Health Partners Medicare Special 2018 Formulary Changes
|
|
|
- Pierce Mosley
- 5 years ago
- Views:
Transcription
1 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. Requirements/ Key: NEDS QL LA PA ST Non-Extended Day Supply Quantity Limit Limited Access Prior Authorization Step Therapy ALIQOPA 60 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 aripiprazole 1 mg/ml solution SOLUTION 1 - Covered Addition 03/01/2018 atazanavir sulfate 150 mg cap CAPSULE 1 - Covered QL: 60/30 DAYS Addition 03/01/2018 atazanavir sulfate 200 mg cap CAPSULE 1 - Covered QL: 60/30 DAYS Addition 03/01/2018 atazanavir sulfate 300 mg cap CAPSULE 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 BENLYSTA 200 MG/ML AUTOINJECT AUTO INJCT 1 - Covered NEDS Addition 03/01/2018 BENLYSTA 200 MG/ML SYRINGE SYRINGE 1 - Covered NEDS Addition 03/01/2018 bortezomib 3.5 mg vial VIAL 1 - Covered PA, NEDS Addition 03/01/2018 BOSULIF 400 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 BYDUREON BCISE 2 MG AUTOINJECT AUTO INJCT 1 - Covered Addition 03/01/2018 CALQUENCE 100 MG CAPSULE CAPSULE 1 - Covered NEDS Addition 03/01/2018 carvedilol ER 10 mg capsule CPMP 24HR 1 - Covered QL: 30/30 DAYS Addition 03/01/ Updated 10/2018
2 carvedilol ER 20 mg capsule CPMP 24HR 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 carvedilol ER 40 mg capsule CPMP 24HR 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 carvedilol ER 80 mg capsule CPMP 24HR 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 caspofungin acetate 50 mg vial VIAL 1 - Covered Addition 03/01/2018 caspofungin acetate 70 mg vial VIAL 1 - Covered Addition 03/01/2018 cholestyramine packet POWD PACK 1 - Covered Addition 03/01/2018 cholestyramine powder POWDER 1 - Covered Addition 03/01/2018 clobetasol emollnt 0.05% foam FOAM 1 - Covered Addition 03/01/2018 clobetasol emulsion 0.05% foam FOAM 1 - Covered Addition 03/01/2018 clobetasol 0.05% cream CREAM (G) 1 - Covered Addition 03/01/2018 dactinomycin 0.5 mg vial VIAL 1 - Covered PA, NEDS Addition 03/01/2018 desogest-eth estra mg TABLET 1 - Covered Addition 03/01/2018 desogestrel-ethinyl estradiol tab TABLET 1 - Covered Addition 03/01/2018 doxycycline hyclate 150 mg tab TABLET 1 - Covered Addition 03/01/2018 doxycycline hyclate 75 mg tab TABLET 1 - Covered Addition 03/01/2018 efavirenz 200 mg capsule CAPSULE 1 - Covered QL: 90/30 DAYS Addition 03/01/2018 efavirenz 50 mg capsule CAPSULE 1 - Covered QL: 240/30 DAYS Addition 03/01/2018 estradiol 10 mcg vaginal insert TABLET 1 - Covered Addition 03/01/2018 ethynodiol-eth estra 1mg-35 mcg TABLET 1 - Covered Addition 03/01/2018 fluocinolone 0.01% scalp oil OIL 1 - Covered Addition 03/01/2018 fluocinolone 0.01% body oil OIL 1 - Covered Addition 03/01/2018 fluocinonide 0.05% cream CREAM (G) 1 - Covered Addition 03/01/ Updated 10/2018
3 fosamprenavir 700 mg tablet TABLET 1 - Covered Addition 03/01/2018 GLATIRAMER 20 MG/ML SYRINGE SYRINGE 1 - Covered NEDS Addition 03/01/2018 GLATIRAMER 40 MG/ML SYRINGE SYRINGE 1 - Covered NEDS Addition 03/01/2018 HAVRIX 1,440 UNITS/ML SYRINGE SYRINGE 1 - Covered Addition 03/01/2018 HAVRIX 720 UNITS/0.5 ML VIAL VIAL 1 - Covered Addition 03/01/2018 HUMALOG JR 100 UNIT/ML KWIKPEN INS PEN HF 1 - Covered QL: 45/30 DAYS Addition 03/01/2018 IDHIFA 100 MG TABLET TABLET 1 - Covered Addition 03/01/2018 IDHIFA 50 MG TABLET TABLET 1 - Covered Addition 03/01/2018 INGREZZA 80 MG CAPSULE CAPSULE 1 - Covered QL: 30/30 DAYS, PA, NEDS Addition 03/01/2018 JULUCA MG TABLET TABLET 1 - Covered Addition 03/01/2018 KADCYLA 160 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 lanthanum carb 1,000 mg tab chew TAB CHEW 1 - Covered Addition 03/01/2018 lanthanum carb 500 mg tab chew TAB CHEW 1 - Covered Addition 03/01/2018 lanthanum carb 750 mg tab chew TAB CHEW 1 - Covered Addition 03/01/2018 LYNPARZA 100 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 LYNPARZA 150 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 meropenem IV 1 gm vial VIAL 1 - Covered Addition 03/01/2018 mesalamine DR 1.2 gm tablet TABLET DR 1 - Covered Addition 03/01/2018 moxifloxacin 0.5% eye drops DROPS 1 - Covered Addition 03/01/2018 MYLOTARG 4.5 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 NERLYNX 40 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 OPDIVO 100 MG/10 ML VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/ Updated 10/2018
4 oseltamivir 6 mg/ml suspension SUSP RECON 1 - Covered Addition 03/01/2018 oxaliplatin 100 mg vial VIAL 1 - Covered Addition 03/01/2018 paroxetine mesylate 7.5 mg cap CAPSULE 1 - Covered Addition 03/01/2018 piperacil-tazo 2.25 gm add vial VIAL PORT 1 - Covered Addition 03/01/2018 piperacil-tazobact 2.25 gm vial VIAL 1 - Covered Addition 03/01/2018 KLOR-CON 20 MEQ PACKET PACKET 1 - Covered Addition 03/01/2018 prasugrel 10 mg tablet TABLET 1 - Covered Addition 03/01/2018 prasugrel 5 mg tablet TABLET 1 - Covered Addition 03/01/2018 RADICAVA 30 MG/100 ML BAG PIGGYBACK 1 - Covered PA, NEDS Addition 03/01/2018 RENFLEXIS 100 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 sevelamer carbonate 800 mg tab TABLET 1 - Covered Addition 03/01/2018 tenofovir disop fum 300 mg tab TABLET 1 - Covered QL: 30/30 DAYS Addition 03/01/2018 TRACLEER 32 MG TABLET FOR SUSP TAB SUSP 1 - Covered PA, LA, NEDS Addition 03/01/2018 TREANDA 25 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 TRISENOX 12 MG/6 ML VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 TWINRIX VACCINE SYRINGE SYRINGE 1 - Covered Addition 03/01/2018 VAQTA 25 UNITS/0.5 ML VIAL VIAL 1 - Covered Addition 03/01/2018 VAQTA 50 UNITS/ML VIAL VIAL 1 - Covered Addition 03/01/2018 VERZENIO 100 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 VERZENIO 150 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 VERZENIO 200 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/2018 VERZENIO 50 MG TABLET TABLET 1 - Covered NEDS Addition 03/01/ Updated 10/2018
5 vigabatrin 500 mg powder packet POWD PACK 1 - Covered LA, NEDS Addition 03/01/2018 VYXEOS 44 MG-100 MG VIAL VIAL 1 - Covered PA, NEDS Addition 03/01/2018 XATMEP 2.5 MG/ML ORAL SOLUTION SOLUTION 1 - Covered Addition 03/01/2018 ALUNBRIG 180 MG TABLET TABLET 1 - Covered NEDS Addition 04/01/2018 ALUNBRIG 90 MG TABLET TABLET 1 - Covered NEDS Addition 04/01/2018 ALUNBRIG 90 MG-180 MG TAB PACK TAB DS PK 1 - Covered NEDS Addition 04/01/2018 doripenem 500 mg vial VIAL 1 - Covered Addition 04/01/2018 ELIQUIS 5 MG STARTER PACK TAB DS PK 1 - Covered QL: 74/30 DAYS Addition 04/01/2018 EMFLAZA 18 MG TABLET TABLET 1 - Covered PA, NEDS Addition 04/01/2018 EMFLAZA MG/ML ORAL SUSP ORAL SUSP 1 - Covered PA, NEDS Addition 04/01/2018 EMFLAZA 30 MG TABLET TABLET 1 - Covered PA, NEDS Addition 04/01/2018 EMFLAZA 