FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs during the year. If DHMC/CHP+ removes drugs from the formulary, or adds a restriction to an existing formulary drug, such as prior authorization, quantity limits and/or step therapy, [and/or moves a drug to a higher cost-sharing tier], DHMC/CHP+ will notify you of the change at least 10 days before the date that the change becomes effective. If the Food and Administration (FDA) deems a drug on the formulary to be unsafe, or the drug s manufacturer removes the drug from the market, DHMC/CHP+ will immediately remove the drug from the formulary. The table below outlines previous and/or recent changes to the formulary. The newest updates are highlighted in yellow. For questions or if you would like more information related to these changes please call the DHMC/CHP+ Pharmacy Services Department at 0-60-070 or 877-57-096. FORMULARY ABBREVIATIONS (Explanations can be found on the website in the DHMC/CHP+ Formulary and Pharmaceutical Management Procedures) LA = Limited Access (must be filled at DH Pharmacy or PA Required); PA = ; QL = ; ST = Atomoxetine Fondaparinux Syringes Buprenorphine/ Naloxone Film 8 mg/ mg Film Praziquantel Atovaquone/ Proguanil Addition Addition Addition Addition Generic Generic for Suboxone 8 mg/ mg Film Generic for Generic Biltricide from to 1; Generic for Norvir Cost Ritonavir Generic Tacrolimus Addition Addition Tradjenta Addition Addition s 10/01/018 LA, QL 07/01/018 LA, QL 07/01/018 LA, QL 07/01/018 LA 07/01/018 1 QL 07/01/018 LA 0/01/018 LA 0/01/018 LA, QL 0/01/018
Jentadueto Narcan Nasal Spray Buprenorphine Sublingual Estradiol Vaginal Cream Efavirenz Tenofovir Disoproxil Fumarate Atazanavir Aripiprazole s LA, QL 0/01/018 Addition Addition Addition Addition QL 0/01/018 Addition Addition LA, QL 0/01/018 Addition Addition 1 QL 0/01/018 Generic for Sustiva Generic for Viread Generic Generic LA 0/01/018 LA 0/01/018 Generic for Reyataz Generic LA 0/01/018 LA, QL 01/01/018 Metformin Cost Metformin LA 01/01/018 Extended-Release from 1 to Extended- (Generic ; Release for Fortamet) Limited Access (Generic for Glucophage XR) Lyrica Addition Addition LA, QL, PA 01/01/018 Oxycodone Addition Addition One Formulary LA, QL, ST 01/01/018 Extended-Release Long-Acting Opioid Victoza Pens Addition Addition One Formulary Diabetic Medication Priftin Addition Addition Abacavir Oral Generic Generic Solution Ziagen Eletriptan Imiquimod Generic Relpax from to 1; Limited Access Generic Sumatriptan and zolmitriptan LA, QL, ST 01/01/018 LA 01/01/018 LA 10/01/017 LA, QL, ST 10/01/017 1 10/01/017
Enoxaparin from to ; Limited Access Mavyret Addition Addition Entresto Addition Addition Risperdal Consta Addition Addition Oral Syringes Risperidone Jardiance Addition Addition One Formulary Diabetic Medication Codeine Products Tramadol Ondansetron and Oral- Disintegrating Norvir Vivitrol Vials Age Updated to 1 Years and Older Age for 1 Years and Older Increased from 0 Per 0 Days to 90 Per 0 Days from to FDA Safety Warning Labeling FDA Safety Warning Labeling s QL 10/01/017 LA, QL, PA 10/01/017 LA, QL 07/01/017 LA, QL, ST 07/01/017 LA, QL, ST 07/01/017 Age, QL 07/01/017 Age, QL 07/01/017 QL 07/01/017 LA 07/01/017 LA, QL 07/01/017
Antipyrine/ Benzocaine Otic Solution Atropine Ophthalmic Solution Cytra-K Crystals and Oral Solution Donnatal Elixir and Esterified Estrogens/ Methyltestosterone Hydrocortisone/ Pramoxine Rectal Cream Phenazopyridine Tacrolimus Ointment from 1 to ; Limited Access Regulatory Requirement Vyvanse Addition Addition Amphetamine Salts and Xarelto 0 mg Venlafaxine Extended-Release Fenofibrate Doxycycline and Duloxetine Aranesp Syringes and Vials s LA 07/01/017 Addition Addition Topical Corticosteroids LA, QL, ST 0/01/017 LA, QL, ST 0/01/017 or Methylphenidate LA, QL 0/01/017 Increased Increased and from to 1 Cost QL 0/01/017 QL 0/01/017 QL 0/01/017 1 QL 0/01/017 LA 01/01/017
Leukine Syringes and Vials Neupogen Syringes and Vials Epinephrine Auto- Injectors Generic Epipen and Epipen Jr s LA 01/01/017 LA 01/01/017 Generic 1 QL 01/01/017 Descovy Addition Addition LA 01/01/017 Genvoya Addition Addition LA 01/01/017 Odefsey Addition Addition LA 01/01/017 Vemlidy Addition Addition LA 01/01/017 Vivitrol Vials Addition Addition LA, QL, PA 01/01/017 Oseltamivir Generic Tamiflu Generic 1 QL 01/01/017 Abacavir/ Lamivudine Aripiprazole Lidocaine 5% Ointment Generic Epzicom ; from 1 to and Limited Access and s Generic Cost Sovaldi Deletion Cost Clozapine, Olanzapine, Quetipaine, Risperidone, Ziprasidone Lidocaine % Cream Epclusa, Harvoni, Zepatier LA 01/01/017 LA, QL, PA 01/01/017 Epclusa Addition Addition LA, QL 01/01/017 01/01/017 LA, PA, QL 10/01/016
s LA, PA, QL 10/01/016 Zepatier Addition Addition Mesalamine Generic Generic 10/01/016 Delayed-Release Asacol HD Colchicine Addition Addition LA, QL, ST 10/01/016 Guanfacine Extended-Release LA, QL 10/01/016 Acitretin Rosuvastatin ; Generic Crestor Methotrexate LA, ST 10/01/016 Generic LA, QL 07/01/016 Modafinil Addition Addition QL 07/01/016 Complera Addition Addition LA 07/01/016 Celecoxib QL 07/01/016 Diclofenac Gel Generic Voltaren Gel Generic 1 QL 07/01/016 Levitra Age QL 07/01/016