2018 Drug List Negative Changes Updated 10/25/2018 The table below shows changes made to our 2018 List of Covered Drugs (Formulary).
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1 2018 Drug List Negative s Updated 10/25/2018 The table below shows changes made to our 2018 List of Covered Drugs (Formulary). Date of 1/1/2018 COLYTE-FLAVOR PACKS SOLR 227.1GM- 21.5GM-5.53GM- 2.82GM-6.36GM 1/1/2018 EGRIFTA SOLR 2 1/1/2018 MENHIBRIX SOLR 1/1/2018 METHYLPHENIDATE HCL ER TBCR 18 METHYLPHENIDATE HCL ER 1/1/2018 molindone hcl 5mg tabs 1/1/2018 PRENAISSANCE BALANCE CAPS Removed non-medicaid and non-part D eligible drug. 1/1/2018 RASUVO SOAJ 27.5 /0.55ML RASUVO SOAJ 7.5 /0.15ML, 10 /0.2ML, 12.5 /0.25ML, 15 /0.3ML, 17.5 /0.35ML, 22.5 /0.45ML, 25 /0.5ML and 30 /0.6ML H1723_18_FormChgWeb_Approved_
2 1/1/2018 TAB-A-VITE WOMENS TABS CENTRUM PERFORMANCE 1/1/2018 ticlopidine hcl TABS 1/1/2018 TREANDA SOLN 180 /2ML, 45 /0.5ML TREANDA SOLR 1/1/2018 VIIBRYD KIT 1/1/2018 VP-CH-PNV CAPS Removed non-medicaid and non-part D eligible drug. 2/1/2018 INTRON A W/DILUENT SOLR INTRON A SOLR 2/1/2018 LOCORT 11-DAY TBPK 2/1/2018 LOCORT 7-DAY TBPK 2/1/2018 NEWGEN TABS Removed non-part D eligible drug (not on NESTABS TABS 2/1/2018 OTREXUP SOAJ 7.5 /0.4ML
3 2/1/2018 ZONACORT 11 DAY TBPK 2/1/2018 ZONACORT 7 DAY TBPK 3/1/2018 IRON FORMULA CAPS 4/1/2018 DIABETA TABS 1.25 glyburide tabs or 1.25 mg 4/1/2018 DIABETA TABS 2.5 glyburide tabs or 2.5 mg 4/1/2018 DIABETA TABS 5 glyburide tabs or 5 mg 4/1/2018 didanosine CPDR 125 4/1/2018 DILAUDID SOLN IJ 2 /ML 4/1/2018 FERGON TABS ferrous gluconate tabs or 240 mg 4/1/2018 molindone hcl 10mg tabs
4 4/1/2018 molindone hcl 25mg tabs 4/1/2018 PROMETHAZINE/PHEN YLEPHRINE Removed non-part D eligible drug (not on promethazine & phenylephrine syrp 4/1/2018 TYZEKA TABS 5/1/2018 GEMCITABINE HYDROCHLORIDE SOLN 2 GM/20ML 5/1/2018 NEVIRAPINE SUSP 50 /5ML Removed non-part D eligible drug (not on VIRAMUNE SUSP 50 /5ML 5/1/2018 TIMOPTIC-XE SOLG 0.5% 6/1/2018 IMOGAM RABIES-HT SOLN Removed non-part D eligible drug (not on HYPERRAB S/D SOLN 6/1/2018 PREDNISOLONE ACETATE P-F Removed non-part D eligible drug (not on 6/1/2018 BRINTELLIX TABS 5 TRINTELLIX TABS 5 6/1/2018 BRINTELLIX TABS 10 TRINTELLIX TABS 10
5 6/1/2018 BRINTELLIX TABS 20 TRINTELLIX TABS 20 6/1/2018 desmopressin acetate refrigerated SOLN DDAVP SOLN NA 0.01 % 6/1/2018 lindane LOTN 7/1/2018 acetic acid-aluminum acetate soln 7/1/2018 oxycodone w/ acetaminophen soln 5mg/5ml-325mg/5ml 7/1/2018 NITROMIST AERS NITROGLYCERIN LINGUAL AERS 7/1/2018 methotrexate Sodium Inj PF 100 /4ML 7/1/2018 methotrexate Sodium Inj PF 200 /8ML 7/1/2018 HAIR/SKIN/NAILS TABS UNIT-150MCG MCG-400MCG- 300MCG CENTRUM CARDIO TABS, CENTRUM ULTRA WOMENS TABS