36 MG TABLET TABLET 1 - Covered PA, NEDS Addition 04/01/2018 EMFLAZA 6 MG TABLET TABLET 1 - Covered PA, NEDS Addition 04/01/2018 estradiol 0.01% cream CREAM/APPL 1 - Covered Addition 04/01/2018 HERCEPTIN 150 MG VIAL VIAL 1 - Covered PA, NEDS Addition 04/01/2018 ROWEEPRA XR 500 MG TABLET TAB ER 24H 1 - Covered QL: 240/30 DAYS Addition 04/01/2018 ROWEEPRA XR 750 MG TABLET TAB ER 24H 1 - Covered QL: 150/30 DAYS Addition 04/01/2018 levonor-eth estrad TABLET 1 - Covered Addition 04/01/2018 LYRICA CR 82.5 MG TABLET TAB ER 24H 1 - Covered QL: 90/30 DAYS, PA Addition 04/01/2018 LYRICA CR 165 MG TABLET TAB ER 24H 1 - Covered QL: 90/30 DAYS, PA Addition 04/01/2018 LYRICA CR 330 MG TABLET TAB ER 24H 1 - Covered QL: 60/30 DAYS, PA Addition 04/01/ Updated 10/2018
6 QVAR REDIHALER 40 MCG HFA AEROBA 1 - Covered QL: 21.2/30 DAYS Addition 04/01/2018 QVAR REDIHALER 80 MCG HFA AEROBA 1 - Covered QL: 21.2/30 DAYS Addition 04/01/2018 RESTASIS MULTIDOSE 0.05% EYE DROPS 1 - Covered QL: 5.5/28 DAYS Addition 04/01/2018 SELZENTRY 20 MG/ML ORAL SOLN SOLUTION 1 - Covered Addition 04/01/2018 SHINGRIX VIAL KIT KIT 1 - Covered Addition 04/01/2018 abacavir 20 mg/ml solution SOLUTION 1 - Covered Addition 05/01/2018 BIKTARVY MG TABLET TABLET 1 - Covered QL: 30/30 DAYS Addition 05/01/2018 efavirenz 600 mg tablet TABLET 1 - Covered QL: 30/30 DAYS Addition 05/01/2018 ENDARI 5 GRAM POWDER PACKET POWD PACK 1 - Covered QL: 180/30 DAYS, PA, LA, NEDS Addition 05/01/2018 ERLEADA 60 MG TABLET TABLET 1 - Covered NEDS Addition 05/01/2018 haloperidol lac 5 mg/ml syringe SYRINGE 1 - Covered Addition 05/01/2018 isotretinoin 10 mg capsule CAPSULE 1 - Covered Addition 05/01/2018 isotretinoin 20 mg capsule CAPSULE 1 - Covered Addition 05/01/2018 isotretinoin 30 mg capsule CAPSULE 1 - Covered Addition 05/01/2018 isotretinoin 40 mg capsule CAPSULE 1 - Covered Addition 05/01/2018 levono-e estrad TBDSPK 3MO 1 - Covered Addition 05/01/2018 memantine ER 14 mg capsule CAP SPR Covered QL: 30/30 DAYS Addition 05/01/2018 memantine ER 21 mg capsule CAP SPR Covered QL: 30/30 DAYS Addition 05/01/2018 memantine ER 28 mg capsule CAP SPR Covered QL: 30/30 DAYS Addition 05/01/2018 memantine ER 7 mg capsule CAP SPR Covered QL: 30/30 DAYS Addition 05/01/2018 naloxone 0.4 mg/ml carpuject SYRINGE 1 - Covered Addition 05/01/ Updated 10/2018
7 trientine hcl 250 mg capsule CAPSULE 1 - Covered QL: 240/30 DAYS Addition 05/01/2018 VIDEX EC 125 MG CAPSULE CAPSULE DR 1 - Covered QL: 60/30 DAYS Addition 05/01/2018 ADMELOG 100 UNIT/ML VIAL VIAL 1 - Covered QL: 40/30 DAYS Addition 06/01/2018 ADMELOG SOLOSTAR 100 UNIT/ML INSULIN PEN 1 - Covered QL: 45/30 DAYS Addition 06/01/2018 ALIMTA 100 MG VIAL VIAL 1 - Covered PA, NEDS Addition 06/01/2018 DALIRESP 250 MCG TABLET TABLET 1 - Covered Addition 06/01/2018 DEPO-MEDROL 20 MG/ML VIAL VIAL 1 - Covered Addition 06/01/2018 DEPO-MEDROL 40 MG/ML VIAL VIAL 1 - Covered Addition 06/01/2018 DEPO-MEDROL 80 MG/ML VIAL VIAL 1 - Covered Addition 06/01/2018 FABRAZYME 5 MG VIAL VIAL 1 - Covered NEDS Addition 06/01/2018 FIASP 100 UNIT/ML VIAL VIAL 1 - Covered QL: 40/30 DAYS Addition 06/01/2018 flunisolide 0.025% spray SPRAY 1 - Covered Addition 06/01/2018 GLATOPA 40 MG/ML SYRINGE SYRINGE 1 - Covered NEDS Addition 06/01/2018 ILARIS 150 MG/ML VIAL VIAL 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 140 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 280 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 420 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 560 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 IMBRUVICA 70 MG CAPSULE CAPSULE 1 - Covered NEDS Addition 06/01/2018 INTRON A 25 MILLION UNIT/2.5ML VIAL 1 - Covered NEDS Addition 06/01/2018 ISENTRESS HD 600 MG TABLET TABLET 1 - Covered QL: 60/30 DAYS Addition 06/01/ Updated 10/2018
