2013 Notice Formulary Drug List Changes - 3 Tier
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- Dorothy Stafford
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1 2013 Notice List s - 3 Tier Community HealthFirst may add remove drugs from our during the year. If we remove drugs from our, add pri authization, quantity limits and/ step therapy restrictions on a drug, we will notify you of the change at least 60 days befe the date that the change becomes effective. However, if the Food and Administration deems a drug on our to be unsafe the drug s manufacturer removes the drug from the market we will immediately remove the drug from our. If you have questions about these changes, please contact Customer Service 8 a.m. to 8 p.m., 7 days a week: Current Members: Prospective Members: TTY Relay: Dial The table below outlines upcoming changes to our that will impact you: Name of Affected ABACAVIR 300 MG 3/1/2013 ACTOPLUS MET 15 7/1/2013 Generic added PIOGLITAZON MG-500 MG TAB E- METFORMIN ACTOPLUS MET 15 7/1/2013 Generic added PIOGLITAZON MG-850 MG TAB E- METFORMIN ACTOS 15 MG 7/1/2013 Generic added PIOGLITAZON E HCL 15 MG TAB ACTOS 30 MG 7/1/2013 Generic added PIOGLITAZON E HCL 30 MG TAB ACTOS 45 MG 7/1/2013 Generic added PIOGLITAZON E HCL 45 MG TAB A-HYDROCORT 100 3/1/2013 MG VIAL ALA-CORT 1% 3/1/2013 CREAM ALOPRIM 500 MG 3/1/2013 H5826_MA_074_ _v_01_NoticeTemp 1
2 VIAL AMEVIVE 15 MG VIAL Remove from 4/25/2013 Remove from ANDROXYL 10 MG AVITA 0.025% CREAM [PA] BETAMETHASONE DP AUG 0.05% GEL BETAMETHASONE VALER 0.12% FOAM BETAXOLOL 10 MG BOSULIF 100 MG [PA] BOSULIF 500 MG [PA] BUPRENORPHIN- NALOXON 8-2 MG TB [QLL] [PA] BUPRENORPHN- NALOXN MG TB [QLL] [PA] BUPROPION HCL XL 150 MG [QLL] BUPROPION HCL XL 300 MG [QLL] BYDUREON 2 MG VIAL[QLL][PA] CALCIPOTRIENE 0.005% CREAM CANDESARTAN- HCTZ MG CANDESARTAN- HCTZ MG CANDESARTAN- HCTZ MG CARAFATE 1 GM/10 ML SUSP Tier change; addition; Tier 1 addition;tier 1 addition;tier 1 Tier change; 3/1/2013 Tier change; 3/1/2013 5/1/2013 4/1/2013 addition; Tier 1 3/1/2013 3/1/2013 3/1/2013 6/1/2013 6/1/2013 5/1/2013 addition;tier 1 5/1/2013 6/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 Tier change; ENBREL, HUMIRA, REMICADE H5826_MA_074_ _v_01_NoticeTemp 2
