VIVA Health, Inc. Part D Cumulative Formulary Changes for 2009

Transcription

1 ulary ulary Effective ADDS ACETASOL HC 2%; 1% SOLN Pref(1) no 1/29/2009 3/1/ ACETAZOLAMIDE 500MG CP12 Pref(1) yes 3/24/2009 5/1/ AFINITOR 5MG TABS Pref (4); PA (new starts;afinitor) no 5/26/2009 7/1/ AFINITOR 10MG TABS Pref (4); PA (new starts;afinitor) no 5/26/2009 7/1/ AMOXICILLIN/CLAVULAN 250MG/5ML; SUSR Pref(1) yes 8/26/ /1/ APIDRA 100UNIT/ML SOLN Pref (2) no 4/27/2009 6/1/ APIDRA SOLOSTAR 100UNIT/ML SOLN Pref (2) no 9/25/ /1/ APTIVUS 100MG/ML SOLN Pref (2) yes 8/26/ /1/ ASTEPRO 137MCG/SPRAY SOLN Pref (2); QL (60.00 per 25 days) no 2/25/2009 4/1/ ASTEPRO 0.15% SOLN Pref (2); QL (60.00 per 25 days) no 9/25/ /1/ ATACAND HCT 32MG; 25MG TABS Pref(3) yes 1/29/2009 3/1/ AVINZA 45MG CP24 Pref (2); QL (60.00 per 25 days) yes 2/25/2009 4/1/ AVINZA 75MG CP24 Pref (2); QL (60.00 per 25 days) yes 2/25/2009 4/1/ BANZEL 200MG TABS Pref (2) no 2/25/2009 4/1/ BANZEL 400MG TABS Pref (2) no 2/25/2009 4/1/ BENZTROPINE 1MG/ML SOLN Pref(1) yes 8/26/ /1/ BICALUTAMIDE 50MG TABS Pref(1) no 8/26/ /1/ BUDEPRION XL 150MG TB24 Pref(1) yes 1/29/2009 3/1/ BYSTOLIC 20MG TABS Pref (2) no 5/26/2009 7/1/ CALCITONIN-SALMON 200UNIT/ACT SOLN Pref(1) no 3/24/2009 5/1/ CARBAMAZEPINE ER 200MG TB12 Pref(1) yes 8/26/ /1/ CARBAMAZEPINE ER 400MG TB12 Pref(1) yes 8/26/ /1/ CARBIDOPA/LEVODOPA 10MG; 100MG TBDP Pref(1) yes 3/24/2009 5/1/ CARBIDOPA/LEVODOPA 25MG; 100MG TBDP Pref(1) yes 3/24/2009 5/1/ CARBIDOPA/LEVODOPA 25MG; 250MG TBDP Pref(1) yes 3/24/2009 5/1/ CICLOPIROX 0.77% GEL Pref(1) yes 3/24/2009 5/1/ CIMZIA 200MG KIT Pref (4); PA no 1/29/2009 3/1/ COLESTIPOL HCL FOR 5GM PACK Pref(1) yes 4/27/2009 6/1/2009 ORAL SUSPENSION CREON 30000UNIT; 6000UNIT; 19000UNIT CPEP Pref(2) yes 8/26/ /1/ /26/ November 09 H0154 Provider HPMS Modification Report_4TIER_Cumulative s.xls

2 ulary ulary Effective CREON 60000UNIT; CPEP Pref(2) yes 8/26/ /1/ UNIT; 38000UNIT CREON UNIT; CPEP Pref(2) yes 8/26/ /1/ UNIT; 76000UNIT DIDANOSINE 125MG CPDR Pref(1) yes 3/24/2009 5/1/ DIVALPROEX SODIUM 250MG TBEC Pref(1) no 1/29/2009 3/1/ DIVALPROEX SODIUM 500MG TBEC Pref(1) no 1/29/2009 3/1/ DIVALPROEX SODIUM 125MG TBEC Pref(1) no 1/29/2009 3/1/ DORZOLAMIDE HCL 2% SOLN Pref(1) no 3/24/2009 5/1/ DORZOLAMIDE 2%; 0.5% SOLN Pref(1) no 3/24/2009 5/1/2009 HCL/TIMOLOL MALEATE DOXYCYCLINE 25MG/5ML SUSR Pref (1) yes 1/29/2009 3/1/ ENDOCET 325MG; 7.5MG