Your prescription benefit updates Formulary Updates - Effective January 1, 2019
|
|
|
- Lorraine Hines
- 5 years ago
- Views:
Transcription
1 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 pay for that prescription. This is decided by your employer or health plan. Please use this chart as you review these updates. Tier 1 Lowest-cost Tier 2 Midrange-cost Tier 3 Highest-cost Medications moving to a lower tier The following are moving to a lower tier, making them more affordable. Therapeutic use Medication name Tier Anticoagulants Blood Thinners Antidiabetic Agents Insulin Topical Acne Anti-inflammatory Agents ELIQUIS TABLET 2.5MG, 5MG 3 2 OZEMPIC INJECTION 2MG/1.5ML EXC 2 REBIF REBIDOSE INJECTION 22MCG/0.5ML, 44MCG/0.5ML EXC 3 REBIF REBIDOSE INJECTION TITRATION PAK EXC 3 REBIF SOLUTION PREFILLED SYRINGE 22MCG/0.5ML, 44MCG/0.5ML EXC 3 REBIF SOLUTION TITRATION PACK EXC 3 ACZONE GEL 7.5% 3 2 SYMPROIC TABLET 0.2 MG 3 2 PROLENSA SOLUTION 0.07% 3 2
2 Medications moving to a higher tier These are moving to a higher tier and will cost more because there are other lower-cost options. If your medication is listed below, you may still take it, but you may pay a higher cost. Please talk to your doctor about lower-cost option(s) to see if they will work for you. Therapeutic use Medication name Tier Drugs for HIV DESCOVY TABLET 200/ Drugs for HIV Drugs for HIV ntral Drugs for HIV ntral GENVOYA TABLET 2 3 ODEFSY TABLET 2 3 STRIBILD TABLET 2 3 Genitourinary Agents Phosphate Binders RENVELA TABLET 800MG 2 3 sevelamer Drugs for Glaucoma BETOPTIC-S SUSPENSION 0.25% 2 3 betaxolol, carteolol, levobunolol, metipranolol, timolol Drugs for Glaucoma TIMOPTIC OCUMETER SOLUTION 0.25%, 0.5% 2 3 betaxolol, carteolol, levobunolol, metipranolol, timolol
3 Medications that are Excluded The following are excluded. Therapeutic use Medication name Tier Analgesics Drugs for Pain/ Inflammatory Conditions SPRIX SPRAY 15.75MG diclofenac, ibuprofen, meloxicam Antibacterial Agents Drugs to treat Bacterial Infections DORYX MPC TAB 120MG doxycycline hyclate Antibacterial Agents Drugs to treat bacterial infections NORITATE CREAM 1% metronidazole cream/ gel/lotion, SOOLANTRA CREAM Anticonvulsant Agents Drugs for Seizure Disorders SABRIL POWDER PAK 500MG vigabatrin Anticonvulsant Agents Drugs for Seizure Disorders OXTELLAR XR TAB 150MG, 300MG, 600MG topiramate IR Antidiabetic Agents Drugs to Regulate Blood Sugar FORTAMET TABLET 500MG, 1000MG metformin er (generic GLUCOPHAGE XR) Antidiabetic Agents Drugs to Regulate Blood Sugar METFORMIN HCL TAB ER 24HR MODIFIED RELEASE 500 MG, 1000MG metformin er (generic GLUCOPHAGE XR) Antidiabetic Agents Drugs to Regulate Blood Sugar METFORMIN HCL TAB ER 24HR OSMOTIC 500 MG, 1000MG metformin er (generic GLUCOPHAGE XR) Antidiabetic Agents Drugs to Regulate Blood Sugar QTERN TABLET 10MG/5MG GLYXAMBI Antiemetics Drugs to Treat Nausea and Vomiting SANCUSO PATCH 3.1MG granisetron tablet, ondansetron ODT
4 Antimigraine Agents Drugs to Treat Migraines ONZETRA XSAIL NASAL EXHALER 11MG rizatriptan ODT, sumatriptan succinate injection, sumatriptan nasal spray, zolmitriptan ODT Antimigraine Agents Drugs to Treat Migraines SUMAVEL INJECTION 4MG/0.5ML, 6MG/0.5ML rizatriptan ODT, sumatriptan succinate injection, sumatriptan nasal spray, zolmitriptan ODT Antimigraine Agents Drugs to Treat Migraines ZEMBRACE SYMTOUCH INJECTION 3MG/0.5ML rizatriptan ODT, sumatriptan succinate injection, sumatriptan nasal spray, zolmitriptan ODT Drugs for HIV ATRIPLA TABLET 2 EXC Patients should talk to their doctor about clinically appropriate alternative(s). Anxiolytics Drugs to Treat Anxiety Topical Acne ATIVAN TABLET 0.5MG, 1MG, 2MG lorazepam ACZONE GEL 5% dapsone 5% gel Topical Acne CLINDAGEL GEL 1% adapalene, adapalene/ benzoyl peroxide, clindamycin gel/lotion/ solution, clindamycin/ benzoyl peroxide, erythromycin/benzoyl peroxide, tretinoin cream, EPIDUO, EPIDUO FORTE, ONEXTON Topical Antifungals JUBLIA SOLUTION 10% terbinafine, KERYDIN