3 CARBAMAZEPINE XR 200 MG 3/1/2013 CARBAMAZEPINE XR 3/1/ MG CEVIMELINE HCL 30 3/1/2013 MG SULE CHENODAL 250 MG 3/1/2013 [LA] [PA] CIDOFOVIR 375 MG/5 3/1/2013 ML VIAL CIPRO 10% 3/1/2013 SUSPENSION CIPRO 5% 3/1/2013 SUSPENSION CIPROFLOXACIN- 5/1/2013 D5W 200 MG/100 ML addition;tier 1 CLINDAMYCIN HCL 5/1/ MG SULE addition;tier 1 CLINDAMYCIN-D5W 5/1/ MG/50 ML CLINDAMYCIN-D5W 5/1/ MG/50 ML CLINDAMYCIN-D5W 5/1/ MG/50 ML addition;tier 1 addition;tier 1 CLORPRES /1/2013 CLORPRES /1/2013 CLORPRES /1/2013 COLOCORT 100 MG 3/1/2013 ENEMA COMBIVENT 3/1/2013 RESPIMAT INHAL SPRAY [QLL] COMETRIQ 60 mg 4/1/2013 DAILY-DOSE PACK addition; addition; [PA] Tier 3 Tier 3 COMETRIQ 100 mg 4/1/2013 DAILY-DOSE PACK addition; [PA] Tier 3 COMETRIQ 140 mg 4/1/2013 DAILY-DOSE addition; addition; PACK[ PA] Tier 3 Tier 3 CONSTULOSE 10 3/1/2013 H5826_MA_074_ _v_01_NoticeTemp 3
4 GM/15 ML SOLN CYCLOSPORINE MODIFIED 25 MG [PA] 5/1/2013 DALIRESP 500 MG 4/1/2013 addition;tier 2 DESLORATADINE 5 3/1/2013 MG [QLL] DESLORATADINE 2.5 4/1/2013 MG ODT [QLL] addition;tier 1 DESLORATADINE 5 4/1/2013 MG ODT [QLL] addition;tier 1 DESOXIMETASONE 3/1/ % OINTMENT DEXTROAMP- 3/1/2013 AMPHET ER 5 MG DEXTROAMP- AMPHET ER 10 MG DEXTROAMP- AMPHET ER 15 MG DEXTROAMP- AMPHET ER 20 MG DEXTROAMP- AMPHET ER 25 MG DEXTROAMP- AMPHET ER 30 MG DICLOFENAC- MISOPROST DICLOFENAC- MISOPROST DISULFIRAM 250 MG DILANTIN 50 MG INFATAB 3/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 7/1/2013 Generic added PHENYTOIN 50 MG CHEW 3/1/2013 DIOVAN 40 MG [ST] DIOVAN 80 MG 3/1/2013 H5826_MA_074_ _v_01_NoticeTemp 4
5 [ST] DIOVAN 160 MG [ST] 3/1/2013 DIOVAN 320 MG 3/1/2013 [ST] DOVONEX 0.005% 7/1/2013 Generic added CALCIPOTRIE CREAM -NE 0.005% CREAM DROSPIRENONE-ETH 5/1/2013 ESTRADIOL TAB DUETACT 30-2 MG DUETACT 30-4 MG 7/1/2013 Generic added PIOGLITAZ- GLIMEPIR 30-2 MG 7/1/2013 Generic added PIOGLITAZ- GLIMEPIR 30-4 MG DURAMORPH 10 Tier change; 3/1/2013 Tier change; MG/10 ML AMPUL DURAMORPH 5 Tier change; 3/1/2013 Tier change; MG/10 ML AMPUL E.E.S. 400 MG 3/1/2013 FILMTAB ELIQUIS 2.5 MG 5/1/2013 [PA] ELIQUIS 5 MG 5/1/2013 [PA] ENOXAPARIN 300 5/1/2013 MG/3 ML VIAL ELIQUIS 5 MG 5/1/2013 [PA] ERGOMAR 2 MG 3/1/2013 SL ELELYSO 200 UNITS 4/1/2013 VIAL ERGOTAMINE- Removed from 4/25/2013 Removed from ERGOMAR CAFFEINE ERY-TAB EC 250 MG Tier change; 3/1/2013 Tier change; ERY-TAB EC 333 MG Tier change; 3/1/2013 Tier change; ESTRADIOL-NORETH 5/1/ MG TAB ETODOLAC 300 MG 6/1/2013 SULE EXELON 13.3 MG/24 4/1/2013 H5826_MA_074_ _v_01_NoticeTemp 5
