EFFECTIVE 01/04/2019 pimecrolimus 1 % cream (g) - ST Added: TOPICAL IMMUNOMODULATORS PAGE 1 LAST UPDATED 03/2019
EFFECTIVE 01/05/2019 LORBRENA 100 MG TABLET lorlatinib LORBRENA 25 MG TABLET lorlatinib TALZENNA 0.25 MG CAPSULE talazoparib tosylate TALZENNA 1 MG CAPSULE talazoparib tosylate VIZIMPRO 15 MG TABLET dacomitinib VIZIMPRO 30 MG TABLET dacomitinib VIZIMPRO 45 MG TABLET dacomitinib - QL Added: 30 / 30 DAYS - PA Added: LORLATINIB - QL Added: 30 / 30 DAYS - PA Added: LORLATINIB - PA Added: TALAZOPARIB - QL Added: 90 / 30 DAYS - QL Added: 30 / 30 DAYS - PA Added: TALAZOPARIB - QL Added: 30 / 30 DAYS - PA Added: DACOMITINIB - QL Added: 30 / 30 DAYS - PA Added: DACOMITINIB - QL Added: 30 / 30 DAYS - PA Added: DACOMITINIB PAGE 2 LAST UPDATED 03/2019
EFFECTIVE 01/10/2019 ACTEMRA ACTPEN 162 MG/0.9 ML tocilizumab levonorgestrel-ethin estradiol 0.1-0.02mg tablet nafcillin in dextrose,iso-osm 2 g/100 ml froz.piggy - PA Added: TOCILIZUMAB - Tier Decreased: Tier 2 to Tier 1 nafcillin sodium 2 g vial port PAGE 3 LAST UPDATED 03/2019
EFFECTIVE 01/11/2019 cinacalcet hcl 30 mg tablet - PA Added: Part D vs Part B cinacalcet hcl 60 mg tablet - PA Added: Part D vs Part B cinacalcet hcl 90 mg tablet - PA Added: Part D vs Part B vancomycin hcl 1.25 g vial PAGE 4 LAST UPDATED 03/2019
EFFECTIVE 01/15/2019 XIFAXAN 200 MG TABLET rifaximin XIFAXAN 550 MG TABLET rifaximin - PA Added: RIFAXIMIN - PA Added: RIFAXIMIN PAGE 5 LAST UPDATED 03/2019
EFFECTIVE 01/25/2019 CEROVITE JR TABLET CHEW pediatric multivitamin no.158/ferrous fumarate/phytonadione MICRODOT PEN NEEDLE 31GX6MM pen needle, diabetic MICRODOT PEN NEEDLE 32GX4MM pen needle, diabetic MICRODOT PEN NEEDLE 33GX4MM pen needle, diabetic - Added to Tier 3 polyvinyl alcohol/povidone 2.7%-2% drops - Added to Tier 3 PAGE 6 LAST UPDATED 03/2019
EFFECTIVE 02/01/2019 vigabatrin 500 mg tablet - PA Added: VIGABATRIN TABLET PAGE 7 LAST UPDATED 03/2019
EFFECTIVE 02/05/2019 DAURISMO 100 MG TABLET glasdegib maleate DAURISMO 25 MG TABLET glasdegib maleate VITRAKVI 100 MG CAPSULE larotrectinib sulfate VITRAKVI 20 MG/ML SOLUTION larotrectinib sulfate VITRAKVI 25 MG CAPSULE larotrectinib sulfate XOSPATA 40 MG TABLET gilteritinib fumarate - QL Added: 30 / 30 DAYS - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - QL Added: 60 / 30 DAYS - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - QL Added: 60 / 30 DAYS - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - QL Added: 300 / 30 DAYS - QL Added: 180 / 30 DAYS - PA Added: ANTINEOPLASTIC AGENTS Miscellaneous - QL Added: 90 / 30 DAYS PAGE 8 LAST UPDATED 03/2019
EFFECTIVE 02/08/2019 QC ANTI-DIARRHEAL 2 MG SOFTGEL loperamide hcl - Added to Tier 3 sirolimus 1 mg/ml solution - PA Added: Part D vs Part B toremifene citrate 60 mg tablet TRUE COMFORT PEN NDL 31GX5MM pen needle, diabetic TRUE COMFORT PEN NDL 31GX6MM pen needle, diabetic TRUE COMFORT PEN NDL 32GX4MM pen needle, diabetic PAGE 9 LAST UPDATED 03/2019
