2017 Elderplan Formulary Addendum

Transcription

1 Elderplan Formulary Addendum Below is a list of formulary changes for the benefit year This is not a complete list of drugs covered by the Part D plan. The formulary changes are reflected in the 2017 downloadable formulary on the Elderplan website. For a complete list of drugs covered by Elderplan please visit our Web site at or call Member Services at , seven days a week, between the hours of 8 a.m. to 8 p.m. TTY/TDD users should call 711. ALPRAZOLAM TAB ODT ALPRAZOLAM TAB ER AMINOSYN M INJ 3.5% ANDROID CAP 10MG ASCOMP/COD CAP 30MG ATROPINE SUL SOL 1% OP AVONEX KIT 30MCG AVONEX PEN KIT 30MCG AVONEX PREFL KIT 30MCG BACIIM INJ 50000UNT BERINERT INJ 500UNIT Clonazepam ODT tabs (QL), Alprazolam tabs Clonazepam ODT tabs (QL), Alprazolam tabs Aminosyn II inj, Aminosyn-RF inj Andoderm patch (QL/PA), Danazol caps, Testosterone inj APAP/Codeine tabs (QL) Pilocarpine opth soln Betaseron (QL/PA), Copaxone 40mg (QL/PA), Glatopa (QL/PA), Gilenya (QL/PA) Betaseron (QL/PA), Copaxone 40mg (QL/PA), Glatopa (QL/PA), Gilenya (QL/PA) Betaseron (QL/PA), Copaxone 40mg (QL/PA), Glatopa (QL/PA), Gilenya (QL/PA) Azactam inj, Aztreonam inj, Cayston inj (PA), Vancomycin inj Cinryze inj (PA)

2 2 BIMATOPROST SOL 0.03% BUPRENORPHIN INJ 0.3MG/ML BUT/APAP/CAF CAP CODEINE BUT/ASA/CAF/ CAP COD 30MG BUTISOL SOD TAB 30MG CALCIPOTRIEN OIN 0.005% CDP/AMITRIP TAB CEFAZOLIN INJ 1GM/50ML CEFOTETAN INJ 10G CEREBYX INJ 500/10ML CHLORAMPHEN INJ 1GM CHLORDIAZEP CAP CHLOROTHIAZ INJ 500MG CICLOPIROX SOL 8% CLEMASTINE TAB 2.68MG CLOBETASOL AER 0.05% CLOBETASOL E CRE 0.05% CLOBETASOL GEL 0.05% Latanoprost opth sol, Lumigan 0.01% opth sol Buprenorphine sublingual tabs (QL/PA), Butorphanol inj, Nalbuphine inj APAP/Codeine tabs (QL) APAP/Codeine tabs (QL) Phenobarbital tabs (PA) Calcipotriene 0.005% cream Clorazepate, Lorazepam, Diazepam and Amitriptyline separately available, Cefazolin inj 500mg Cefoxitin inj, Cefuroxime inj Phenytoin caps Ceftriaxone inj Alprazolam tabs (QL), Lorazepam tabs (QL) Chlorthiazide tabs, HCTZ tabs Ciclopirox cream/gel, Nystatin powder Levocetirizine 5mg tabs, Cetirizine syrup

3 3 CLOBETASOL LOT 0.05% CLOBETASOL OIN 0.05% CLOBETASOL SHA 0.05% CLOBETASOL SOL 0.05% CLODAN SHA 0.05% CLONIDINE TAB 0.1MG ER CLOTRIM/BETA CRE DIPROP CLOTRIM/BETA LOT DIPROP COLCHICINE CAP 0.6MG CORMAX SCALP SOL 0.05% CUPRIMINE CAP 250MG CYCLOBENZAPR TAB 7.5MG CYCLOSET TAB 0.8MG CYRAMZA INJ DARAPRIM TAB 25MG Clonidine 0.1mg tabs, Guanfacine ER tabs (PA) Clotrimazole cream and Betamethasone Dipropionate cream- available separately Clotrimazole ointment and Betamethasone Dipropionate oint- available separately Colcrys 0.6mg tabs (QL) Depen Titra 250mg tabs, Syprine 250mg tabs Cyclobenzaprine 5mg tabs (PA), Baclofen tabs, Tizanidine tabs Bromocriptine caps/tabs Avastin inj (PA) Chloroquine tabs, Hydroxychloroquine tabs, Mefloquine tabs

4 4 DARZALEX SOL 100MG/5M DESVENLAFAX TAB ER DEXEDRINE TAB DEXMETHYLPH TAB DEXTROAMPHET TAB DICLOFENAC GEL 1% DICLOFENAC GEL 3% DIFLORASONE CRE 0.05% DIFLORASONE OIN 0.05% DULOXETINE CAP 40MG ECONAZOLE CRE 1% ELIDEL CRE 1% EMPLICITI INJ ENBREL INJ ENBREL SRCLK INJ 50MG/ML ERGOLOID MES TAB 1MG ORAL ERWINAZE INJ 10000UNT ESTAZOLAM TAB ESTROPIPATE TAB ETIDRON DISD TAB Herceptin inj (PA), Keytruda inj (PA), Rituxan inj (PA), Tecentriq inj (PA), Yervoy inj (PA) Pristiq caps (QL), Venlafaxine ER caps (QL) Amphetamine/Dextroamphetamine tabs (QL), Amphetamine ER caps (QL) Methylphenidate tabs (QL), Methylphenidate ER tabs (QL) Amphetamine/Dextroamphetamine tabs (QL), Amphetamine ER caps (QL) Diclofenac 1.5% sol Diclofenac 1.5% sol Halobetasol 0.05% cream Halobetasol 0.05% ointment Duloxetine 20mg caps (QL) Ketoconazole 2% cream Tacrolimus ointment Herceptin inj (PA), Keytruda inj (PA), Rituxan inj (PA), Tecentriq inj (PA), Yervoy inj (PA) Humira inj (QL/PA) Humira inj (QL/PA) Pimozide tabs Consult Health Care Professional Temazepam 7.5mg (QL/PA), Temazepam 15mg (QL/PA) Estradiol tabs (PA) Alendronate tabs (QL)

5 5 FENTANYL DIS 37.5MCG FENTANYL DIS 62.5MCG FENTANYL DIS 87.5MCG FLAVOXATE TAB 100MG FLECTOR DIS 1.3% FLUOCINONIDE CRE 0.05% FOLOTYN INJ 40MG/2ML FOMEPIZOLE INJ 1GM/ML FOSPHENYTOIN INJ 100/2ML GLYB/METFORM TAB GLYBURIDE TAB GUANIDINE TAB 125MG H.P. ACTHAR INJ 80UNIT HARVONI TAB MG HYPERRAB S/D INJ 150/ML ILARIS INJ 180MG IRENKA CAP 40MG IXEMPRA KIT INJ 45MG JEVTANA INJ 60/1.5ML KETEK TAB Fentanyl 25mcg (PA), Fentanyl 50mcg (PA), Fentanyl 75mcg (PA) Fentanyl 25mcg (PA), Fentanyl 50mcg (PA), Fentanyl 75mcg (PA) Fentanyl 25mcg (PA), Fentanyl 50mcg (PA), Fentanyl 75mcg (PA) Oxybutynin ER tabs (QL) Diclofenac 1.5% sol Fluocinonide 0.1% cream Adrucil inj, Alimta inj, Fludarabine inj, Fluorouracil inj, Methotrexate inj/tabs Consult Health Care Professional Phenytoin caps/soln Glipizide/Metformin tabs (QL) Glipizide tabs (QL) Pyridostigmine tabs Methotrexate tabs, Prednisone tabs, Humira inj (PA) Zepatier tabs (PA), Sovaldi (PA) Flebogamma inj DIF (PA), Bivigam inj 10% (PA) Araclyst (PA) Duloxetine 20mg caps (QL) Abraxane inj, Docetaxel inj, Paclitaxel inj Abraxane inj, Docetaxel inj, Paclitaxel inj Azithromycin tabs

6 6 KHEDEZLA TAB ER KINERET INJ LACTATED RIN SOL IRRIGAT LEVOCARNITIN INJ 200MG/ML LINDANE SHA 1% LUPRON DEPOT INJ 45MG MECLOFEN SOD CAP MEMANT TITRA PAK 5-10MG MENEST TAB MEPROBAMATE TAB METAPROTEREN SYP 10MG/5ML METAPROTEREN TAB METHYLD/HCTZ TAB METHYLDOPA TAB 250MG METHYLTESTOS CAP 10MG MONUROL PAK GRANULES NAMENDA TAB 5-10MG NEVANAC SUS 0.1% NYSTAT/TRIAM CRE NYSTAT/TRIAM OIN Duloxetine caps (QL), Venlafaxine tabs, Venlafaxine ER caps (QL) Humira inj (QL/PA) Sterile Water Irrigation Soln Levocarnitine sol 1gm/10ml, Levocarnitine 330mg tabs Malathion 0.5% lotion, Permethrin 5% cream Lupron Depot 22.5mg inj (PA), Eligard inj, Trelstar Mix inj (PA) Diclofenac sodium tabs, Naproxen tabs, Ibuprofen tabs Memantine tabs (PA) Estradiol tabs (PA) Buspirone tabs, Hydroxyzine tabs (PA) Albuterol Neb soln, Terbutaline inj 1mg/ml Albuterol tabs, Terbutaline tabs Clonidine and HCTZ tabs- available separately Clonidine tabs Andoderm patch (QL/PA), Danazol caps, Testosterone inj Methenamine 1gm tabs, Nitrofurantoin caps (PA) Memantine tabs (PA) Bromfenac 0.09% opth sol, Diclofenac 0.1% opth sol, Ketorolac 0.4% opt sol, Ketorolac 0.5% opth sol Nystatin cream and Triamcinolone creamavailable separately Nystatin ointment and Triamcinolone ointment- available separately

7 7 OFLOXACIN TAB 400MG OLANZA/FLUOX CAP ONCASPAR INJ 750/ML OPDIVO INJ 40MG/4ML ORENCIA INJ OXAZEPAM CAP OXYMORPHONE TAB ER PEG-INTRON KIT PERPHEN/AMIT TAB PHYSIOSOL SOL IRRIGAT PREDNISONE PAK PREMPHASE TAB PROCAINAMIDE INJ QUINIDINE GL INJ 80MG/ML REBIF INJ REBIF REBIDO INJ REBIF TITRTN INJ PACK RINGERS IRR SOL ROZEREM TAB 8MG SECONAL SOD CAP 100MG Ciprofloxacin tabs, Levofloxacin tabs Olanzapine and Fluoxetine- available separately Consult Health Care Professional Herceptin inj (PA), Keytruda inj (PA), Rituxan inj (PA), Tecentriq inj (PA), Yervoy inj (PA) Humira inj (QL/PA) Alprazolam tabs (QL), Lorazepam tabs (QL) Hydromorphone tabs (QL), Morphine Sulfate ER tabs (QL), Oxycodone tabs (QL) Pegasys inj (PA), Ribavirin caps/tabs Perphenazine and Amitriptyline- available separately Sterile Water Irrigation Soln Prednisone tabs Fyavolv tabs (PA), Jinteli (PA) Disopyramide caps (PA), Quinidine sulfate tabs Disopyramide caps (PA), Quinidine sulfate tabs Betaseron 0.3mg inj (QL/PA) Betaseron 0.3mg inj (QL/PA) Betaseron 0.3mg inj (QL/PA) Sterile Water Irrigation Soln Hetlioz 20mg caps (PA) Phenobarbital tabs (PA)

8 8 SOD LACTATE INJ 5MEQ/ML SYNALGOS-DC CAP TEMAZEPAM CAP 22.5MG TEMAZEPAM CAP 30MG TOLAZAMIDE TAB TOLBUTAMIDE TAB 500MG TRAVOPROST DRO 0.004% TRIAZOLAM TAB TRIHEXYPHEN TAB TYZINE PED DRO 0.05% VARIZIG INJ 125UNIT VENLAFAXINE TAB ER VIRAZOLE INH 6GM VOLTAREN GEL 1% ZALTRAP INJ 100/4ML ZARXIO INJ ZENZEDI TAB ZOLPIDEM ER TAB ZYFLO TAB 600MG Consult Health Care Professional Hydrocodone/APAP tabs (QL), Naproxen tabs, Ibuprofen tabs Temazepam 7.5mg (QL/PA), Temazepam 15mg (QL/PA) Temazepam 7.5mg (QL/PA), Temazepam 15mg (QL/PA) Glimepiride tabs (QL), Glipizide tabs (QL), Glipizide ER tabs (QL) Glimepiride tabs (QL), Glipizide tabs (QL), Glipizide ER tabs (QL) Travatan Z 0.004% opth sol, Latanoprost opth sol Temazepam 7.5mg (QL/PA), Temazepam 15mg (QL/PA) Benztropine tabs (PA) Consult Health Care Professional Flebogamma inj DIF (PA), Bivigam inj 10% (PA) Venlafaxine ER caps (QL), Venlafaxine tabs Consult Health Care Professional Diclofenac 1.5% sol Avastin inj (PA) Neupogen inj (PA), Neulasta inj (PA), Granix inj (PA) Vyvanse caps (QL) Zolpidem tabs (PA/QL) Montelukast tabs, Zafirlukast tabs If we remove drugs from our formulary, or add prior authorization, quantity limits, tiering and/or step therapy

9 9 restrictions on a drug, you may ask Elderplan to make an exception to our coverage rules. To request a formulary or utilization restriction exception, please contact CVS/ Caremark at , 24 hours a day, 7 days a week. TTY/TDD users should call711. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1,2018. Elderplan is an HMO plan with Medicare and Medicaid contracts. Enrollment in Elderplan depends on contract renewal. The Formulary may change at any time. You will receive notice when necessary. Elderplan, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Elderplan, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. ATTENTION: If you speak a non-english language or require assistance in ASL, language assistance services, free of charge, are available to you. Call (TTY: 711). (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711). (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). )Yiddish* אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט (TTY: 711) (Bengali) ক য কর ন đć আন Čৎ ৎ, কĆৎ Č তą ৎতĒন, ąৎ ত ন খĒচৎয় ďৎৎ ৎয়ąৎ ĒতČৎ উ ব আতছ ফপৎন কর ন (TTY: 711) (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711).. -1 ΑرقϢ ΗصϞ.ΎϩΎجϣ ϟك ΘΗىϓر ϠϟػىΔ ϤϟشΎعدΓ خدΕΎϣ ϓئϧ ASL ϓي ϣشύعدγ إϟى ΗحΎΘج أو غ ر إلϩجϠ زΔ Δػϟ ΘΗحدΙ لنΖ إذ ( ϠϣحىظΔ : Arabic* (TTY: 711)

10 10 (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). ( Urdu )خΒردر: گر آپ ردو ΑىΘϟے ہ ں Ηى آپ کى زϧΎΑ کی ϣدد کی خدΕΎϣ ϣ ں Ζϔϣ دسΏΎ Θ ہ ں کϝΎ کر ں (TTY: 711) (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέφονται δωρεάν. Καλέστε (TTY: 711). (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711).