6 H5826_MA_074_ _v_01_NoticeTemp HR PATCH [ST] FENOFIBRATE 48 MG 3/1/2013 FENOFIBRATE 145 3/1/2013 MG FLUOROURACIL 2% 3/1/2013 TOPICAL SOLN FLUOROURACIL 5% 3/1/2013 TOPICAL SOLN GABITRIL 2 MG 7/1/2013 Generic added TIAGABINE HCL 2 MG GABITRIL 4 MG GAMASTAN S-D VIAL GENERLAC 10 GM/15 ML SOLUTION GILDAGIA 0.4 MG MG TAB GRIFULVIN V 500 MG GRISEOFULVIN MICRO 500 MG TAB GRISEOFULVIN ULTRA 125 MG TAB GRISEOFULVIN ULTRA 250 MG TAB GRIS-PEG 125 MG GRIS-PEG 250 MG GUANIDINE HCL 125 MG HP ACTHAR GEL 80 UNIT/ML VIAL [PA] HYDROCORTISONE 0.1% SOLN HYDROCORTISONE BUTY 0.1% CREAM HYDROCORTISONE BUTY 0.1% OINT 7/1/2013 Generic added TIAGABINE HCL 4 MG 3/1/2013 3/1/2013 5/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 7/1/2013 Generic added GRISEOFULVI N ULTRA 125 MG 7/1/2013 Generic added GRISEOFULVI N ULTRA 250 MG 4/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 6
7 ICLUSIG 15 MG [QLL] [PA] 4/1/2013 ICLUSIG 45 MG 4/1/2013 [QLL] [PA] IMOVAX RABIES 3/1/2013 VACCINE INTRALIPID 20% IV 3/1/2013 FAT EMUL ISENTRESS 25 MG 3/1/2013 CHEW ISENTRESS 100 MG 3/1/2013 CHEW ISOSORBIDE MN 10 3/1/2013 MG ISOTON GENTAMICIN 3/1/ MG/100 ML JUVISYNC MG 4/1/2013 [QLL] JUVISYNC MG 4/1/2013 [QLL] JUVISYNC MG 4/1/2013 [QLL] JUXTAPID 10 MG 4/1/2013 SULE [LA] JUXTAPID 20 MG 4/1/2013 SULE [LA] JUXTAPID 5 MG 4/1/2013 SULE [LA] KEPIVANCE 6.25 MG 3/1/2013 VIAL [LA] KETODAN 2% FOAM 3/1/2013 KIT KIONEX POWDER 3/1/2013 LACTATED RINGERS 4/1/2013 IRRIGATION LACLOTION 12% 3/1/2013 LOTION LAMOTRIGINE ER 4/1/ MG LAMOTRIGINE ER 4/1/ MG LAMOTRIGINE ER 4/1/ MG LAMOTRIGINE ER 4/1/2013 H5826_MA_074_ _v_01_NoticeTemp 7
8 H5826_MA_074_ _v_01_NoticeTemp 200 MG LAMOTRIGINE ER 250 MG 4/1/2013 LAMOTRIGINE ER 4/1/ MG LATUDA 120 MG 4/1/2013 [QLL] LEVONOR-ETH 4/1/2013 ESTRAD LEVONEST-28 5/1/2013 LINDANE 1% Tier change; 3/1/2013 Tier change; SHAMPOO LINZESS 145 MG 3/1/2013 SULE LINZESS 290 MG 3/1/2013 SULE LYRICA 20 MG/ML 3/1/2013 ORAL SOLN [PA] MAFENIDE ACETATE 5/1/ GM POWD PK addition;tier 1 METFORMIN HCL ER 5/1/ GRAM TAB [QLL] METHYLPHENIDATE 5/1/2013 ER 27 MG METHYLPHENIDATE 3/1/2013 CD 10 MG METHYLPHENIDATE 4/1/2013 CD 50 MG METHYLPHENIDATE 4/1/2013 CD 60 MG METHYLPREDNISOL- 3/1/2013 ONE 40 MG VIAL METHYLPREDNISOL- 3/1/2013 ONE 125 MG VIAL MILLIPRED 5 MG 3/1/2013 MISOPROSTOL 100 5/1/2013 MCG MODAFINIL 100 MG 3/1/2013 [PA] MODAFINIL 200 MG 3/1/2013 [PA] MONTELUKAST SOD 5/1/ MG GRANULES 8
