R.Ph., GHS
TO: Maine Drug Utilization Review Board DATE: April 23, 2015 RE: Maine DUR Board Meeting minutes from April 14 th, 2015 ATTENDANCE PRESENT ABSENT ECUSED Robert Weiss, M.D., Cardiologist, Chair Linda Glass,
UPMC for You Pharmacy and Therapeutics Committee Meeting April 8, 2013 meeting
UPMC for You Pharmacy and Therapeutics Committee Meeting April 8, 2013 meeting 1. Call to order: The meeting was called to order at 7:05 a.m. 2. Review of the minutes: The minutes of the January meeting
MEDICAL NECESSITY GUIDELINE
PAGE: 1 of 10 IMPORTANT REMINDER This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted
True Health New Mexico List of Medications with Quantity Limits
True Health New Mexico List of Medications with Quantity Limits Specialty Medications Contact True Health New Mexico Pharmacy Services at 1-866- 341-8561 for quantity limits on specialty medications. Maximum
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice The formulary changes listed in the table below were reviewed and approved at our second quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October
GEMCare Medicare Plus (HMO) & Physicians Choice Medicare Plus (HMO) 2015 Formulary (List of Covered Drugs)
GEMCare Medicare Plus (HMO) & Physicians Choice Medicare Plus (HMO) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved
2018 Formulary Update
MEDICARE ADVANTAGE BlueShield of Northeastern New York 2018 Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January 2018. This
Superior Select Health Plans: Tribute-1 Tier May 2018 Formulary Addendum
Superior Select Health Plans: Tribute-1 Tier May 2018 Formulary Addendum Below is a list formulary changes for the benefit year 2018. This is not a complete list of drugs covered by the Part D plan. The
Quarterly pharmacy formulary change notice
Provider Bulletin October 2018 Quarterly pharmacy formulary change notice The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. The changes listed in the table
SASKATCHEWAN FORMULARY COMMITTEE UPDATE BULLETIN TO THE 55th EDITION OF THE SASKATCHEWAN FORMULARY
Saskatchewan Health Drug Plan and Extended Benefits Branch April 2006 Bulletin #106 ISSN 0708-3246 SASKATCHEWAN FORMULARY COMMITTEE UPDATE BULLETIN TO THE 55th EDITION OF THE SASKATCHEWAN FORMULARY All
Pharmacy and Therapeutics (P&T) Committee Provider Update
Pharmacy and Therapeutics (P&T) Committee Provider Update FIRST QUARTER 2017 P&T Committee Decisions effective March 1, 2017 Dear Healthcare Practitioner: The Presbyterian Health Plan, Inc., and Presbyterian
Pharmacy Updates Summary
All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 04/15/2015 Effective date: 05/15/2015 Therapeutic Classes reviewed: Testosterone replacement
Look-Alike/Sound-Alike (LASA) Medication Chart
Look-Alike/Sound-Alike (LASA) Medication Chart Last Revised: August 2018 Lipid based amphotericin products amphotericin B lipid complex (Abelcet ) amphotericin B liposomal (Ambisome ) Conventional forms
December 2016 Formulary Updates
December 2016 Formulary Updates ABACAVIR/LAMIVUDINE AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-20MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-40MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 5-20MG QL AMLODIPINE/OLMESARTAN
Health Partners Medicare Special 2018 Formulary Changes
Health Partners Medicare Special 2018 Changes Changes occur, for example, because new drugs come on the market, a drug is moved to a different cost-sharing level (tier), or a generic version becomes available.
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
New Generics: Specialty Network: Retail Pharmacies Dispensing Specialty Products
SUPPORTING OUR PROVIDER PARTNERS THROUGH COMMUNICATION AND COLLABORATION. DATE JANUARY 2016 ISSUE 1 HELPFUL NUMBERS FOR PROVIDERS Magellan: 1-800-846-7971 Bin: 016523 Processor control: 747 HELPFUL NUMBERS
Quarterly pharmacy formulary change notice
MEDICAID PROVIDER BULLETIN October 2018 The formulary changes listed in the table below were reviewed and approved at the second-quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October
November 2018 P & T Updates
November 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AIMOVIG 3 2 Detailed s 70 mg per month: 2 ml per 60 days 140 mg per month: 2 ml per 30 days AJOVY 3 2 4.5 ml
Drug Name Tier Drug Name Tier
Drug Name Tier Drug Name Tier ABELCET 100 MG/20 ML VIAL 4 ACETYLCYSTEINE 10% VIAL 2 ACETYLCYSTEINE 20% VIAL 2 ACYCLOVIR 1,000 MG/20 ML VIAL 2 ACYCLOVIR 500 MG/10 ML VIAL 2 ADRUCIL 500 MG/10 ML VIAL 2 ALBUTEROL
2019 Drug List Negative Changes
2019 Drug List Negative Changes Updated 03/26/2019 If you are taking a drug that is removed from the formulary (also known as the Drug List), we will tell you. We will also tell you if we add any restrictions
Step Therapy Requirements
Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet
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
Medication Guide. July Contents. Click to search for a drug name in this document
July 06 Medication Guide Click to search for a drug name in this document Contents Introduction... I Medication list... II Changes to the formulary... II Your Share of Expenses... III Pharmacy Benefits...
