Enclosed you will find updates for 2018 to the SummaCare Comprehensive Formulary for Small Group and Individual plans.
|
|
|
- Barnaby Jackson
- 6 years ago
- Views:
Transcription
1 February 2018 Dear SummaCare Member, Enclosed you will find updates for 2018 to the SummaCare Comprehensive Formulary for Small Group and Individual plans. New for 2018! Members are now able to get many preventive vaccines at their retail pharmacy for a zero dollar copay. Please refer to the formulary for a complete listing of covered vaccines and restrictions. Effective 1/1/2018 a new opioid edit has been put into place in correspondence with Ohio Senate Bill 319. Members with prescriptions for opioids that meet the following criteria may be stopped at the point of service and require Prior Authorization (PA): o The members total cumulative Morphine Equivalent Dose (MED) is 80 mg or greater; o The member continues an opioid medication for more than 90 days; or o The member is being treated with a benzodiazepine at the time an opioid analgesic is prescribed. There are several ways to save on your key medications in 2018: Members can utilize our Mail Order Pharmacy for additional savings and convenience. Please refer to your member handbook for specific copay information. Members can purchase a 90-day supply of generic medications at their retail pharmacy. This allows members to enjoy the convenience of filling a 90-day prescription while taking advantage of generic discounts at retail pharmacies. Please note: Since benefits and formularies differ among plans, please refer to your benefit materials to see which formulary applies to your plan and if these programs are included in your plan. If your pharmacy benefit has a deductible, this benefit may apply only after the deductible is met. Visit for all formulary updates along with comprehensive information regarding the tier status, applicable limitations and possible alternatives for all covered drugs. The 2018 formulary can be located by clicking on the Find a Drug button on the right-hand side of the homepage. If you have any questions about your pharmacy benefit or would like a copy of the formulary that applies to your plan, please contact Customer Service at the number listed on the back of your SummaCare ID card. For persons with hearing and/or speech disabilities, please call Thank you for being a SummaCare member. Tiffanie Swartz, Pharm.D. Pharmacy Director Enclosure
2 2018 SummaCare Comprehensive Formulary Changes Formulary Tier Changes **Please refer to the comprehensive formulary document posted on the SummaCare website, to determine if any of the drugs listed below have utilization management (i.e. Prior Authorization, Step Therapy, Quantity Limits) requirements. Prior Authorization = PA Step Therapy = ST Quantity Limits = QL Non-Formulary = The drug is not covered on the 2018 formulary ABOUT 2018 TIERS Prescription Drug Tier Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6 Description Zero Cost Share Preventive Drugs (This tier will contain low cost medications that may be preferred generic, single source, or multi-source Brand Drugs.) Preferred Generics Non-Preferred Generics Preferred Brand Non-Preferred Brand Specialty Drugs The list below represents the changes made for the 2018 Plan Year. These formulary changes are for the 2018 SummaCare Comprehensive Drug Formulary only. Because benefits and formularies vary, please refer to your benefit documents to see if these programs/restrictions are included in your plan. If your pharmacy benefit has a deductible, benefits may apply only after the deductible is met. Tier 1 w/ QL XULANE NUVARING Tier 2 CHLOROQUINE PHOSPHATE CLOBETASOL PROPIONATE CLOZAPINE MINOCYCLINE HCL SULFACETAMIDE SODIUM/SULFUR TRETINOIN TRETINOIN/EMOLLIENT BASE Tier 2 w/ PA TESTOSTERONE CYPIONATE Tier 2 w/ QL ALENDRONATE SODIUM DEXTROAMPHETAMINE/AMPHET AMINE DIDANOSINE DOXYCYCLINE HYCLATE DOXYCYCLINE MONOHYDRATE ERGOTAMINE TARTRATE/CAFFEINE ESTRADIOL EZETIMIBE FELBAMATE GALANTAMINE HBR HYDROCODONE/ACETAMINOPHE MEMANTINE HCL MEPERIDINE HCL METHADONE HCL METHYLPHENIDATE HCL NEVIRAPINE OLANZAPINE OLANZAPINE/FLUOXETINE HCL OXYCODONE /ACETAMINOPHEN PRAMIPEXOLE DI HCL QUETIAPINE FUMARATE RASAGILINE MESYLATE RISPERIDONE STAVUDINE
3 TESTOSTERONE ENANTHATE ZIDOVUDINE ZIPRASIDONE HCL Tier 3 ADAPALENE AMCINONIDE AMLODIPINE/ATORVASTATIN ANAGRELIDE HCL BROMFENAC SODIUM BUTALB/ACETAMIN/CAFFEINE BUTALB/ACETAMIN/CAFF/CODEIN BUTALBITAL/ASPIRIN/CAFFEINE CAPTOPRIL CAPTOPRIL/HYDROCHLOROTHIAZI CEVIMELINE HCL CHLORPROPAMIDE CICLOPIROX SHAMPOO CICLOPIROX GEL CLINDAMYCIN/BENZOYL PEROX CLINDAMYCIN PHOSPHATE CLOTRIMAZOLE/BETAMETHAS DIP CODEINE/BUTALBITAL/ASA/CAFFE DOXYCYCLINE HYCLATE TAB DOXYCYCLINE MONOHYDRA CAP ECONAZOLE NITRATE ENOXAPARIN SODIUM ETIDRONATE DISODIUM FAMOTIDINE FENOFIBRATE FENOPROFEN CALCIUM FLUOCINONIDE INDOMETHACIN LAMIVUDINE/ZIDOVUDINE LIDOCAINE MALATHION MEFENAMIC ACID MEPROBAMATE METHAZOLAMIDE MINOCYCLINE HCL NADOLOL NADOLOL/BENDROFLUMETHIAZID NAPROXEN SODIUM NISOLDIPINE NITROFURANTOIN NITROGLYCERIN NYSTATIN/TRIAMCIN OXAPROZIN PIOGLITAZONE HCL/METFORMIN PIROXICAM PROPRANOLOL HCL TIMOLOL MALEATE TOLAZAMIDE TOLMETIN SODIUM TRIMETHOBENZAMIDE HCL TROSPIUM CHLORIDE VORICONAZOLE Tier 3 w/ QL ABACAVIR ADAPALENE BENZOYL PEROXIDE ANDROXY BUDESONIDE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMI AMPHET ER DOXYCYCLINE IR DR DRONABINOL DULOXETINE HCL ESTRADIOL FENTANYL FLUVASTATIN SODIUM FLUVOXAMINE MALEATE ER GALANTAMINE ER GRANISETRON HCL GRANISOL HYDROCODONE ACETAMINO LAMIVUDINE LAMOTRIGINE ER LAMOTRIGINE ODT LANSOPRAZ AMOX CLARITHRO METHYLPHENIDATE ER METHYLPHENIDATE HCL CD MOLINDONE HCL MOMETASONE FUROATE MORPHINE SULFATE ER NEVIRAPINE ER OLOPATADINE HCL OMEGA 3 ACID ETHYL ESTERS OXYMORPHONE HCL ER PRAMIPEXOLE ER PRASUGREL HCL RISEDRONATE SODIUM RISEDRONATE SODIUM DR RIVASTIGMINE ROPINIROLE ER TIAGABINE HCL TOLCAPONE TRIAMCINOLONE ACETONIDE VANCOMYCIN HCL VIGABATRIN ZIAGEN Tier 3 w/ PA & QL DOXYCYCLINE HYCLATE TAB METHYLTESTOSTERONE TESTOSTERONE GEL TESTOSTERONE PMP Tier 3 w/ ST & QL TOLTERODINE TARTRATE Tier 4 OTREXUP Tier 4 w/ PA LYRICA Tier 4 w/ QL ATROVENT HFA BANZEL CLIMARA PRO EMTRIVA GABITRIL JANUMET JANUMET XR JANUVIA LINZESS MENOSTAR NORVIR PATADAY TRAVATAN Z VIDEX Tier 4 w/ PA & QL VIMPAT Tier 5 DEXPAK BEYAZ MINASTRIN 24 FE
4 Tier 5 w/ QL ALORA AMITIZA BREO ELLIPTA BRILINTA COMBIPATCH DAYTRANA EDURANT EFFIENT EMADINE EMSAM EPIDUO EPIDUO FORTE ERGOMAR FELBATOL GEODON LAMICTAL LAMICTAL ODT LAMICTAL XR MIGERGOT MINIVELLE MIRVASO NAMENDA XR ORTHO EVRA PRIMLEV RESCULA RISPERDAL RISPERDAL M TAB ROZEREM SABRIL SEROQUEL SILENOR TRADJENTA VIIBRYD ZAMICET ZELAPAR ZENZEDI ZIOPTAN ZONTIVITY ZYCLARA ZYPREXA ZYPREXA ZYDIS Tier 5 w/ PA & QL ANDROGEL ANDRODERM AXIRON METHITEST STRIANT Tier 5 w/ ST ENSTILAR Tier 5 w/ ST & QL PRADAXA TANZEUM Tier 6 ALOSETRON HCL Tier 6 w/ QL APTIVUS KALETRA REYATAZ SELZENTRY Tier 6 w/ PA & QL CUPRIMINE DEPEN DARAPRIM RELISTOR Tier 6 w/ PA NEUPOGEN ORFADIN Non Formulary ABSTRAL ALTOPREV AMRIX ANDROID ANTARA APLENZIN ASACOL HD ATELVIA AZILECT AZOR BENICAR BENICAR HCT BENZACLIN BENZAMYCIN BINOSTO CAFERGOT CHILDREN'S ADVIL CODEINE SULFATE COPEGUS CORDARONE CORDRAN CRESTOR CYCLOBENZAPRINE HCL DDAVP DEXEDRINE DICLOFENAC SODIUM DILAUDID DISKETS DORYX DUEXIS DUTOPROL EDECRIN EDLUAR EMEND ENABLEX EPIPEN EPIPEN 2 PAK EPIPEN JR 2 PAK ESGIC PLUS FEMHRT FENOFIBRATE FENTORA FLUVASTATIN ER FOCALIN XR FORFIVO XL FROVA GLYSET GRALISE HORIZANT JEVANTIQUE LO KADIAN KAZANO LAZANDA LOVENOX MACRODANTIN MAGNACET M CLEAR WC METHADOSE MONDOXYNE NL MORGIDOX MORPHINE SULFATE ER NAPRELAN NAPROXEN SODIUM CR NASONEX NESINA NITROLINGUAL NITROMIST
5 NITROSTAT NORITATE NUVIGIL OMEPRAZOLE SODIUM BICARBONATE ONSOLIS OSENI PERIOMED PEXEVA PHRENILIN FORTE PRAMOSONE PROMACET PRUDOXIN PULMICORT RAYOS REBETOL RIBATAB RILUTEK RITALIN LA SANDOSTATIN SPRIX SUBSYS SULAR SUPRAX TAMIFLU TIKOSYN TOBI TRIBENZOR VAGIFEM VALCYTE VELTIN VEREGEN VIMOVO VOLTAREN XENAZINE XOPENEX HFA ZEBUTAL ZEGERID ZETIA ZIANA ZILEUTON ER ZIPSOR ZOLPIMIST ZYBAN ZYFLO CR
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
High-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
High-Cost Drug Exclusions
Pharmacy Services High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
Enclosed you will find updates for 2018 to the SummaCare Commercial Drug Formulary.
February 2018 Dear SummaCare Member, Enclosed you will find updates for 2018 to the SummaCare Commercial Drug Formulary. New for 2018! Members are now able to get many preventive vaccines at their retail
Avoid paying too much for your prescriptions
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to
BLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES
BLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES Blue Shield is committed to covering safe, effective and affordable medications, so we regularly review and update our drug formularies.
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
1/1/2019 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS
1/1/2019 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS Effective 1/1/19, Cigna is making changes to our formularies that may impact medication coverage for customers at your pharmacy. We have included a
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
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
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
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
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
Health Net Health Plan of Oregon, Inc. Oregon Drugs with a quantity limit Effective January 1, 2015 (Published December 15, 2014)
Health Net Health Plan of Oregon, Inc. Oregon Drugs with a quantity limit Effective January 1, 2015 (Published December 15, 2014) Abstral SL Actonel 35mg Limited to 4 s per month. Actonel 5,30mg adapalene
2015 Step Therapy Prior Authorization Medical Necessity Guidelines
Tufts Health Unify 2015 Step Therapy Prior Authorization Medical Necessity Guidelines Effective: 01/01/2015 Updated: 10/01/2015 Tufts Health Plan P.O. Box 9194 Watertown, MA 02471-9194 Phone: 855-393-3154
2016 PRESCRIPTION DRUG LIST UPDATES
2016 PRESCRIPTION DRUG LIST UPDATES Evergreen Health 1 st Quarter Below are key updates to the four-tier EHB Prescription Formulary, effective January 1, 2016. Please consult the full formulary for more
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
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Generic Additions These generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the
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
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
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
207 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Plus Plan (HMO) H5087-002, H5087-07 This is a listing of the changes that have occurred in our formulary.
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
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
Step Therapy Medications
Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on
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
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
2017 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Best Plan (HMO) H5087-005 This is a listing of the changes that have occurred in our formulary. Please
SmithRx Standard Formulary Step Therapy List
SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations
TN Cover Rx Tennessee CoverRx MAC Price Change List As of: 04/26/2018
1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25
Step Therapy Group Algorithm Steps
Step Therapy Group Algorithm Steps ACTONEL AMITIZA ANTICONVULSANT ANTIDEPRESSION Previous trial on alendronate Step 1: ALENDRONATE SODIUM Step 2: RISEDRONATE SODIUM, RISEDRONATE SODIUM DR Previous trial
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
ATYPICAL ANTIPSYCHOTICS
Step Therapy CareOregon 2018 Last Updated: 07/27/2018 ATYPICAL ANTIPSYCHOTICS Fanapt Fanapt Titration Pack Paliperidone Er Vraylar The following criteria applies to members who newly start on the drug:
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
Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE
Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Drug List Changes - UPDATE Note: This article was previously published in the December 2014 Medicaid
Pharmacy Formulary Updates for January 2019
Pharmacy Formulary Updates for January 2019 To offer a pharmacy benefit that is clinically appropriate and cost effective, we constantly review how we cover prescription medications. Periodic adjustments
2013 Step Therapy (ST) Criteria
2013 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
High-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
ABILIFY ABILIFY DISCMELT ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ADCIRCA ADVAIR DISKUS ADVAIR HFA
Quantity Limits Paramount Medicare Formulary 2012 Formulary ID 12112, Version 22. CMS Approved 10-23-2012. ABILIFY Abilify TABS ABILIFY DISCMELT Abilify Discmelt ACTONEL Actonel TABS 150MG Actonel TABS
AGGRENOX. Products Affected. Details. GRP B2 Last Updated: 09/01/2018. Aggrenox
GRP B2 Last Updated: 09/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 15 1 ANTICONVULSANTS
ADHD STIMULANTS-S(SHC)
Step Therapy Simply Health Care 2014 Formulary ID: 14406 Version: 14 Last Updated: 08/01/2014 ADHD STIMULANTS-S(SHC) Daytrana Focalin Xr Strattera Patient needs to have a paid claim for one Step 1 drug
Hospitality Rx Step Therapy
agents may not be a generic medication. Second line agent may not be a brand medication. Some Step Therapy category may require trial of more than one medication. CLINDAMYCIN/BENZOYL PEROX Acne Combo Antibiotic
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary October 1, 2018 Updates. Formulary. Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select October 1, 2018 Updates Drug Name efavirenz 600mg (Brand = Sustiva ) trientine (Brand = Syprine ) hydrocortisone lot 0.1% (Brand = Locoid ) sumatriptan-naproxen
ALLERGIC RHINITIS-NASAL
ALLERGIC RHINITIS-NASAL FLUNISOLIDE Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone Rx, fluticasone OTC, Budesonide OTC. Prior to filling the Step
2014 Preferred Drug List An evidence-based pharmacy program that works for you
2014 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed
Your prescription benefit updates Formulary Updates - Effective January 1, 2019
Your prescription benefit updates Formulary Updates - Effective January 1, 2019 Medications are grouped by the conditions they treat. Each medication is placed in a tier that shows the amount you will
AGGRENOX. Products Affected. Details. First Health Part D Value Plus (PDP) Last Updated: 10/01/2017. Aggrenox
First Health Part D Value Plus (PDP) Last Updated: 10/01/2017 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18059:
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
2014 Assurant Health Step Therapy Edits Created 11/04/2013; Effective 01/01/2014
2014 Assurant Health Step Therapy Edits Created 11/04/2013; Effective 01/01/2014 Drug Class Restricted Drug Pre-requisite Drugs (Try First) Acne Products Tretin-X topical tretinoin- must try Veltin AND
STEP THERAPY ALGORITHMS PUP Select Formulary
The Step Therapy drug will be dispensed if the drug has been dispensed within 120 days of current fill or if alternative (Step 1) drugs have been used first. If the member s prescription claim fails the
2013 Preferred Drug List An evidence-based pharmacy program that works for you
2013 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed
Drug Formulary Update, April 2017 Commercial and State Programs
Drug Formulary Update, April 2017 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
Lower your costs. Save money with preferred generic and preferred brand-name drugs 2018 Aetna Rx Step Program Medicine List
Call out bold Call out light Contact information, call X-XXX-XXX-XXXX or visit www.aetna.com Call to action small copy (especially related to mobile apps). Hendani adionse rferum faceatis incte voluptassi
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
Medication and Dose 10/04/ /05/2016 Total % Change Since 10/2012 ABILIFY 10 MG TABLET $18.76 $ %
Table Comparing NADAC prices for select brand name prescription medications on October 4, 2012 and October 5, 2016 to show how much prices have gone up for these medications. These medications increased
2013 Preferred Drug List An evidence-based pharmacy program that works for you
2013 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed
Prescription Step Therapy Program
Prescription Step Therapy Program 04HQ3972 R11/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross
2013 Preferred Drug List An evidence-based pharmacy program that works for you
2013 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed
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
Drug List exclusions for Blue Cross commercial plans
Drug List exclusions for Blue Cross commercial plans The drugs shown below aren t covered on the commercial Blue Cross Blue Shield of Michigan drug lists. In most cases, if you fill a prescription for
U T I L I Z A T I O N E D I T S
I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, 2 0 1 2 s for s Refer to Provider Bulletin BT200709 for additional information regarding the Mental
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017
Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2017 DRUG LIST CHANGES Based on the availability of new prescription medications and Prime s National Pharmacy and Therapeutics Committee
LABEL NAME CHANGE EFFECTIVE DATE ARCALYST 220 MG INJECTION
LABEL NAME CHANGE EFFECTIVE DATE ARCALYST 220 MG INJECTION Added Prior Authorization 7/1/17 CORLANOR 5 MG TABLET Added Prior Authorization 7/1/17 CORLANOR 7.5 MG TABLET Added Prior Authorization 7/1/17
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
Effective: 01/01/2017 Updated 11/2016 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA GABITRIL OXTELLAR XR POTIGA
ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY
South Country Health Alliance 2017 Step Therapy Formulary ID: 17431 Last Updated: 10/20/2017 Effective Date: 11-01-2017 ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY BENICAR 20 MG BENICAR 40 MG BENICAR 5
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
FORMULARY LIST OF COVERED DRUGS
FORMULARY LIST OF COVERED DRUGS 2018 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID 00018248, Version Number #3 This formulary
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
VIVA MEDICARE IMPORTANT T EXPANDED PERFORMANCE FORMULARY UPDATES
NORE/ETH/FER CHW 0.MG Added to the 07 //07 ALYACEN TAB / Added to the 07 //07 AMETHIA LO TAB Added to the 07 //07 ERGOT/CAFFEN TAB 00MG Added to the 07 //07 NORETH/ETHIN TAB /0 Added to the 07 //07 LORCET
Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List
Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List Drug Name Monthly Limit (30 days unless otherwise noted) abacavir 300 mg abacavir/lamivudine/zidovudine
Generics. Lead with. Prescription Step Therapy Program
Lead with Generics Prescription Step Therapy Program WWW.BCBSLA.COM 04HQ3972 R11/10 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company GENERIC DRUGS: A
Drug / Pregnancy Conflicts Excessive Daily Doses Ingredient Duplication Insufficient Daily Doses
Drug Utilization Review (DUR) ations (QL), Age, Gender Edits The Health Net DUR program evaluates a prescription when the pharmacy provider electronically submits the prescription. As the prescription
Mercy Care ALBENDAZOLE. Products Affected. ALBENZA TABLET 200 MG ORAL Details. Criteria. Refer to PA Guideline for approval criteria
ALBENDAZOLE Mercy Care ALBENZA TABLET 200 MG ORAL Refer to PA Guideline for approval criteria 1 BRIMONIDINE-TIMOLOL COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC Requires use of separate ingredients for at least
Drug Formulary Update, January 2017 Commercial and State Programs
Drug Formulary Update, January 2017 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
ANTICONVULSANT THERAPY
Network Health Insurance Corporation NetworkCares Step Therapy Last Updated: 7/2017 ANTICONVULSANT THERAPY Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200
CHANGES TO YOUR DRUG LIST
CHANGES TO YOUR DRUG LIST More generics and lower-cost brands to help you stay healthy and save money As your health partner, we want to help you get and stay healthy. That means making sure you have access
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
May 2016 P & T Updates
Commercial Triple Tier 4th Tier Applicabl e Traditional Detailed s 2 films - DESCOVY 2 2 1 tablet NARCAN 2 2 ODEFSEY 2 2 1 tablet REPATHA 2 2 HoFH: 3 ml per 28 ROSUVASTATIN 1 1 - UPTRAVI 3 2 - Alternatives
2015 Allegian Choice Preferred Drug List (formulary)
2015 Allegian Choice Preferred Drug List (formulary) The Allegian Choice Preferred Drug List is a list of drugs covered by Allegian Health Plans, Inc. for its Allegian Choice HMO and PPO plans. This drug
FORMULARY LIST OF COVERED DRUGS
FORMULARY LIST OF COVERED DRUGS 2017 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID 00017274, Version Number 6 This formulary
SelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA
Section I contains changes to the Highmark Select/Choice Formulary.
June 2007 2 nd Quarter Update: Highmark Drug Formulary Enclosed is the 2 nd Quarter 2007 update to the Highmark Drug Formulary and pharmaceutical management procedures. The Formulary and pharmaceutical
Responsible Quantity Program Effective 4/1/10. Abilify oral solution
Abilify Abilify Discmelt Abilify oral solution Aciphex Actiq Page 1 of 9 750 ml 120 units Actonel 5 mg, 30 mg Actonel 35 mg 4 tabs Actonel 75 mg 2 tabs Actonel 150 mg 1 tab Actonel with Calcium Adcirca
2014 FORMULARY LIST OF COVERED DRUGS
PLEASE READ: This formulary was updated on January 1, 2014. For more recent information or other questions, please contact Viva Medicare Member Services at 1-800-633-1542 or, for TTY users, 711, Monday
Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
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,
VIVA Health, Inc. Part D Cumulative Formulary Changes for 2009
ulary ulary Effective ADDS 00472088282 ACETASOL HC 2%; 1% SOLN Pref(1) no 1/29/2009 3/1/2009 68382026101 ACETAZOLAMIDE 500MG CP12 Pref(1) yes 3/24/2009 5/1/2009 00078056651 AFINITOR 5MG TABS Pref (4);
2019 PacificSource Health Plans Step Therapy Criteria. Last Modified: 02/22/2019 (All criteria reviewed at least once per year)
2019 PacificSource Health Plans Step Therapy Criteria Last Modified: 02/22/2019 (All criteria reviewed at least once per year) Table of Contents ACTICLATE... 3 AMITIZA/LINZESS... 4 ANTIDIABETICS Farxiga,
Beneficiary Advisory Panel Handout Uniform Formulary Decisions 23 June 2011
Beneficiary Advisory Panel Handout Uniform Formulary Decisions 23 June 211 PURPOSE: The purpose of this handout is to provide BAP Committee members with a reference document for the relative clinical effectiveness
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
Drug Therapy Guidelines
Classes of medications may be targeted for preferred products when there are multiple entries into the market in the same therapeutic category. Coverage of any non-preferred medication can be granted when
Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: Version 26 Updated: 11/1/2016
Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: 16162 Version 26 Updated: 11/1/2016 ANALGESICS acetaminophen w/ codeine (300-15 mg, 300-30 mg, 300-60 mg) acetaminophen w/ codeine soln 120-12
2015 Medicare Step Therapy Criteria. Last Modified: 12/31/2014 Last Submitted to CMS: 10/29/2014
2015 Medicare Step Therapy Criteria Last Modified: 12/31/2014 Last Submitted to CMS: 10/29/2014 1 Table of Contents AMITIZA, LINZESS... 3 ANTIDEPRESSANTS - Viibryd / Pexeva / Pristiq / Desvenlafaxine...
2017 Formulary Exclusions Drug List
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Formulary Exclusions Drug List aetna.com 05.03.912.1 H (3/17) These drugs are not covered under your plan.
Step Therapy Program Precision Formulary
Step Therapy Program Precision Formulary Physician Guidelines Failure of previous steps in the Step Therapy Program: For most therapies, Magellan Rx Management will review the most recent 180 days of claim
SOURCE:
SOURCE: http://www.kgw.com/news/investigations/side-effects/database/100-prescription-drugs-with-skyrocketing-c Over four years, drug prices skyrockected Top 100 Price Increases Unit Basic Category Simple
TRICARE Uniform Formulary. Pre-Authorization Requirements
TRICARE Uniform Formulary Pre-Authorization Requirements The Department of Defense (DoD) requires pre-authorization on select medications. These medications are on the DoD s pre-authorization list because
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
Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)
![Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)](/thumbs/85/91743011.jpg "Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)")
CareAdvantage CMC 2018 Formulary Supplement II (List of Covered Drugs) Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs) Formulary ID: 00018157 Formulary Version:11 19 CMS Approved: 08/21/2018
SecureBlue Formulary 2016 Master Negative Changes from 2015 to 2016
Beta-lactam, SUPRAX TAB 400MG Suprax 400 mg cap Antibacterials Cephalosporins Beta-lactam, CEFOTAXIME INJ 10GM cefotaxime 2 gm inj Antibacterials Cephalosporins ERYTHROCIN INJ 1000MG Erythrocin 500 mg
Quantity Management. October 2017
Quantity Management October 2017 What Is Quantity Management? It s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications we cover. We