6 7/1/2018 MEGA MULTI MEN TBCR 7/1/2018 MEGA MULTI WOMEN TBCR 7/1/2018 DAILY MULTIPLE VITAMIN PLUS IRON TABS 7/1/2018 EQL MEGA SELECT WOMENS TABS ENDUR-VM TBCR, ENDUR-VM WITH IRON TBCR, ULTRA MEGA TWO TBCR ENDUR-VM TBCR, ENDUR-VM WITH IRON TBCR, ULTRA MEGA TWO TBCR Multiple Vitamins w/ Iron Tab Multiple Vitamins w/ Minerals Tab 7/1/2018 EQL MEGA SELECT MENS TABS 7/1/2018 EQL ONE DAILY DIET SUPPORT TABS 7/1/2018 EQL ONE DAILY MENS 50+ ADVANCED TABS 7/1/2018 MULTIVITAL PLATINUM TABS Multiple Vitamins w/ Minerals Tab Multiple Vitamins w/ Minerals Tab Multiple Vitamins w/ Minerals Tab Multiple Vitamins w/ Minerals Tab 7/1/2018 B-100 COMPLEX TABS B Complex
7 7/1/2018 biotin TABS OR 800 MCG 7/1/2018 CAMINO PRO RESTORE/GLYTACTIN LIQD 7/1/2018 COMPLETE NUTRITION LIQD 7/1/2018 COMPLETE NUTRITION PLUS LIQD 7/1/2018 EQL NUTRITIONAL DRINK PLUS LIQD 7/1/2018 EQL ONE DAILY MENS 50+ ADVANCED TABS 7/1/2018 EQL PEDIATRIC BALANCED NUTRITION DRINK LIQD 7/1/2018 EQL PEDIATRIC BALANCED NUTRITION DRINK WITH FIBER LIQD 7/1/2018 EQL PROTECTAVISION CAPS 7/1/2018 EQL SUPER ENERGY BOOSTER PACK
8 7/1/2018 HEMOCYTE-F ELIX 7/1/2018 ZINC LOZENGES/VITAMIN C LOZG /1/2018 EQL NUTRITIONAL DRINK ADVANCED LIQD 8/1/2018 acyclovir sodium solr 500 mg 8/1/2018 GILENYA CAP 0.25 Removed non-part D eligible drug (CMS excluded clinic pack) 8/1/2018 PREMESISRX Removed non-medicaid and non-part D eligible drug. PRENATE AM 8/1/2018 ZODEX 6-DAY TBPK 9/1/2018 BENDAMUSTINE HYDROCHLORIDE SOLN Removed non-part D eligible drug (CMS excluded labeler code) BENDEKA SOLN 9/1/2018 KEYTRUDA SOLR 9/1/2018 NUEDEXTA Added prior authorization for new starts
9 9/1/2018 THERANATAL LACTATION SUPPORT MISC 9/1/2018 VENLAFAXINE HCL ER THERANATAL LACTATION COMPLETE venlafaxine hcl er 10/1/2018 ONDANSETRON HYDROCHLORIDE SOLN Removed non-part D eligible drug (not on 10/1/2018 GLEOSTINE CAPS 5 10/1/2018 POTIGA TABS /1/2018 SODIUM CHLORIDE SOLN IV 0.9 % 10/1/ /1/2018 ISTODAX SOLR PEG-INTRON REDIPEN PAK 4 KIT Removed non-part D eligible drug (Unapproved drug other) ondansetron hcl sodium chloride soln iv 0.9% 11/1/2018 ORBACTIV for other options. 11/1/2018 FORTICAL SOLN calcitonin (salmon) soln for other options. Absolute Total Care (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits of both programs to enrollees.
10 The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Limitations, copays, and restrictions may apply. For more information, call Absolute Total Care Member Services or refer to the Absolute Total Care Member Handbook. Benefits and/or copays may change on January 1 of each year.
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