EFFECTIVE 02/15/2019 MUCUS-CHEST CONG 200 MG/10 ML guaifenesin - Added to Tier 3 ranitidine hcl 75 mg tablet - Added to Tier 3 tadalafil 20 mg tablet - QL Added: 60 / 30 DAYS - PA Added: TADALAFIL PAGE 10 LAST UPDATED 03/2019
EFFECTIVE 02/20/2019 loperamide hcl 2 mg capsule - Added to Tier 3 PAGE 11 LAST UPDATED 03/2019
EFFECTIVE 02/22/2019 acetaminophen 325 mg tablet - Added to Tier 3 acyclovir 5 % cream (g) fluticasone propion/salmeterol 100-50 mcg blst w/dev fluticasone propion/salmeterol 250-50 mcg blst w/dev fluticasone propion/salmeterol 500-50 mcg blst w/dev - QL Added: 60 / 30 DAYS - QL Added: 60 / 30 DAYS - QL Added: 60 / 30 DAYS PAGE 12 LAST UPDATED 03/2019
EFFECTIVE 02/25/2019 naproxen 375 mg tablet dr - ST Added: INFLAMMATION naproxen 500 mg tablet dr - ST Added: INFLAMMATION PAGE 13 LAST UPDATED 03/2019
EFFECTIVE 03/01/2019 ARANESP 150 MCG/0.75 ML VIAL darbepoetin alfa in polysorbate 80 - PA Removed: DARBEPOETIN loperamide hcl 2 mg capsule - Added to Tier 3 QC ANTI-DIARRHEAL 2 MG SOFTGEL loperamide hcl SM ANTI-DIARRHEAL 2 MG SOFTGEL loperamide hcl VEXOL 1% EYE DROPS rimexolone - Added to Tier 3 - Added to Tier 3 - QL Removed: 10 / 30 OVER TIME - PA Removed: OPHTHALMIC CORTICOSTEROIDS PAGE 14 LAST UPDATED 03/2019
EFFECTIVE 03/05/2019 SYMPAZAN 10 MG FILM clobazam SYMPAZAN 20 MG FILM clobazam SYMPAZAN 5 MG FILM clobazam PAGE 15 LAST UPDATED 03/2019
EFFECTIVE 03/08/2019 MAXICOMFORT PEN NDL 29G X 5MM pen needle, diabetic, safety MAXICOMFORT PEN NDL 29G X 8MM pen needle, diabetic, safety PRO COMFORT PEN NDL 4MM 32G pen needle, diabetic ranolazine 1000 mg tab er 12h ranolazine 500 mg tab er 12h SAFETY PEN NEEDLE 5MM X 31G pen needle, diabetic, safety ULTICARE PEN NEEDLES 6MM 32G pen needle, diabetic PAGE 16 LAST UPDATED 03/2019
EFFECTIVE 03/11/2019 chlordiazepoxide hcl 10 mg capsule - QL Added: 4 / DAY chlordiazepoxide hcl 25 mg capsule - QL Added: 4 / DAY chlordiazepoxide hcl 5 mg capsule - QL Added: 4 / DAY PAGE 17 LAST UPDATED 03/2019
EFFECTIVE 03/15/2019 aliskiren hemifumarate 150 mg tablet - PA Added: ALISKIREN aliskiren hemifumarate 300 mg tablet - PA Added: ALISKIREN CHLD ALLEGRA ALLERGY 30 MG ODT fexofenadine hcl ethinyl estradiol/drospirenone 0.02-3(24) tablet PERSERIS ER 120 MG SYRINGE KIT risperidone PERSERIS ER 90 MG SYRINGE KIT risperidone TREMFYA 100 MG/ML INJECTOR guselkumab - Added to Tier 98 - ST Added: Loratadine - QL Added: 1 / 30 DAYS - PA Added: PERSERIS - QL Added: 1 / 30 DAYS - PA Added: PERSERIS - PA Added: Interleukin 23 Receptor Antagonists PAGE 18 LAST UPDATED 03/2019
EFFECTIVE 03/20/2019 clotrimazole 2 % cream/appl - Added to Tier 3 loperamide hcl 2 mg capsule - Added to Tier 3 nicotine 7mg/24hr patch td24 - Added to Tier 3 - QL Added: 28 / 28 DAYS PAGE 19 LAST UPDATED 03/2019