8 KELNOR 1-50 TABLET TABLET 1 - Covered Addition 06/01/2018 lamotrigine 25 mg tab start kit TAB DS PK 1 - Covered Addition 06/01/2018 lamotrigine tab start kit-blue TAB DS PK 1 - Covered Addition 06/01/2018 lamotrigine tab start kit-green TAB DS PK 1 - Covered Addition 06/01/2018 lamotrigine tab start kit-orang TAB DS PK 1 - Covered Addition 06/01/2018 levoleucovorin 50 mg vial VIAL 1 - Covered PA Addition 06/01/2018 levonor-eth estrad TBDSPK 3MO 1 - Covered Addition 06/01/2018 ORFADIN 20 MG CAPSULE CAPSULE 1 - Covered NEDS Addition 06/01/2018 PLEGRIDY SYRINGE STARTER PACK SYRINGE 1 - Covered NEDS Addition 06/01/2018 ritonavir 100 mg tablet TABLET 1 - Covered QL: 360/30 DAYS Addition 06/01/2018 RUBRACA 250 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 SYLVANT 400 MG VIAL VIAL 1 - Covered PA, NEDS Addition 06/01/2018 SYMFI LO MG TABLET TABLET 1 - Covered QL: 30/30 DAYS Addition 06/01/2018 tiagabine hcl 12 mg tablet TABLET 1 - Covered QL: 120/30 DAYS Addition 06/01/2018 tiagabine hcl 16 mg tablet TABLET 1 - Covered QL: 90/30 DAYS Addition 06/01/2018 triamcinolone 200 mg/5 ml vial VIAL 1 - Covered Addition 06/01/2018 triamcinolone 400 mg/10 ml VIAL 1 - Covered Addition 06/01/2018 triamcinolone acet 40 mg/ml VIAL 1 - Covered Addition 06/01/2018 VIRAMUNE 50 MG/5 ML SUSP ORAL SUSPENSION 1 - Covered Addition 06/01/2018 ZYTIGA 500 MG TABLET TABLET 1 - Covered NEDS Addition 06/01/2018 benznidazole 100 mg tablet TABLET 1 - Covered Addition 07/01/ Updated 10/2018
9 benznidazole 12.5 mg tablet TABLET 1 - Covered Addition 07/01/2018 OCELLA 3 MG-0.03 MG TABLET TABLET 1 - Covered Addition 07/01/2018 SYEDA 28 TABLET TABLET 1 - Covered Addition 07/01/2018 FIASP 100 UNIT/ML FLEXTOUCH INSULIN PEN 1 - Covered QL: 45/30 DAYS Addition 07/01/2018 GLYXAMBI 10 MG-5 MG TABLET TABLET 1 - Covered Addition 07/01/2018 GLYXAMBI 25 MG-5 MG TABLET TABLET 1 - Covered Addition 07/01/2018 HUMIRA 10 MG/0.1 ML SYRINGE SYRINGEKIT 1 - Covered PA, NEDS Addition 07/01/2018 HUMIRA 40 MG/0.4 ML SYRINGE SYRINGEKIT 1 - Covered PA, NEDS Addition 07/01/2018 HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT 1 - Covered PA, NEDS Addition 07/01/2018 HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT 1 - Covered PA, NEDS Addition 07/01/2018 HUMIRA 40 MG/0.4 ML PEN PEN IJ KIT 1 - Covered PA, NEDS Addition 07/01/2018 levonor-eth estrad mg TABLET 1 - Covered Addition 07/01/2018 TRI-VYLIBRA 28 TABLET TABLET 1 - Covered Addition 07/01/2018 VYLIBRA 28 TABLET TABLET 1 - Covered Addition 07/01/2018 TASIGNA 50 MG CAPSULE CAPSULE 1 - Covered NEDS Addition 07/01/2018 TOUJEO MAX SOLOSTAR 300 UNIT/ML INSULIN PEN 1 - Covered QL: 18/30 DAYS Addition 07/01/2018 AIMOVIG 140 MG DOSE-2 AUTOINJ AUTO INJCT 1 - Covered QL: 2/28 DAYS, PA Addition 08/01/2018 AIMOVIG 70 MG/ML AUTOINJECTOR AUTO INJCT 1 - Covered QL: 2/28 DAYS, PA Addition 08/01/2018 baclofen 5 mg tablet TABLET 1 - Covered Addition 08/01/2018 buprenorp-nalox 8-2 mg SL film FILM 1 - Covered QL: 60/30 DAYS Addition 08/01/2018 colesevelam 625 mg tablet TABLET 1 - Covered Addition 08/01/ Updated 10/2018