TABS Pref (1) yes 2/25/2009 4/1/ ENDOCET 325MG; 10MG TABS Pref (1) yes 2/25/2009 4/1/ ENDOCET 500MG; 7.5MG TABS Pref (1) yes 2/25/2009 4/1/ ENDOCET 650MG; 10MG TABS Pref (1) yes 2/25/2009 4/1/ EPLERENONE 25MG TABS Pref (1) no 1/29/2009 3/1/ EPLERENONE 50MG TABS Pref (1) no 1/29/2009 3/1/ EXFORGE HCT 5MG; 12.5MG; TABS Pref (2) yes 9/25/ /1/ EXFORGE HCT 5MG; 25MG; TABS Pref (2) yes 9/25/ /1/ EXFORGE HCT 10MG; 12.5MG; TABS Pref (2) yes 9/25/ /1/ EXFORGE HCT 10MG; 25MG; TABS Pref (2) yes 9/25/ /1/ EXFORGE HCT 10MG; 25MG; TABS Pref (2) yes 9/25/ /1/ FLOVENT DISKUS 50MCG/BLIST AEPB Pref (2); QL ( per 25 days) yes 2/25/2009 4/1/ FLOVENT DISKUS 250MCG/BLIST AEPB Pref (2); QL ( per 25 days) yes 2/25/2009 4/1/ FLOVENT DISKUS 100MCG/BLIST AEPB Pref (2); QL ( per 25 days) yes 2/25/2009 4/1/ FORTEO 600MCG/2.4ML SOLN Pref (4); PA yes 1/29/2009 3/1/ GALANTAMINE 4MG TABS Pref(1) no 1/29/2009 3/1/ GALANTAMINE 8MG TABS Pref(1) no 1/29/2009 3/1/ GALANTAMINE 8MG CP24 Pref(1) no 3/24/2009 3/1/ /26/ November 09 H0154 Provider HPMS Modification Report_4TIER_Cumulative s.xls

3 GALANTAMINE GALANTAMINE ulary ulary Effective 12MG TABS Pref(1) no 1/29/2009 3/1/ MG CP24 Pref(1) no 3/24/2009 5/1/ GALANTAMINE 24MG CP24 Pref(1) no 3/24/2009 5/1/ GAVILYTE-G 236GM; 2.97GM; SOLR Pref(1) no 8/26/ /1/ GM; 5.86GM; 22.74GM HALFLYTELY BOWEL PREP HALFLYTELY BOWEL PREP/FLAVOR PACKS 5MG; 210GM; 0.74GM; 2.86GM; 5.6GM 5MG; 210GM; 0.74GM; 2.86GM; 5.6GM KIT Pref(2) no 1/29/2009 3/1/2009 KIT Pref(2) no 1/29/2009 3/1/ HECTOROL 1MCG CAPS Pref (2) yes 8/26/ /1/ HUMALOG KWIKPEN 100UNIT/ML SOLN Pref(2) yes 1/29/2009 3/1/ HUMALOG MIX 50/50 50%; 50% SUSP Pref(2) yes 1/29/2009 3/1/2009 KWIKPEN HUMALOG MIX 75/25 25%; 75% SUSP Pref(2) yes 1/29/2009 3/1/2009 KWIKPEN HUMULIN R U UNIT/ML SOLN Pref(2) yes 1/29/2009 3/1/ IMITREX STATDOSE 6MG/0.5ML KIT Pref (2); QL (4.00 per 25 days) yes 4/27/2009 6/1/ IMITREX STATDOSE 4MG/0.5ML KIT Pref (2); QL (4.00 per 25 days) yes 4/27/2009 6/1/ KADIAN 20MG CP24 Pref (2); QL (60.00 per 25 days) no 1/29/2009 3/1/ KADIAN 50MG CP24 Pref (2); QL (60.00 per 25 days) no 1/29/2009 3/1/ KADIAN 100MG CP24 Pref (2); QL (60.00 per 25 days) no 1/29/2009 3/1/ KADIAN 30MG CP24 Pref (2); QL (60.00 per 25 days) no 1/29/2009 3/1/ KADIAN 60MG CP24 Pref (2); QL (60.00 per 25 days) no 1/29/2009 3/1/ KADIAN 200MG CP24 Pref (2); QL (60.00 per 25 days) no 1/29/2009 3/1/ KADIAN 10MG CP24 Pref (2); QL (60.00 per 25 days) no 1/29/2009 3/1/ KADIAN 80MG CP24 Pref (2); QL (60.00 per 25 days) no 1/29/2009 3/1/ KAPIDEX 30MG CPDR Pref (3); QL (90.00 per 365 days) no 9/25/ /1/ /26/ November 09 H0154 Provider HPMS Modification Report_4TIER_Cumulative s.xls