9 MONTELUKAST SOD 4 MG TAB CHEW 3/1/2013 MONTELUKAST SOD 3/1/ MG TAB CHEW MONTELUKAST SOD 3/1/ MG MUPIROCIN 2% 5/1/2013 CREAM NEXIUM DR 2.5 MG 5/1/2013 PACKET [QLL] [ST] NEXIUM DR 5 MG 5/1/2013 PACKET [QLL] [ST] NOVAREL 10,000 3/1/2013 UNITS VIAL [PA] OLANZAPINE- 3/1/2013 FLUOXETINE MG OLANZAPINE- 3/1/2013 FLUOXETINE MG OLANZAPINE- 3/1/2013 FLUOXETINE 3-25 MG OLANZAPINE- 3/1/2013 FLUOXETINE 6-25 MG OLANZAPINE- 3/1/2013 FLUOXETINE 6-50 MG OXCARBAZEPINE 300 5/1/2013 MG/5 ML SUSP OXYCODONE HCL 4/1/ MG OXYCODONE HCL 4/1/ MG OXYCODONE HCL 5 4/1/2013 MG/5 ML SOL OXYMORPHONE HCL 5/1/2013 ER 10 MG TAB [QLL] OXYMORPHONE HCL 5/1/2013 ER 20 MG TAB [QLL] OXYMORPHONE HCL 5/1/2013 ER 30 MG TAB [QLL] OXYMORPHONE HCL 5/1/2013 ER 40 MG TAB [QLL] OXYMORPHONE HCL 5/1/2013 ER 5 MG TAB [QLL] PANTOPRAZOLE 4/1/2013 H5826_MA_074_ _v_01_NoticeTemp 9
10 H5826_MA_074_ _v_01_NoticeTemp SODIUM 40 MG VIAL PFIZERPEN 20 MILLION UNIT VIAL 3/1/2013 PHENOBARBITAL 15 3/1/2013 MG PHENOBARBITAL 60 3/1/2013 MG PHENOBARBITAL 100 3/1/2013 MG PHENOBARBITAL Remove PA 3/1/2013 Remove PA 16.2 MG restriction; Tier 1 restriction; Tier 1 PHENOBARBITAL 20 Remove PA 3/1/2013 Remove PA MG/5 ML ELIX restriction; Tier 1 restriction; Tier 1 PHENOBARBITAL 30 Remove PA 3/1/2013 Remove PA MG restriction; Tier 1 restriction; Tier 1 PHENOBARBITAL Remove PA 3/1/2013 Remove PA 32.4 MG restriction; Tier 1 restriction; Tier 1 PHENOBARBITAL Remove PA 3/1/2013 Remove PA 64.8 MG restriction; Tier 1 restriction; Tier 1 PHENOBARBITAL Remove PA 3/1/2013 Remove PA 97.2 MG restriction; Tier 1 restriction; Tier 1 PHENYTOIN 50 MG 4/1/2013 CHEW PIOGLITAZONE HCL 3/1/ MG [QLL] PIOGLITAZONE HCL 3/1/ MG [QLL] PIOGLITAZONE HCL 3/1/ MG [QLL] PIOGLITAZONE- 4/1/2013 GLIMEPIR 30-2 MG [QLL] PIOGLITAZONE- GLIMEPIR 30-4 MG [QLL] PIOGLITAZONE- METFORMIN [QLL] PIOGLITAZONE- METFORMIN [QLL] POMALYST 1 MG SULE POMALYST 2 MG SULE 4/1/2013 3/1/2013 3/1/2013 5/1/2013 5/1/
11 POMALYST 3 MG SULE 5/1/2013 POMALYST 4 MG 5/1/2013 SULE POTASSIUM CITRATE 3/1/2013 ER 5 MG TAB POTASSIUM CITRATE 3/1/2013 ER 10 MG TAB PREDNISOLONE SOD 5/1/2013 PH 25 MG/5 ML PREMASOL 10% IV Tier change; 3/1/2013 Tier change; SOLUTION PREZISTA 100 MG/ML 6/1/2013 SUSPENSION PREZISTA 800 MG 4/1/2013 PROCTO-PAK 1% 3/1/2013 CREAM PROCTOZONE-HC 3/1/ % CREAM PROVIGIL 100 MG 7/1/2013 Generic added MODAFINIL 100 MG PROVIGIL 200 MG 7/1/2013 Generic added MODAFINIL 200 MG PRUDOXIN 5% 5/1/2013 CREAM QUALAQUIN 324 MG 7/1/2013 Generic added QUININE SULE SULFATE 324 MG SULE QUININE SULFATE 4/1/ MG SULE REGONOL 10 MG/2 3/1/2013 ML AMPUL RINGERS 4/1/2013 IRRIGATION SOLUTION RIZATRIPTAN 5 MG 4/1/2013 ODT [QLL] RIZATRIPTAN 10 MG 4/1/2013 ODT [QLL] RIZATRIPTAN 5 MG 4/1/2013 [QLL] RIZATRIPTAN 10 MG 4/1/2013 H5826_MA_074_ _v_01_NoticeTemp 11