10 HUMIRA 20 MG/0.2 ML SYRINGE SYRINGEKIT 1 - Covered PA, NEDS Addition 08/01/2018 ESTARYLLA MG TABLET TABLET 1 - Covered Addition 08/01/2018 MILI MG TABLET TABLET 1 - Covered Addition 08/01/2018 TRI-MILI 28 TABLET TABLET 1 - Covered Addition 08/01/2018 NORVIR 100 MG POWDER PACKET POWD PACK 1 - Covered QL: 360/30 DAYS Addition 08/01/2018 SYMFI MG TABLET TABLET 1 - Covered QL: 30/30 DAYS Addition 08/01/2018 SYNJARDY XR 10-1,000 MG TABLET TAB BP 24H 1 - Covered QL: 60/30 DAYS Addition 08/01/2018 SYNJARDY XR ,000 MG TABLET TAB BP 24H 1 - Covered QL: 60/30 DAYS Addition 08/01/2018 SYNJARDY XR 25-1,000 MG TABLET TAB BP 24H 1 - Covered QL: 30/30 DAYS Addition 08/01/2018 SYNJARDY XR 5-1,000 MG TABLET TAB BP 24H 1 - Covered QL: 60/30 DAYS Addition 08/01/2018 ARNUITY ELLIPTA 50 MCG INH BLST W/DEV 1 - Covered QL: 30/30 DAYS Addition 09/01/2018 budesonide er 9 mg tablet TABDR - ER 1 - Covered Addition 09/01/2018 estradiol-noreth mg tab TABLET 1 - Covered Addition 09/01/2018 estradiol-noreth mg tab TABLET 1 - Covered Addition 09/01/2018 KUVAN 500 MG POWDER PACKET POWD PACK 1 - Covered NEDS Addition 09/01/2018 LUCEMYRA 0.18 MG TABLET TABLET 1 - Covered QL: 16/1 DAY, PA Addition 09/01/2018 miglustat 100 mg capsule CAPSULE 1 - Covered NEDS Addition 09/01/2018 MONO-LINYAH 28 TABLET TABLET 1 - Covered Addition 09/01/2018 oxacillin 1 gm add-vantage vial VIAL PORT 1 - Covered Addition 09/01/2018 oxacillin 1 gm vial VIAL 1 - Covered Addition 09/01/2018 YONSA 125 MG TABLET TABLET 1 - Covered NEDS Addition 09/01/ Updated 10/2018
11 CIMDUO MG TABLET TABLET 1 - Covered QL: 30/30 DAYS Addition 10/01/2018 MYORISAN 10 MG CAPSULE CAPSULE 1 - Covered Addition 10/01/2018 MYORISAN 20 MG CAPSULE CAPSULE 1 - Covered Addition 10/01/2018 MYORISAN 30 MG CAPSULE CAPSULE 1 - Covered Addition 10/01/2018 MYORISAN 40 MG CAPSULE CAPSULE 1 - Covered Addition 10/01/2018 ORKAMBI MG GRANULE PKT GRAN PACK 1 - Covered PA, NEDS Addition 10/01/2018 ORKAMBI MG GRANULE PKT GRAN PACK 1 - Covered PA, NEDS Addition 10/01/2018 clobazam 10 mg tablet TABLET 1 - Covered QL: 60/30 DAYS Addition 11/01/2018 clobazam 2.5 mg/ml suspension ORAL SUSP 1 - Covered QL: 480/30 DAYS Addition 11/01/2018 clobazam 20 mg tablet TABLET 1 - Covered QL: 60/30 DAYS Addition 11/01/2018 dalfampridine er 10 mg TAB ER 12H 1 - Covered NEDS Addition 11/01/2018 ertapenem 1 gram vial VIAL 1 - Covered Addition 11/01/2018 HUMIRA PEN CROHN-UC-HS 80 MG PEN IJ KIT 1 - Covered PA, NEDS Addition 11/01/2018 HUMIRA PEN PSOR-UVEI 80 MG-40 MG PEN IJ KIT 1 - Covered PA, NEDS Addition 11/01/2018 itraconazole 10 mg/ml solution SOLUTION 1 - Covered Addition 11/01/2018 SYMTUZA MG TAB TABLET 1 - Covered QL: 30/30 DAYS Addition 11/01/2018 tadalafil 20 mg tablet TABLET 1 - Covered PA Addition 11/01/ Updated 10/2018
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
2018 Formulary Update
MEDICARE ADVANTAGE BlueShield of Northeastern New York Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January. This document
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
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
You ll find the most up-to-date comprehensive version of our formulary on our website, Click on Drug Finder.