4 ulary ulary Effective KAPIDEX 60MG CPDR Pref (3); QL (90.00 per 365 days) no 9/25/ /1/ LANOXIN 0.125MG TABS Pref(2) no 1/29/2009 3/1/ LANOXIN 0.25MG TABS Pref(2) no 1/29/2009 3/1/ LANTUS FOR OPTICLIK 100UNIT/ML SOLN Pref(2) yes 1/29/2009 3/1/ LEVETIRACETAM 1000MG TABS Pref(1) no 3/24/2009 5/1/ LEVETIRACETAM 100MG/ML SOLN Pref(1) no 3/24/2009 5/1/ LEVETIRACETAM 250MG TABS Pref(1) no 3/24/2009 5/1/ LEVETIRACETAM 500MG TABS Pref(1) no 3/24/2009 5/1/ LEVETIRACETAM 750MG TABS Pref (4); PA no 1/29/2009 3/1/ LIOTHYRONINE 5MCG TABS Pref (1) no 6/26/2009 8/1/ LIOTHYRONINE 25MCG TABS Pref (1) no 6/26/2009 8/1/ LIOTHYRONINE 50MCG TABS Pref (1) no 6/26/2009 8/1/ MYCOPHENOLATE 500MG TABS Pref (1); PA(Part B) no 5/26/2009 7/1/2009 MOFETIL MYCOPHENOLATE 250MG CAPS Pref (1); PA(Part B) no 5/26/2009 7/1/2009 MOFETIL NEXT CHOICE 0.75MG TABS Pref(1) no 8/26/ /1/ NORDITROPIN NORDIFLEX PEN 5MG/1.5ML SOLN Pref (4); PA (Growth Hormone) yes 3/24/2009 5/1/ NULYTELY/FLAVOR 420GM; 1.48GM; SOLR Pref(3) yes 1/29/2009 3/1/ OLUX-E 0.05% FOAM Pref (3); ST(new starts)(#1:topical IMMUNOSUPRESSANT) no 1/30/2009 3/1/ OMEPRAZOLE 40MG CPDR Pref (1); QL (90.00 per 365 days) yes 3/24/2009 5/1/ ONGLYZA 2.5MG TABS Pref(2) no 9/25/ /1/ ONGLYZA 5MG TABS Pref(2) no 9/25/ /1/ OXALIPLATIN 50MG/10ML SOLN Pref (4) no 8/26/ /1/ OXALIPLATIN 100MG/20ML SOLN Pref (4) no 8/26/ /1/ OXYBUTYNIN CHLORIDE 5MG/5ML SYRP Pref(1) yes 1/29/2009 3/1/ OXYCODONE 325MG; 2.5MG TABS Pref(1) yes 5/26/2009 7/1/2009 /ACETAMINOPHEN OXYCODONE HCL 10MG TABS Pref(1) yes 1/29/2009 3/1/ OXYCODONE HCL 20MG TABS Pref(1) yes 1/29/2009 3/1/ PREZISTA 75MG TABS Pref (4) yes 2/25/2009 4/1/ PREZISTA 600MG TABS Pref (4) yes 1/29/2009 3/1/ PREZISTA 400MG TABS Pref (4) yes 1/29/2009 3/1/ /26/ November 09 H0154 Provider HPMS Modification Report_4TIER_Cumulative s.xls

