Health Partners Medicare Prime and Value (2017) Updates
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- Clara Lawson
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1 March/April 2017 Effective Date Brand Name Name Type of Change Previous Value New Value SPS sodium polystyrene sulfonate/sorbitol solution ORKAMBI ADRENACLICK ADRENACLICK levalbuterol tartrate hfa EXONDYS 51 EXONDYS 51 mesalamine PEDIARIX lumacaftor/ivacaftor epinephrine epinephrine levalbuterol tartrate eteplirsen eteplirsen mesalamine hep b virus,rcmb/dipth,pertus(acell ),tet,polio vaccine/pf KINRIX diphtheria, pertussis(acell),tetanus,polio vaccine/pf IMOGAM rabies immune globulin/pf RABIES-HT GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml mycophenolate mofetil mycophenolate mofetil hcl Brands Brands Brands Brands Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 1 UPDATED 03/2017
2 Effective Date Brand Name Name Type of Change Previous Value New Value ORENCIA CLICKJECT abatacept INFLECTRA infliximab-dyyb ethynodiol-ethinyl ethynodiol diacetate-ethinyl AMABELZ AMABELZ FEMYNOR LARISSIA ALYACEN CAMRESE LO /norethindrone acetate /norethindrone acetate norgestimate-ethinyl levonorgestrel-ethinyl norethindrone-ethinyl levonorgestrel/ethinyl and ethinyl norethin-eth norethindrone-ethinyl estra-ferrous fum /ferrous fumarate drospirenone-eth drospirenone/ethinyl estra-levomef /levomefolate calcium prednisone prednisone flurandrenolide TRIDESILON flurandrenolide desonide REMOVE FROM FORMULARY MYTESI crofelemer Non- Drug BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 2 UPDATED 03/2017
3 Effective Date Brand Name RELISTOR OCALIVA Name methylnaltrexone bromide obeticholic acid Type of Change Previous Value New Value Brands OCALIVA obeticholic acid PANCREAZE PERTZYE clindamycin phos-tretinoin MICORT-HC ALA-CORT lipase/protease/amylase lipase/protease/amylase clindamycin phosphate/tretinoin hydrocortisone acetate hydrocortisone Brands Brands methylphenidate methylphenidate hcl hcl cd,methylphenida te hcl er methylphenidate methylphenidate hcl hcl cd,methylphenida te hcl er GONITRO nitroglycerin nitroglycerin REPATHA PUSHTRONEX nitroglycerin nitroglycerin nitroglycerin evolocumab QBRELIS lisinopril olmesartan medoxomil olmesartan medoxomil Brands Brands Brands AFREZZA insulin regular, human Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 3 UPDATED 03/2017
4 Effective Date Brand Name AFREZZA Name insulin regular, human BASAGLAR insulin glargine,human KWIKPEN U-100 recombinant analog INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl INVOKAMET XR canagliflozin/metformin hcl metformin hcl er metformin hcl Type of Change Previous Value New Value metformin hcl er metformin hcl oseltamivir phosphate oseltamivir phosphate oseltamivir phosphate abacavirlamivudine oseltamivir phosphate oseltamivir phosphate oseltamivir phosphate abacavir sulfate/lamivudine valganciclovir hcl valganciclovir hcl quetiapine fumarate er quetiapine fumarate er quetiapine fumarate er quetiapine fumarate er quetiapine fumarate quetiapine fumarate quetiapine fumarate quetiapine fumarate Brands Brands Brands Brands Brands Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 4 UPDATED 03/2017
5 Effective Date Brand Name Name Type of Change Previous Value New Value quetiapine fumarate er rasagiline mesylate rasagiline mesylate pramipexole er KYPROLIS KYPROLIS RUBRACA RUBRACA epirubicin hcl nilutamide YONDELIS TREXIMET ergotaminecaffeine allopurinol sodium quetiapine fumarate rasagiline mesylate rasagiline mesylate pramipexole di-hcl carfilzomib carfilzomib rucaparib camsylate rucaparib camsylate epirubicin hcl nilutamide trabectedin sumatriptan succinate/naproxen sodium ergotamine tartrate/caffeine allopurinol sodium REMOVE FROM FORMULARY Brands GAMASTAN S-D immune Brands globulin,gamma(igg)/glycine LARTRUVO EMEND olaratumab Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 5 UPDATED 03/2017