EFFECTIVE 03/22/2019 ferrous sulfate 140(45)mg tablet er - Added to Tier 3 polyvinyl alcohol/povidone 0.5%-0.6% drops - Added to Tier 3 pyridostigmine bromide 60 mg/5 ml syrup PAGE 20 LAST UPDATED 03/2019
EFFECTIVE 04/01/2019 AIMOVIG 140 MG DOSE-2 AUTOINJ erenumab-aooe AIMOVIG 70 MG/ML AUTOINJECTOR erenumab-aooe amlodipine bes/olmesartan med 10 mg- 20mg tablet amlodipine bes/olmesartan med 10 mg- 40mg tablet amlodipine bes/olmesartan med 5 mg-20 mg tablet amlodipine bes/olmesartan med 5 mg-40 mg tablet amlodipine besylate/valsartan 10mg- 160mg tablet amlodipine besylate/valsartan 10mg- 320mg tablet amlodipine besylate/valsartan 5 mg- 160mg tablet amlodipine besylate/valsartan 5 mg- 320mg tablet - QL Added: 2 ML / 30 DAYS - PA Added: AIMOVIG - QL Added: 2 ML / 30 DAYS - PA Added: AIMOVIG armodafinil 150 mg tablet - QL Added: 30 / 30 DAYS - PA Added: ARMODAFINIL armodafinil 200 mg tablet - QL Added: 30 / 30 DAYS - PA Added: ARMODAFINIL armodafinil 250 mg tablet - QL Added: 30 / 30 DAYS - PA Added: ARMODAFINIL armodafinil 50 mg tablet - QL Added: 30 / 30 DAYS - PA Added: ARMODAFINIL PAGE 21 LAST UPDATED 03/2019
EFFECTIVE 04/01/2019 AZOPT 1% EYE DROPS brinzolamide bimatoprost 0.03 % drops citric acid/sodium citrate 334-500mg solution DIFFERIN 0.1% GEL adapalene - QL Added: 15 ML / 28 DAYS - ST Added: SIMBRINZA - Added to Tier 3 - Added to Tier 3 - QL Added: 45 / 30 OVER TIME - PA Added: TRETINOIN, TOPICAL fluocinolone acetonide oil 0.01 % drops - QL Added: 20 ML / 30 OVER TIME latanoprost 0.005 % drops LIBTAYO 350 MG/7 ML VIAL cemiplimab-rwlc - ST Added: SIMBRINZA - PA Added: ONCOLOGY GENERAL lidocaine 4 % cream (g) - Added to Tier 3 LUMIGAN 0.01% EYE DROPS bimatoprost LUMOXITI 1 MG VIAL moxetumomab pasudotox-tdfk NIVESTYM 300 MCG/ML VIAL filgrastim-aafi NIVESTYM 480 MCG/1.6 ML VIAL filgrastim-aafi PIN-X 250 MG (BASE) TAB CHEW pyrantel pamoate RHOPRESSA 0.02% OPHTH SOLUTION netarsudil mesylate - ST Added: SIMBRINZA - PA Added: ONCOLOGY GENERAL - PA Added: FILGRASTIM-AAFI - PA Added: FILGRASTIM-AAFI - Added to Tier 3 - ST Added: RHOPRESSA - QL Added: 5 ML / 30 DAYS PAGE 22 LAST UPDATED 03/2019
EFFECTIVE 04/01/2019 SIMBRINZA 1%-0.2% EYE DROPS brinzolamide/brimonidine tartrate SYLVANT 400 MG VIAL siltuximab TRAVATAN Z 0.004% EYE DROP travoprost UDENYCA 6 MG/0.6 ML SYRINGE pegfilgrastim-cbqv VYZULTA 0.024% OPHTH SOLUTION latanoprostene bunod ZIOPTAN 0.0015% EYE DROPS tafluprost/pf - QL Added: 8 ML / 28 DAYS - ST Added: SIMBRINZA - Removed From Coverage - ST Added: SIMBRINZA - QL Added: 5 ML / 28 DAYS - PA Added: PEGFILGRASTIM - ST Added: SIMBRINZA - QL Added: 5 ML / 28 DAYS - QL Removed: 5 ML / 28 DAYS - ST Added: SIMBRINZA PAGE 23 LAST UPDATED 03/2019