Quarterly Pharmacy Formulary Change Notice
MEDICAID PROVIDER BULLETIN February 26, 2015 Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our September 24,
November 2016 Formulary Updates
November 2016 Formulary Updates DAPTOMYCIN LARISSIA NITROGLYCERIN SUBL ORFADIN 20MG CAP PA RELISTOR 150MG TAB PA; QL Over-the-Counter (OTC) Drugs Added* COLEMAN SKINSMART INSECT REP CUTTER BACKWOODS AERO
Health New England Medicare Advantage 2018 Formulary (List of Covered Drugs) HMO
Health New England Medicare Advantage 2018 Formulary (List of Covered Drugs) HMO A comprehensive list of the brand name and generic medications that your Health New England Medicare Advantage plan covers.
HEALTHTEAM ADVANTAGE PLAN 2017 Step Therapy Criteria Pending CMS Approval
ARISTADA - ARISTADA INJ 441MG/1.6 ARISTADA INJ 662MG/2.4 ARISTADA INJ 882MG/3.2 CLAIM WILL PAY AUTOMATICALLY FOR ARISTADA IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ABILIFY MAINTENA AND
The following list of recommended PDL changes were reviewed and approved by the MHS P&T Committee on December 14 th, 2016.
Q4 MHS PDL Changes Provider Notice The following list of recommended PDL changes were reviewed and approved by the MHS P&T Committee on December 14 th, 2016. Table 1: Summary of Medicaid PDL Additions
UPMC for You Pharmacy and Therapeutics Committee Meeting April 7, 2014 meeting
UPMC for You Pharmacy and Therapeutics Committee Meeting April 7, 2014 meeting 1. Call to order: The meeting was called to order at 7:05 a.m. 2. Review of the minutes: The minutes of the January meeting
3 Tier Formulary Additions
3 Tier Formulary Additions Drug Name Tier Category Management ACCU-CHECK GUIDE ME GLUCOSE METER 3 Diabetic Supplies Step Therapy applies pyridostigmine bromide 60mg/5ml syrup 1 Antimyasthenic Agents New
Medication Guide. January Contents
January 06 Medication Guide Contents Introduction... I Medication list... II Changes to the formulary... II Your Share of Expenses... III Pharmacy Benefits... III Medications that are not covered... III
FORMULARY CHANGE NOTICE 2008 JULY
FORMULARY CHANGE NOTICE 2008 JULY Drug Name Dosage Form Strength Alternative Medicine* Formulary Formulary Change and Reason Status of Alternative Medication Updated Status On Formulary STARLIX TABS 120MG
January 2018 Pharmacy & Therapeutics Committee Decisions
UCare s Pharmacy and Therapeutics Committee (P&T) is a group of physicians and pharmacists that meet throughout the year to make changes to the UCare formulary (approved drug list). These changes are reviewed
Prescription benefit updates Large group
Prescription benefit updates Large group Moda Health s prescription program is a pharmacy benefit that offers members a choice of safe effective medication treatments. The program also helps you save money
Memorial Hermann Advantage HMO February 2019 Formulary Addendum
Memorial Hermann Advantage HMO February 2019 Formulary Addendum Changes may have occurred since the printing of your current Memorial Hermann Advantage HMO Formulary. Medications that may have been added
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand
ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Provider update Summary: Effective August 1, 2018, the preferred formulary changes detailed in the table below will apply to District of Columbia Healthy Families
MArch The 2014 Drug Trend Report MEDICARE
MArch 2015 The 2014 Drug Trend Report MEDICARE content MedicaRE 3 Medicare Year in Review A Look at Medicare Overall Drug Trend for 2014 Medicare: Traditional Therapy Classes and Insights Top 10 Medicare
TRICARE Retail Vaccination Program Vaccine List - September 2018*
Diphtheria, tetanus and pertussis Diphtheria and tetanus toxoids adsorbed acellular pertussis adsorbed DT DTaP Diphtheria and tetanus toxoids adsorbed Daptacel, Infanrix Tetanus and diphtheria toxoids
FirstCarolinaCare Insurance Company. Step Therapy Requirements
FirstCarolinaCare Insurance Company Step Therapy Requirements Effective: 12/01/2018 ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION
Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E
Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET
ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET BANZEL 200 MG TABLET BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG TABLET FYCOMPA 0.5 MG/ML ORAL SUSPENSION
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand
Formulary. Update. At A Glance. Formulary Additions
ISSUE 2 VOLUME 8 APRIL 2014 u Formulary Additions..... 1 u Formulary Deletions......2 u New standing Order...... 2 u Floorstock Additions.... 3 u Quanitity Limits........ 3 u New Approved Compound.. 3
2017 Step Therapy Criteria
FRESENIUS TOTAL HEALTH 2017 Step Therapy Updated 07/01/2017. For more recent information or other questions, please contact Fresenius Total Health Customer Service at 1-855-598-6774 / TTY 1-844-209-9094.
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
Appropriate Use & Safety Edits
Appropriate Use & Safety Edits Envolve Pharmacy Solutions provides a variety of safety edits to promote the use of the right medication, in the right patient, at the right time. These edits are routinely
Oregon Health Plan prescription benefit updates
Oregon Health Plan prescription benefit updates EOCCO s prescription program is a pharmacy benefit that offers members a choice of safe and effective medication treatments. The program also helps you save
5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release
5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum.