Medicare Part D 2017 Formulary Changes OC Preferred
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- Alyson Francis
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1 Medicare Part D 2017 Formulary s OC Preferred Inter Valley Health Plan may add or remove drugs from our formulary during the year. If we remove a drug from our formulary, add prior authorization, quantity limits and/or step therapy restrictions or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the U.S. Food and Drug Administration (FDA) determines a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. The table below outlines changes made to our formulary throughout VERSION: FORMULARY ADDITIONS UPDATE AS OF JUNE 1, 2017: FORMULARY ID: Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of Utilization Management to an existing formulary drug Covered Drug Name Tier Utilization Management Notes BUTRANS DIS 10MCG/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BUTRANS DIS 15MCG/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BUTRANS DIS 20MCG/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BUTRANS DIS 5MCG/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BUTRANS DIS 7.5/HR BUPRENORPHINE ADDITION 6/1/ QL (4 PER 28 DAYS) BYDUREON INJ BYDUREON INJ EXENATIDE EXTENDED RELEASE EXENATIDE EXTENDED RELEASE REDUCTION 6/1/ QL (4 PER 28 DAYS) REDUCTION 6/1/ QL (4 PER 28 DAYS) FARXIGA TAB 10MG DAPAGLIFLOZIN ADDITION 6/1/ FARXIGA TAB 5MG DAPAGLIFLOZIN ADDITION 6/1/
2 Tier Utilization Management Notes FLECTOR DIS 1.3% DICLOFENAC ADDITION 6/1/ HYSINGLA ER TAB 100 MG HYSINGLA ER TAB 120 MG HYSINGLA ER TAB 20 MG HYSINGLA ER TAB 30 MG HYSINGLA ER TAB 40 MG HYSINGLA ER TAB 60 MG HYSINGLA ER TAB 80 MG KISQALI TAB 200DOSE RIBOCICLIB ADDITION 6/1/ PA KISQALI TAB 400DOSE RIBOCICLIB ADDITION 6/1/ PA KISQALI TAB 600DOSE RIBOCICLIB ADDITION 6/1/ PA OXYCONTIN TAB 10MG CR OXYCONTIN TAB 15MG CR OXYCONTIN TAB 20MG CR OXYCONTIN TAB 30MG CR OXYCONTIN TAB 40MG CR 2
3 Tier Utilization Management Notes OXYCONTIN TAB 60MG CR OXYCONTIN TAB 80MG CR TRULICITY INJ 0.75/0.5 DULAGLUTIDE ADDITION 6/1/ QL (2 PER 28 DAYS) TRULICITY INJ 1.5/0.5 DULAGLUTIDE ADDITION 6/1/ QL (2 PER 28 DAYS) XIGDUO XR TAB XIGDUO XR TAB MG XIGDUO XR TAB MG XIGDUO XR TAB 5-500MG SELZENTRY TAB 25MG MARAVIROC ADDITION 5/1/ SELZENTRY TAB 75MG MARAVIROC ADDITION 5/1/ APREPITANT CAP 40MG EMEND ADDITION 5/1/ QL (30 PER 30 DAYS), PA APREPITANT CAP 80MG EMEND ADDITION 5/1/ QL (30 PER 30 DAYS), PA APREPITANT CAP 125MG EMEND ADDITION 5/1/ QL (30 PER 30 DAYS), PA MIRCERA INJ 50MCG MIRCERA INJ 75MCG 3
4 Tier Utilization Management Notes MIRCERA INJ 100MCG MIRCERA INJ 200MCG ASA/DIPYRIDA CAP MG AGGRENOX ADDITION 5/1/ QL (60 PER 30 DAYS) AMIFOSTINE INJ 500MG AMIFOSTINE DELETION 4/1/ PA AMIODARONE TAB 100MG PACERONE ADDITION 4/1/ DOXYCYCL HYC INJ 100MG DOXY DELETION 4/1/ PA LOPIN/RITON SOL 80-20/ML KALETRA ADDITION 4/1/ QL (480 PER 30 DAYS) MENOMUNE INJ A/C/Y/W MENINGOCOCCAL POLYSACCHARIDE VACCINE DELETION 4/1/ NECON TAB 1/35 ETHINYL ESTRADIOL AND NORETHINDRONE DELETION 4/1/ MOP CAP 10MG METHOXSALEN DELETION 3/1/ PA ABACA/LAMIVU TAB EPZICOM ADDITION 3/1/ QL (30 PER 30 DAYS) A-HYDROCORT INJ 100MG CORTEF DELETION 3/1/ PA BUPROBAN TAB 150MG BUPROPION DELETION 3/1/ QL (90 PER 30 DAYS) CERVARIX INJ HUMAN PAPILLOMAVIRUS (HPV) BIVALENT(TYPES 16,18) RECMB VAC DELETION 3/1/ DOCEFREZ INJ 20MG DOCETAXEL DELETION 3/1/ PA ERGOMAR SUB 2MG ERGOTAMINE DELETION 3/1/ EZETIMIBE TAB 10MG ZETIA ADDITION 3/1/ QL (30 PER 30 DAYS) GENGRAF CAP 50MG NEORAL ADDITION 3/1/ PA KYPROLIS SOL 30MG CARFILZOMB ADDITION 3/1/ PA KYPROLIS SOL 60MG CARFILZOMB ADDITION 3/1/ PA LANTUS INJ SOLOSTAR INSULIN GLARGINE ADDITION 3/1/ QL (30 PER 30 DAYS) 4
5 Tier Utilization Management Notes LARTRUVO INJ 10MG/ML OLARATUMAB ADDITION 3/1/ PA MENEST TAB 2.5MG ESTERIFIED ESTROGENS DELETION 3/1/ METHOTREXATE INJ 25MG/ML METHOTREXATE ADDITION 3/1/ PA NAPHAZOLINE SOL 0.1% OP NAPHAZOLINE DELETION 3/1/ NIFEDICAL XL TAB 30MG PROCARDIA XL, ADALAT CC DELETION 3/1/ NIFEDICAL XL TAB 60MG PROCARDIA XL, ADALAT CC DELETION 3/1/ NILUTAMIDE TAB 150MG NILANDRON ADDITION 3/1/ QL (30 PER 30 DAYS) RANITIDINE INJ 150/6ML ZANTAC DELETION 3/1/ PA RASAGILINE TAB 0.5MG AZILECT ADDITION 3/1/ RASAGILINE TAB 1MG AZILECT ADDITION 3/1/ ROSUVASTATIN TAB 10MG CRESTOR ADDITION 3/1/ QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 20MG CRESTOR ADDITION 3/1/ QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 40MG CRESTOR ADDITION 3/1/ QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 5MG CRESTOR ADDITION 3/1/ QL (30 PER 30 DAYS), (90) RUBRACA TAB 200MG RUCAPARIB ADDITION 3/1/ PA RUBRACA TAB 300MG RUCAPARIB ADDITION 3/1/ PA STAVUDINE SOL 1MG/ML ZERIT DELETION 3/1/ QL (2400 PER 30 DAYS) TRAVOPROST DRO 0.004% TRAVATAN DELETION 3/1/ TYZEKA TAB 600MG TELBIVUDINE DELETION 3/1/ PA VITEKTA TAB 150MG ELVITEGRAVIR DELETION 3/1/ QL (30 PER 30 DAYS) VITEKTA TAB 85MG ELVITEGRAVIR DELETION 3/1/ QL (30 PER 30 DAYS) XIIDRA DRO 5% LIFITEGRAST ADDITION 3/1/ QL (60 PER 30 DAYS) YONDELIS INJ 1MG TRABECTEDIN ADDITION 3/1/ PA ZERIT SOL 1MG/ML STAVUDINE ADDITION 3/1/ QL (2400 PER 30 DAYS) 5
6 Tier Utilization Management Notes 6
7 Tier Utilization Management Notes 7
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