6 Effective Date Brand Name NAMZARIC memantine hcl/donepezil hcl NAMZARIC NAMZARIC erythromycin ethylsuccinate ofloxacin EVZIO nitroglycerin Name Type of Change Previous Value New Value memantine hcl/donepezil hcl memantine hcl/donepezil hcl erythromycin ethylsuccinate ofloxacin naloxone hcl nitroglycerin CAZIANT desogestrel-ethinyl norgestimateethinyl norgestimate-ethinyl YUVAFEM AMETHIA LO levonorgestrel/ethinyl and ethinyl Non- Drug Non- Drug Non- Drug Brands norethindron- norethindrone acetate- ethinyl ethinyl ZARAH ethinyl /drospirenone prednisone prednisone ezetimibe ezetimibe ethacrynic acid ethacrynic acid BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 6 UPDATED 03/2017
7 Effective Date Brand Name Name Type of Change Previous Value New Value olmesartanamlodipine-hctz olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide olmesartanamlodipine-hctz olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide olmesartan- amlodipine-hctz olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide olmesartan- olmesartan hydrochlorothiazi medoxomil/hydrochlorothiazi de de olmesartan- olmesartan hydrochlorothiazi medoxomil/hydrochlorothiazi de de olmesartan- olmesartan hydrochlorothiazi medoxomil/hydrochlorothiazi de de amlodipineolmesartan amlodipineolmesartan amlodipineolmesartan amlodipineolmesartan olmesartanamlodipine-hctz amlodipine besylate/olmesartan medoxomil amlodipine besylate/olmesartan medoxomil amlodipine besylate/olmesartan medoxomil amlodipine besylate/olmesartan medoxomil olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 7 UPDATED 03/2017
8 Effective Date Brand Name Name Type of Change Previous Value New Value olmesartanamlodipine-hctz olmesartan medoxomil olmesartan medoxomil OTREXUP daptomycin omeprazolesodium bicarbonate omeprazolesodium bicarbonate amlodipine besylate atorvastatin calcium atorvastatin calcium metoprolol tartrate metoprolol succinate metoprolol succinate metoprolol succinate olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide olmesartan medoxomil olmesartan medoxomil methotrexate/pf daptomycin omeprazole/sodium bicarbonate omeprazole/sodium bicarbonate amlodipine besylate atorvastatin calcium atorvastatin calcium metoprolol tartrate metoprolol succinate metoprolol succinate metoprolol succinate REMOVE FROM FORMULARY REMOVE FROM FORMULARY Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 8 UPDATED 03/2017
9 Effective Date Brand Name Name Type of Change Previous Value New Value fenofibrate fenofibrate nanocrystallized fenofibrate fenofibrate pravastatin sodium warfarin sodium warfarin sodium warfarin sodium warfarin sodium nifedipine er,nifedipine pravastatin sodium warfarin sodium warfarin sodium warfarin sodium warfarin sodium nifedipine nifedipine nifedipine er,nifedipine nifedipine er nifedipine glipizide er glipizide glipizide xl glipizide duloxetine hcl duloxetine hcl duloxetine hcl glimepiride duloxetine hcl glimepiride BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 9 UPDATED 03/2017
10 Effective Date Brand Name Name Type of Change Previous Value New Value NIFEDICAL XL nifedipine NIFEDICAL XL nifedipine enalapril maleate enalapril maleate diltiazem er diltiazem hcl ADD UM: QUANTITY diltiazem 24hr cd diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem er diltiazem hcl bumetanide bumetanide bumetanide bumetanide pioglitazone hcl pioglitazone hcl pioglitazone hcl pioglitazone hcl azathioprine azathioprine sodium sodium abacavirlamivudine abacavir sulfate/lamivudine ELIQUIS apixaban CHANGE UM: QUANTITY oxybutynin chloride er oxybutynin chloride CHANGE UM: QUANTITY 2 / 1 DAYS 1 / 1 DAYS 1 / 1 DAYS 74 / 30 DAYS 2 / 1 DAYS BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 10 UPDATED 03/2017
11 Effective Date Brand Name Name Type of Change Previous Value New Value GENTAK gentamicin sulfate hydrocortisone hydrocortisone hydrocortisone hydrocortisone ACTEMRA tocilizumab SF 5000 PLUS sodium fluoride ZERIT stavudine lopinavir-ritonavir lopinavir/ritonavir norgestimateethinyl norgestimate-ethinyl azithromycin azithromycin REMOVE UM: QUANTITY oxiconazole nitrate oxiconazole nitrate SOLU-MEDROL methylprednisolone sodium succinate/pf,methylprednisol one sodium succinate spironolactone spironolactone torsemide verapamil er,verapamil hcl verapamil sr spironolactone spironolactone torsemide verapamil hcl verapamil hcl 10 / 30 DAYS Brands Brands BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 11 UPDATED 03/2017
12 Effective Date Brand Name Name Type of Change Previous Value New Value warfarin sodium warfarin sodium warfarin sodium warfarin sodium warfarin sodium warfarin sodium ramipril ramipril propranolol hcl propranolol hcl propranolol hcl propranolol hcl metoprolol succinate metoprolol succinate metformin hcl er metformin hcl lamotrigine lamotrigine labetalol hcl isosorbide mononitrate er glipizidemetformin fenofibrate labetalol hcl isosorbide mononitrate glipizide/metformin hcl fenofibrate nanocrystallized enalapril- enalapril hydrochlorothiazi maleate/hydrochlorothiazide de enalapril maleate enalapril maleate PAGE 12 BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. UPDATED 03/2017
13 Effective Date Brand Name Name Type of Change Previous Value New Value enalapril maleate enalapril maleate duloxetine hcl diltiazem er duloxetine hcl diltiazem hcl diltiazem 24hr cd diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem er diltiazem hcl diltiazem 24hr cd diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem 24hr er diltiazem hcl diltiazem er diltiazem hcl diltiazem 24hr cd diltiazem hcl diltiazem er abacavir diltiazem hcl abacavir sulfate bumetanide bumetanide diltiazem er diltiazem hcl BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 13 UPDATED 03/2017
14 Effective Date Brand Name Name Type of Change Previous Value New Value diltiazem er diltiazem hcl diltiazem 24hr cd diltiazem hcl diltiazem 24hr er diltiazem hcl acarbose acarbose acetazolamide acetazolamide acetazolamide acetazolamide amlodipinevalsartan amlodipine besylate/valsartan captopril captopril DILT-XR diltiazem hcl diltiazem hcl diltiazem hcl diltiazem hcl fenofibrate fenofibrate diltiazem hcl fenofibrate,micronized fenofibrate glipizide- glipizide/metformin hcl metformin irbesartan- irbesartan/hydrochlorothiazi hydrochlorothiazi de de BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 14 UPDATED 03/2017
15 Effective Date Brand Name Name Type of Change Previous Value New Value lamivudine lamivudine lamivudine lamivudine nisoldipine nisoldipine propranolol hcl propranolol hcl propranolol hcl propranolol hcl propranolol hcl propranolol hcl er,propranolol hcl propranolol hcl er,propranolol hcl propranolol hcl er,propranolol hcl propranolol hcl er,propranolol hcl quinapril hcl verapamil er,verapamil hcl verapamil sr verapamil er verapamil sr zidovudine propranolol hcl propranolol hcl propranolol hcl quinapril hcl verapamil hcl verapamil hcl verapamil hcl verapamil hcl zidovudine BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 15 UPDATED 03/2017
16 Effective Date Brand Name Name Type of Change Previous Value New Value amlodipine besylate DILT-CD,DILT- XR amlodipine besylate CHANGE UM: QUANTITY 2 / 1 DAYS 3 / 1 DAYS diltiazem hcl BRAND-NAME DRUGS are CAPITALIZED. drugs are lower-case italics. PAGE 16 UPDATED 03/2017
17 Health Partners Medicare is an HMO plan with Medicare and Pennsylvania State Medicaid program contracts. Enrollment in Health Partners Medicare depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary may change at any time. You will receive notice when necessary. H9207_HPM _NMR
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2 Cardiovascular System 2.1 Positive inotropic drugs Digoxin Digoxin specific antibody ( DigiFab ) 2.2 Diuretics 2.2.1 Thiazides and related diuretics Indapamide (1 st Line) Bendroflumethiazide Metolazone
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