3/1/2018 Medicare Part D Formulary Change In an effort to cover the most needed, cost-effective prescriptions, the AlohaCare Advantage Plus (HMO SNP) Formulary is updated monthly. The following are drugs
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
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
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
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
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
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
UPHP Advantage (HMO) (H ) and UPHP Choice (HMO) (H ) Updates
March, 2018 03/01/2018 clindacin p clindamycin phosphate 03/01/2018 glatiramer acetate 03/01/2018 glatiramer acetate 03/01/2018 oseltamivir phosphate 03/01/2018 oseltamivir phosphate 03/01/2018 ADACEL
Blue Shield 65 Plus Choice Plan (HMO) Blue Shield of California is an independent member of the Blue Shield Association. Formulary Updates:
Blue Shield 65 Plus Choice Plan (HMO) Formulary Updates: The enclosed table lists the changes made to your formulary such as removing or adding: a drug, prior authorization, quantity limits or step therapy
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
Upper Peninsula MI Health Link Updates
January, 2018 01/01/2018 TAMIFLU oseltamivir phosphate CHANGE UM: QUANTITY 720 / 365 days 720 / 365 OVER 01/01/2018 oseltamivir phosphate 01/01/2018 oseltamivir phosphate 01/01/2018 oseltamivir phosphate
HAP/Midwest Health Advantage MI Health Link (MMP) Updates
January, 2018 01/01/2018 hydrocortisone butyrate hydrocortisone butyrate 01/01/2018 MIRVASO brimonidine tartrate 01/01/2018 AZACTAM aztreonam 01/01/2018 AZACTAM aztreonam 01/01/2018 mesalamine mesalamine
Blue Shield Rx Enhanced (PDP) Formulary Updates:
Blue Shield Rx Enhanced (PDP) Formulary Updates: The enclosed table lists the changes made to your such as removing or adding: a drug, prior authorization, quantity limits or step therapy as well as any
Blue Shield 65 Plus (HMO) Formulary Updates:
Blue Shield 65 Plus (HMO) Updates: The enclosed table lists the changes made to your such as removing or adding: a drug, prior authorization, quantity limits or step therapy as well as any changes to a
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
Emblem Medicaid 3Q18 Formulary Updates
ALKERAN 2 MG TABLET Removed from Formulary 7/9/2018 AMITIZA 24 MCG CAPSULES Removed from Formulary 7/9/2018 AMITIZA 8 MCG CAPSULE Removed from Formulary 7/9/2018 avo cream topical emulsion Removed from
Quarterly pharmacy formulary change notice
Provider update Quarterly pharmacy formulary change notice Summary: The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018, Pharmacy and Therapeutics Committee
Quarterly pharmacy formulary change
Medi-Cal Managed Care L. A. Care Major Risk Medical Insurance Program Provider Bulletin The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018 Pharmacy and
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
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
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Provider update Summary: The formulary changes listed in the table below were reviewed and approved at our second quarter 2018, Pharmacy and Therapeutics Committee
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
EFFECTIVE 01/05/2018. atazanavir sulfate 150 mg capsule - Added to Tier 1 TYPHIM VI 25 MCG/0.5 ML VIAL. - Added to Tier 2
EFFECTIVE 01/05/2018 atazanavir sulfate 150 mg capsule TYPHIM VI 25 MCG/0.5 ML VIAL typhoid vaccine vi capsular polysaccharide atazanavir sulfate 200 mg capsule atazanavir sulfate 300 mg capsule PAGE 1
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
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
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
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
AETNA BETTER HEALTH January 2017 Formulary Change(s)
AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on February 1, 2017 Drug Name, Strength, Dosage Form IVERMECTIN 3 MG TABLET
2018 OPEN FORMULARY Updates
January, 2018 01/01/2018 OPDIVO nivolumab 01/01/2018 KEVZARA sarilumab 01/01/2018 KEVZARA sarilumab 01/01/2018 AIMOVIG AUTOINJECTOR,AIMOVIG AUTOINJECTOR (2 PACK) erenumab-aooe 01/02/2018 glucose in water
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
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
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG
These programs and quantity limitations may not apply. Check your certificate or other plan information for benefit details.
FlexRx Standard Utilization Management (PA, QL,) Updates January 1, 2018 How to use this drug list This drug list includes updates to Utilization Management (UM) programs. UM may include a prior authorization
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
Reason for change. Recently approved. Recently approved. Recently approved. Recently approved. Recently updated. Recently approved.
2017 Formulary Change Notice Please note these changes to your 2017 List of Covered Drugs Drug name (medication) Rubraca Aprepitant Onivyde Oseltamivir Restasis Xiidra Daptomycin Selzentry Linzess Butalb/APAP/caff
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;
AETNA BETTER HEALTH January 2017 Formulary Change(s)
AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 Drug Name, Strength, Dosage Form ALFUZOSIN HCL ER 10
TennCare Program TN MAC Price Change List As of: 03/30/2017
1 TN List Run : 03/30/17 Old PRAZOSIN HCL 5 MG CAPSULE ORAL 03/29/2017 1.11209 1.12560 ( 1.2) CAPTOPRIL 12.5 MG TABLET ORAL 07/07/2015 1.07191 1.10416 ( 2.9) ISOSORBIDE DINITRATE 5 MG TABLET ORAL 03/29/2017
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. NOTIFICATION OF FORMULARY CHANGES
NOTIFICATION OF FORMULARY CHANGES The following summary describes changes to the Presbyterian Commercial Large Group Plans (Non-Metal Plans) Formularies effective 2018. For the most recent list of drugs,
2019 Formulary Update
MEDICARE ADVANTAGE BlueShield of Northeastern New York Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January. This document
Quarterly pharmacy formulary change notice
Provider Bulletin April 2018 This table is used by HealthKeepers, Inc. to indicate formulary changes applicable to all Anthem HealthKeepers Plus members. These changes were reviewed and approved at the
Updates to your prescription benefits
Updates to your prescription benefits Effective January 1, 2019 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
BlueLink TPA FlexRx Updates
BlueLink TPA FlexRx Updates April 2018 TRADE NAME (generic name) or generic name abacavir sulfate soln 20 mg/ml (base equiv) Generic Addition, generic for ZIAGEN alclometasone dipropionate cream 0.05%
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
Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. NOTIFICATION OF FORMULARY CHANGES
NOTIFICATION OF FORMULARY CHANGES The following summary describes changes to the 2017 Presbyterian Individual and Family Metal Plan/Employer Group Metal Plan Formularies effective 2018. For the most recent
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
EFFECTIVE 01/04/2019. pimecrolimus 1 % cream (g) - Added to Tier 1 - ST Added: TOPICAL IMMUNOMODULATORS
EFFECTIVE 01/04/2019 pimecrolimus 1 % cream (g) - ST Added: TOPICAL IMMUNOMODULATORS PAGE 1 LAST UPDATED 03/2019 EFFECTIVE 01/05/2019 LORBRENA 100 MG TABLET lorlatinib LORBRENA 25 MG TABLET lorlatinib
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
EFFECTIVE 01/02/2018 TYPHIM VI 25 MCG/0.5 ML VIAL. - Added to Tier 1. typhoid vaccine vi capsular polysaccharide
EFFECTIVE 01/02/2018 TYPHIM VI 25 MCG/0.5 ML VIAL typhoid vaccine vi capsular polysaccharide PAGE 1 LAST UPDATED 09/2018 EFFECTIVE 01/05/2018 atazanavir sulfate 150 mg capsule atazanavir sulfate 200 mg
Neighborhood Medicaid Formulary Changes: June 2017
Neighborhood Medicaid Formulary Changes: June 2017 The following changes to the Neighborhood Medicaid Formulary were recently approved by the Pharmacy and Therapeutics (P&T) Committee. All changes were
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
March 2018 P & T Updates
March 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AURYXIA 3 2 12 tablets per BAXDELA TABLETS 3 2 2 tablets per Depending on your specific benefits and in which
HEALTH SHARE/PROVIDENCE (OHP)
HEALTH SHARE/PROVIDENCE (OHP) STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered
JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
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
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates
Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates April 2018 TRADE NAME (generic name) or generic name Brand/Generic Description of Change abacavir sulfate soln 20 mg/ml (base equiv) Generic
Drug Name Description of Change Formulary Coverage Formulary Alternative(s)
NOTIFICATION OF FORMULARY CHANGES The following summary describes changes to the Presbyterian Centennial Care Formulary effective 2018. For the most recent list of drugs, information on asking for a prior
September 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 UCare (approved drug list). These changes are reviewed based
Quarterly pharmacy formulary change notice
Provider Bulletin June 2017 The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. These changes were reviewed and approved at the first quarter Pharmacy and Therapeutics
WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions
WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions ANORO ELLIPTA 62.5-25MCG BLST W/DEV INHALATION ARCAPTA NEOHALER 75 MCG CAP W/DEV INHALATION CALCIPOTRIENE
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
Updates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2019 Traditional Three-Tier PDL Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount
Quarterly pharmacy formulary change notice
MEDICAID PROVIDER BULLETIN March 2019 Quarterly pharmacy formulary change notice The formulary changes listed in the table below were reviewed and approved at the fourth quarter pharmacy and therapeutics
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Summary of change: The Pharmacy and Therapeutics Committee (P&T) reviewed and approved the formulary changes listed in the table below on March 29, 2016. What
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
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
Emblem Medicaid 4th Quarter Formulary Updates
abacavir 20 mg/ml solution Added to Formulary (generic) with Quantity Limits 12/1/2017 abacavir 300 mg tablet Added Quantity Limits 10/1/2017 abacavir-lamivudine 600-300 mg Added Quantity Limits 10/1/2017
2017 Medicare Part D Formulary Change
2017 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
March 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
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
2017 Medicare Part D Formulary Change
2017 Medicare Part D 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 restrictions
Quarterly pharmacy formulary change notice
Provider Bulletin June 24, 2016 Summary of change The Pharmacy and Therapeutics Committee reviewed and approved the formulary changes listed in the table below on March 29, 2016. What this means to you
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
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
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
2018 Step Therapy (ST) Criteria
2018 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a
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
San Francisco Health Plan (SFHP)
San Francisco Health Plan (SFHP) The following changes to SFHP formulary and prior authorization criteria were reviewed and approved by the SFHP Pharmacy and Therapeutics (P&T) Committee on 07/18/2018.
2017 Medicare Part D Formulary Change
2017 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
Peach State Health Plan routinely reviews the medications available on the Preferred Drug
Effective date: December 27, 2016 Peach State Health Plan Preferred Drug List (PDL) Updates Q4 2016 Peach State Health Plan routinely reviews the medications available on the Preferred Drug List (PDL).
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,
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
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
Formulary Change Notice
Formulary Change Notice HealthPartners may remove drugs from our formulary (list of covered drugs) or add rules about whether and when certain drugs are covered during the year. The chart below contains
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
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,
2017 Medicare Part D Formulary Change
2017 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
Step Therapy Requirements. Effective: 05/01/2018
Step Therapy Requirements Effective: 05/01/2018 ANTIDEPRESSANTS TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK VIIBRYD 10 MG
Nebraska Medicaid Program NE Weekly MAC Price Change List For Period: 12/14/ /20/2017
1 Medicaid Run : 12/21/17 NE Weekly List Old AMIODARONE HCL 200 MG TABLET ORAL 12/20/2017 0.15321 0.14370 6.6 HYDRALAZINE HCL 10 MG TABLET ORAL 12/20/2017 0.05226 0.05213 0.2 LISINOPRIL 10 MG TABLET ORAL
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
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
PRESCRIPTION SAVINGS CLUB FLAT- PRICED GENERIC DRUG LIST (EMDEON) Effective August 20, 2014
PRESCRIPTION SAVINGS CLUB FLAT- PRICED GENERIC DRUG LIST (EMDEON) Effective August 20, 2014 The Prescription Savings Club provides its members with significant savings on prescription medications. The
Mercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
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