5 ulary ulary Effective PROMACTA 25MG TABS Pref (4) no 2/25/2009 4/1/ PROMACTA 50MG TABS Pref (4) no 2/25/2009 4/1/ PROTRIPTYLINE HCL 5MG TABS Pref(1) no 3/24/2009 5/1/ PROTRIPTYLINE HCL 10MG TABS Pref(1) no 3/24/2009 5/1/ RELENZA DISKHALER 5MG/BLISTER AEPB Pref(2) no 4/27/2009 6/1/ RELISTOR 12MG/0.6ML SOLN Pref(2) no 1/29/2009 3/1/ RELISTOR 12MG/0.6ML KIT Pref(2) no 1/29/2009 3/1/ RENVELA 2.4GM PACK Pref(2) yes 9/25/ /1/ RENVELA 0.8GM PACK Pref(2) yes 9/25/ /1/ RIMANTADINE HCL 100MG TABS Pref(1) no 4/27/2009 6/1/ RISPERIDONE 1MG/ML SOLN Pref(1) yes 3/24/2009 5/1/ RISPERIDONE ODT 0.5MG TBDP Pref(1) yes 5/26/2009 7/1/ RISPERIDONE ODT 2MG TBDP Pref(1) yes 5/26/2009 7/1/ RISPERIDONE ODT 0.25MG TBDP Pref(1) yes 8/26/ /1/ RISPERIDONE ODT 3MG TBDP Pref(1) yes 8/26/ /1/ RISPERIDONE ODT 4MG TBDP Pref(1) yes 8/26/ /1/ REQUIP XL 6MG TB24 Pref(3) no 5/26/2009 7/1/ REQUIP XL 12MG TB24 Pref(3) no 1/29/2009 3/1/ SAVELLA 100MG TABS Pref(2) no 9/25/ /1/ SAVELLA 12.5MG TABS Pref(2) no 9/25/ /1/ SAVELLA 25MG TABS Pref(2) no 9/25/ /1/ SAVELLA 50MG TABS Pref(2) no 9/25/ /1/ SAVELLA TITRATION 0 MISC Pref(2) no 9/25/ /1/ SEROQUEL XR 50MG TB24 Pref(2) yes 8/26/ /1/ SEROQUEL XR 150MG TB24 Pref(2) yes 8/26/ /1/ SIMCOR 500MG; 20MG TB24 Pref(2) no 1/29/2009 3/1/ SIMCOR 750MG; 20MG TB24 Pref(2) no 1/29/2009 3/1/ SIMCOR 1000MG; 20MG TB24 Pref(2) no 1/29/2009 3/1/ SPRYCEL 100MG TABS Pref(2) yes 4/27/2009 6/1/ STALEVO MG; TABS Pref(2) yes 1/29/2009 3/1/ STALEVO MG; TABS Pref(2) yes 1/29/2009 3/1/ STAVUDINE 15MG CAPS Pref(1) no 3/24/2009 5/1/ STAVUDINE 20MG CAPS Pref(1) no 3/24/2009 5/1/ STAVUDINE 30MG CAPS Pref(1) no 3/24/2009 5/1/ STAVUDINE 40MG CAPS Pref(1) no 3/24/2009 5/1/ /26/ November 09 H0154 Provider HPMS Modification Report_4TIER_Cumulative s.xls

6 ulary ulary Effective STAVUDINE 1MG/ML SOLR Pref(1) no 5/26/2009 7/1/ SULFACETAMIDE 10% SOLN Pref (1) yes 2/25/2009 4/1/ SUMATRIPTAN 6MG/0.5ML SOLN Pref (1); QL (10.00 per 25 days) no 3/24/2009 5/1/ SUMATRIPTAN 25MG TABS Pref (1); QL (9.00 per 25 days) no 3/24/2009 5/1/ SUMATRIPTAN 50MG TABS Pref (1); QL (9.00 per 25 days) no 3/24/2009 5/1/ SUMATRIPTAN 100MG TABS Pref (1); QL (9.00 per 25 days) no 3/24/2009 5/1/ SUMATRIPTAN 4MG/0.5ML SOLN Pref (1); QL (10.00 per 25 days) no 4/27/2009 6/1/ TACROLIMUS 0.5MG CAPS Pref (1); PA(Part B) no 8/26/ /1/ TACROLIMUS 1MG CAPS Pref (1); PA(Part B) no 8/26/ /1/ TACROLIMUS 5MG CAPS Pref (1); PA(Part B) no 8/26/ /1/ TOBRAMYCIN 0.1%; 0.3% SUSP Pref(1) yes 3/24/2009 5/1/2009 /DEXAMETHASONE TOPIRAMATE 15MG CPSP Pref(1) no 5/26/2009 7/1/ TOPIRAMATE 25MG CPSP Pref(1) no 5/26/2009 7/1/ TOPIRAMATE 25MG TABS Pref(1) no 5/26/2009 7/1/ TOPIRAMATE 100MG TABS Pref(1) no 5/26/2009 7/1/ TOPIRAMATE 200MG TABS Pref(1) no 