5 Drugs to treat Stomach Conditions ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 20MG, 40MG (BASE EQ) lansoprazole, omeprazole, pantoprazole Drugs to treat stomach conditions OMEPRAZOLE- SODIUM BICARBONATE CAP MG, MG lansoprazole, omeprazole, pantoprazole Drugs to treat stomach conditions OMEPRAZOLE- SODIUM BICARBONATE POWD PACK FOR SUSP MG, MG lansoprazole, omeprazole, pantoprazole Drugs to treat Inflammatory Bowel Disease DIPENTUM CAPSULE 250MG balsalazide, APRISO AMITIZA CAPSULE 8MCG, 24MCG 2 EXC LINZESS ( for IBS-C/CIC ); SYMPROIC ( for OIC ) TRULANCE TABLET 3MG LINZESS ( for IBS-C/ CIC ) RELISTOR INJECTION 8/0.4ML, 12/0.6ML SYMPROIC ( for OIC ) RELISTOR TABLET 150MG SYMPROIC ( for OIC ) IBS-C/CIC= Irritable Bowel Syndrome with Constipation/ Chronic Idiopathic Constipation OIC= Opioid-Induced Constipation
6 Genitourinary Agents Drugs for Erectile Dysfunction Hormonal Agents Suppressant (Pituitary) VIAGRA TABLET 25MG, 50MG, 100MG SANDOSTATIN INJECTION 50MCG/ ML, 100MCG/ ML, 200MCG/ ML, 500MCG/ML, 1000MCG/ML sildenafil octereotide injection Hormonal Agents Stimulant/Re/ Modifying (Adrenal) RAYOS TABLET 1MG, 2MG, 5MG prednisone Anti-inflammatory Agents ILEVRO DROP 0.3% PROLENSA Antiinflammatory Agents BROMSITE DROP 0.075% PROLENSA Antiinflammatory Agents NEVANAC SUSP 0.1% PROLENSA Pulmonary Agents Drugs for COPD BEVESPI AEROSOL 9-4.8MCG ANORO ELLIPTA, STIOLTO RESPIMAT Pulmonary Agents Drugs for COPD UTIBRON NEOHALER CAPSULE MCG ANORO ELLIPTA, STIOLTO RESPIMAT Pulmonary Agents Drugs for COPD SEEBRI NEOHALER CAPSULE 15.6MCG INCRUSE ELLIPTA, SPIRIVA Pulmonary Agents ARMONAIR AEROSOL 55/ACT, 113/ACT, 232/ACT ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER
7 Topical Hormonal Agents Topical Hormonal Agents Topical Hormonal Agents TOPICORT SPRAY 0.25% HALOG CREAM 0.1% HALOG OINTMENT 0.1% desoximetasone cream/ gel/ointment/spray, fluocinonide solution 0.05% fluticasone ointment, halobetasol cream/ointment, triamcinolone cream/ ointment fluticasone ointment, halobetasol cream/ointment, triamcinolone cream/ ointment Need more information? Call or visit us online to learn more about your pharmacy benefits. Call the member phone number on the back of your ID card. Visit optumrx.com. optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription and consumer health products. We are an Optum company a leading provider of integrated health services. Learn more at optum.com. All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners Optum, Inc. All rights reserved. ORX7236B-L-CTRX_190101_67871B Applies to the Premium Formulary
ALOGLIPTIN STEP. Step Therapy Requirements Effective April 1, 2018
Step Therapy Requirements Effective April 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
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
ALOGLIPTIN STEP. Step Therapy Requirements Effective June 1, 2018
Step Therapy Requirements Effective June 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
ANTIEMETICS STEP. Step Therapy Requirements Effective April 1, 2019
Step Therapy Requirements Effective April 1, 2019 ANTIEMETICS STEP Sancuso 3.1 mg/24 hour transdermal patch Zuplenz 4 mg oral soluble film Zuplenz 8 mg oral soluble film COVERAGE OF CERTAIN BRAND NAME