12 H5826_MA_074_ _v_01_NoticeTemp [QLL] SANCTURA XR 60 MG SULE 7/1/2013 Generic added TROSPIUM CHLORIDE ER 60 MG SILDENAFIL 20 MG 3/1/2013 [PA] [QLL] SIMCOR MG 5/1/2013 [QLL] STAVUDINE 1 MG/ML 4/1/2013 SOLUTION STERILE WATER FOR 4/1/2013 IRRIGATION STIVARGA 40 MG 3/1/2013 [PA] STRIBILD 3/1/2013 SUBOXONE 12 MG-3 MG SL FILM [QLL] [PA] SUBOXONE 4 MG-1 MG SL FILM [QLL] [PA] SUPRAX 100 MG CHEW SUPRAX 200 MG CHEW SYNAGIS 50 MG/0.5 ML VIAL [LA] SYNRIBO 3.5 MG/ML VIAL TERCONAZOLE 0.8% CREAM [QLL] TETANUS TOXOID ADSORBED VIAL TIAGABINE HCL 2 MG TIAGABINE HCL 4 MG TINIDAZOLE 250 MG TINIDAZOLE 500 MG TOLTERODINE TARTRATE 1 MG TAB 4/1/2013 4/1/2013 3/1/2013 3/1/2013 3/1/2013 4/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/2013 3/1/
13 TOLTERODINE TARTRATE 2 MG TAB 3/1/2013 TRANEXAMIC ACID 5/1/ MG TRAVASOL 10% Tier change; 3/1/2013 Tier change; SOLN VIAFLEX TROSPIUM 4/1/2013 CHLORIDE ER 60 MG TUDORZA PRESSAIR 3/1/ MCG INH [QLL] UCERIS 9 MG ER 5/1/2013 VALSARTAN-HCTZ 4/1/ MG TAB VALSARTAN-HCTZ 4/1/ MG TAB VALSARTAN-HCTZ 4/1/ MG TAB VALSARTAN-HCTZ 4/1/ MG TAB VALSARTAN-HCTZ 4/1/ MG TAB VASCEPA 1 GM 5/1/2013 SULE [PA] VFEND IV 200 MG 7/1/2013 Generic added VORICONAZO VIAL -LE 200 MG VIAL VIOKASE 10,440-3/1/ ,150 UNITS TB VIOKASE 20,880-3/1/ ,300 UNITS TB VIRAZOLE 6 GM VIAL 3/1/2013 VIVELLE-DOT /1/2013 MG PATCH [QLL] VIVELLE-DOT /1/2013 MG PATCH [QLL] VIVELLE-DOT /1/2013 MG PATCH [QLL] VIVELLE-DOT /1/2013 MG PATCH [QLL] VIVELLE-DOT 0.1 MG 3/1/2013 PATCH [QLL] VORICONAZOLE 200 3/1/2013 H5826_MA_074_ _v_01_NoticeTemp 13
14 MG VIAL XTANDI 40 MG SULE [PA] 3/1/2013 ZALTRAP 100 MG/4 4/1/2013 ML VIAL ZAZOLE VAGINAL 3/1/ % CREAM [QLL] ZENCHENT FE 4/1/2013 CHEWABLE ZERIT 1 MG/ML 7/1/2013 Generic added STAVUDINE SOLUTION 1 MG/ML ZIAGEN 300 MG ZOLEDRONIC ACID 4 MG/5 ML VIAL SOLUTION 7/1/2013 Generic added ABACAVIR 300 MG 6/1/2013 * drugs are drugs in the same therapeutic categy/class cost-sharing tier as the affected drug. Only your physician can determine if the alternate listed here is appropriate f you given the individualized nature of drug therapy. Please consult with your physician as to whether this is an appropriate drug f you. H5826_MA_074_ _v_01_NoticeTemp 14
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Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
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