5/26/2009 7/1/ TOPIRAMATE 50MG TABS Pref(1) no 5/26/2009 7/1/ UNITHROID 137MCG TABS Pref(1) yes 1/29/2009 3/1/ URSODIOL 250MG TABS Pref(1) yes 8/26/ /1/ URSODIOL 500MG TABS Pref(1) yes 8/26/ /1/ VANCOMYCIN HCL ISO- OSMOTIC DEXTROSE 0; 500MG/100ML SOLN Pref(2) yes 3/26/2009 5/1/ VANCOMYCIN HCL ISO- 0; 1GM/200ML SOLN Pref(2) yes 3/26/2009 5/1/2009 OSMOTIC DEXTROSE VENLAFAXINE 37.5MG TB24 Pref(3) yes 6/26/2009 8/1/ VENLAFAXINE 75MG TB24 Pref(3) yes 6/26/2009 8/1/ VENLAFAXINE 150MG TB24 Pref(3) yes 6/26/2009 8/1/ VENLAFAXINE 225MG TB24 Pref(3) yes 6/26/2009 8/1/ VIMPAT 50MG TABS Pref(2) no 4/27/2009 6/1/ VIMPAT 100MG TABS Pref(2) no 4/27/2009 6/1/ VIMPAT 150MG TABS Pref(2) no 4/27/2009 6/1/ VIMPAT 200MG TABS Pref(2) no 4/27/2009 6/1/ VIMPAT 200MG/20ML SOLN Pref(2) no 5/26/2009 7/1/ /26/ November 09 H0154 Provider HPMS Modification Report_4TIER_Cumulative s.xls

7 ulary ulary Effective VOLTAREN 1% GEL Pref(2) no 1/29/2009 3/1/ XENAZINE 12.5MG TABS Pref (4); PA (XENAZINE) no 2/25/2009 4/1/ XENAZINE 25MG TABS Pref (4); PA (XENAZINE) no 2/25/2009 4/1/ XYZAL 5MG TABS Pref(3) no 5/27/2009 7/1/ XYZAL 2.5MG/5ML SOLN Pref(3) no 5/27/2009 7/1/2009 Modified AVINZA 30MG CP24 QL increased to 60 per 25 days yes 2/25/2009 4/1/ AVINZA 60MG CP24 QL increased to 60 per 25 days yes 2/25/2009 4/1/ AVINZA 90MG CP24 QL increased to 60 per 25 days yes 2/25/2009 4/1/ EMEND 40MG CAPS QL increased to 3 per 180 days yes 1/29/2009 3/1/ IMITREX 6MG/0.5ML SOLN QL increased to 10 per 25 days yes 2/25/2009 4/1/ LYRICA 25MG CAPS QL increased to 120 per 25 days yes 1/29/2009 3/1/ LYRICA 50MG CAPS QL increased to 120 per 25 days yes 1/29/2009 3/1/ LYRICA 75MG CAPS QL increased to 120 per 25 days yes 1/29/2009 3/1/ LYRICA 100MG CAPS QL increased to 120 per 25 days yes 1/29/2009 3/1/ LYRICA 150MG CAPS QL increased to 120 per 25 days yes 1/29/2009 3/1/ LYRICA 200MG CAPS QL increased to 120 per 25 days yes 1/29/2009 3/1/ LYRICA 225MG CAPS QL increased to 120 per 25 days yes 1/29/2009 3/1/ ZOMIG 5MG SOLN QL increased to 12 per 25 days yes 2/25/2009 4/1/ ZOMIG 2.5MG TABS QL increased to 12 per 25 days yes 2/25/2009 4/1/ ZOMIG 5MG TABS QL increased to 12 per 25 days yes 2/25/2009 4/1/ ZOMIG ZMT 2.5MG TBDP QL increased to 12 per 25 days yes 2/25/2009 4/1/ ZOMIG ZMT 5MG TBDP QL increased to 12 per 25 days yes 2/25/2009 4/1/ /26/ November 09 H0154 Provider HPMS Modification Report_4TIER_Cumulative s.xls