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
ALOGLIPTIN STEP. Details. Step Therapy Requirements Effective November 1, 2017
ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone 15 mg tablet alogliptin 12.5 mg-pioglitazone
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
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
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
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
5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
5-ASA DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum. 1 ANTIEMETICS
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:
5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release
Updated 11/1/17 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
BLUE SHIELD OF CALIFORNIA JUNE 2016 PLUS DRUG FORMULARY CHANGES
BLUE SHIELD OF CALIFORNIA JUNE 2016 PLUS DRUG FORMULARY CHANGES Blue Shield is committed to covering safe, effective and affordable medications, so we regularly review and update our drug formularies.
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
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
Pequot Health Care Smart Quantity Program*
Pequot Health Care 1 Annie George Drive Mashantucket, CT 06338 Phone: 1-888-779-6638 Fax: 1-860-396-6494 Pequot Health Care Smart Quantity Program* Updated January 2018 *Quantity Program limits apply to
Step Therapy Requirements. Effective: 12/01/2016
Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER
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
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
STEP THERAPY CRITERIA
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 under your medical or prescription
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
STEP THERAPY CRITERIA
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 under your medical or prescription
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
WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum
WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call WellCare if you
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
2014 Step Therapy Criteria (List of Step Therapy Criteria)
Criteria Last Updated: November 1, 2014 2014 Step Therapy Criteria (List of Step Therapy Criteria) PLEASE READ CAREFULLY: IEHP MEDICARE DUALCHOICE (HMO SNP) REQUIRES YOU TO FIRST TRY CERTAIN DRUGS TO TREAT
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
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
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
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
Prescription benefit updates Individual/small group
Prescription benefit updates Individual/small group Moda Health s prescription program is a pharmacy benefit that offers members a choice of safe and effective medication treatments. The program also helps
Magellan Rx Precision Formulary Formulary Updates First Quarter 2019
Magellan Rx Precision Formulary Formulary Updates First Quarter 2019 The Magellan Rx Management Pharmacy & Therapeutics Committee (P&T) and Value Assessment Committee (VAC) meet periodically to review
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
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
Quarterly pharmacy formulary change
Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect This is an update about information in the provider manual. For access to the latest manual, go online to www.anthem.com/inmedicaiddoc.
ANTICONVULSANTS. Details. Step Therapy Criteria Date Effective: April 1, 2019
Step Therapy Date Effective: April 1, 2019 ANTICONVULSANTS APTIOM TABLET 200 MG ORAL APTIOM TABLET 400 MG ORAL APTIOM TABLET 600 MG ORAL APTIOM TABLET 800 MG ORAL BANZEL SUSPENSION 40 MG/ML ORAL BANZEL
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
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
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
Updates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Step Therapy Reference Number: HIM.PA.109 Effective Date: 08.01.17 Last Review Date: 05.18 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the end
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
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
MDI Bonanza. Dwayne Griffin, DO
MDI Bonanza Dwayne Griffin, DO Bonanza 3. A MDI costing $200 - $500 per month SISYPHUS MDI Griffin Mountain Evolution of Deliver Systems for COPD in the US 2003 2009 2011 2013 2004 2012 2014 Prescribing
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
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
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
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
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Step Therapy Reference Number: HIM.PA.109 Effective Date: 08.01.17 Last Review Date: 05.18 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the end
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
TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder
TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific
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
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
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These formulary changes,
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
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
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500
Matching, Fill in the Blank, Multiple Choice (1 point each)
Name Quiz 3 grade /out of 50 Session 2 Quiz 3 July 2018 Matching, Fill in the Blank, Multiple Choice (1 point each) 1) The prescription reads as follows Lopressor 50mg sig: 2 tab po bid dispense #60 tabs.
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 04/01/2019 Updated 03/2019 AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED
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
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500
Updates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
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
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
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS GLYXAMBI 10 MG-5 MG GLYXAMBI 25 MG-5 MG INVOKAMET 150 MG-1,000 MG INVOKAMET 150 MG-500 MG INVOKAMET 50 MG-1,000 MG INVOKAMET 50 MG-500 MG INVOKAMET XR 150 MG-1,000 MG,
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
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
DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %
June 2016 On 13th May, the DH announced that there would be reductions to Category M prices from June until September. http://psnc.org.uk/our-news/contractor-notice-category-m-price-reduction/ This has
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
Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs)
Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5
MEDICAID QUANTITY LIMIT DRUG LIST
MEDICAID QUANTITY LIMIT DRUG LIST PH51-R-02162018 Brand Name Generic Name Dosage Form Tier Quantity Limit Details Cambia Diclofenac Potassium PACK Tier 2 QL: 9 per 30 days Fentanyl (12 Mcg/Hr, 25 Mcg/
Part D Pharmacy. An Independent Licensee of the Blue Cross Blue Shield Association ( )
Part D Pharmacy 1 An Independent Licensee of the Blue Cross Blue Shield Association 044507 (12-21-2017) New MA pharmacy partner We ve selected CVS Caremark to manage our part D pharmacy benefits Providence
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
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 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.
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
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
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
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
ARBS MEDICATION(S) SUBJECT TO STEP THERAPY DIOVAN HCT MG TAB, DIOVAN HCT MG TABLET
ARBS DIOVAN HCT 160-12.5 MG TAB, DIOVAN HCT 80-12.5 MG TABLET 30-day trial of a Step 1 drug in the previous 120 days is required. Step 1 Drugs: Losartan, Losartan/HCTZ PAGE 1 LAST UPDATED 05/2016 BILE
Step Therapy Approval Criteria
Effective Date: 07/01/2015 This document contains for the following medications: 1. Ambien CR (zolpidem ER) 2. Chantix Continuing Month (varenicline) 3. Chantix Starting Month (varenicline) 4. Cymbalta
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017 Providers may call the Pharmacy Help Desk at 800-641-8921 for more information or questions about criteria. The formulary may change
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
ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria
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 tablet Viibryd 20 mg tablet Viibryd 40 mg tablet
Step Therapy Requirements. Effective: 1/1/2019
Effective: 1/1/2019 Updated 1/2019 AMANTADINE ER Sharp Health Plan (HMO) OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE
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
DT Description Price Category Price change
Tariff T Watch October 2014 Readers are no doubt aware of this quarter's bad news for primary care prescribing allocations: NHS England has d the remuneration mechanism for community pharmacies gaining
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1 ANTICONVULSANTS
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