Medicare Part D 2015 Formulary s Desert Preferred Choice 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 2015. VERSION: 22 2015 FORMULARY ADDITIONS UPDATE AS OF NOVEMBER 1, 2015: FORMULARY ID: 00015525 Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of to an existing formulary drug SOMATULINE INJ120/.5ML SOMATULINE INJ60/0.2ML SOMATULINE INJ90/0.3ML LANREOTIDE LANREOTIDE LANREOTIDE Tier Removed prior authorization 11/1/15 5 Removed prior authorization 11/1/15 5 Removed prior authorization 11/1/15 5 OTREXUP INJ10MG METHOTREXATE Addition 11/1/15 4 OTREXUP INJ15MG METHOTREXATE Addition 11/1/15 4 OTREXUP INJ20MG METHOTREXATE Addition 11/1/15 4 1
OTREXUP INJ25MG METHOTREXATE Addition 11/1/15 4 OTREXUP INJ7.5/0.4MG METHOTREXATE Addition 11/1/15 4 THIOTEPA INJ15MG THIOTEPA Addition 11/1/15 5 Tier ARIPIPRAZOLE TAB 10MG ABILIFY Addition 10/1/15 2 QL (90 per 30 days) ARIPIPRAZOLE TAB 15MG ABILIFY Addition 10/1/15 2 QL (60 per 30 days) ARIPIPRAZOLE TAB 20MG ABILIFY Addition 10/1/15 2 QL (60 per 30 days) ARIPIPRAZOLE TAB 2MG ABILIFY Addition 10/1/15 2 QL (450 per 30 days) ARIPIPRAZOLE TAB 30MG ABILIFY Addition 10/1/15 2 QL (30 per 30 days) ARIPIPRAZOLE TAB 5MG ABILIFY Addition 10/1/15 2 QL (180 per 30 days) AVASTIN INJ 400/16ML BEVACIZUMAB Addition 10/1/15 5 BEXAROTENE CAP 75MG TARGRETIN Addition 10/1/15 5 CYRAMZA INJ 100/10ML RAMUCIRUMAB Addition 10/1/15 5 CYRAMZA INJ 500/50ML RAMUCIRUMAB Addition 10/1/15 5 ERBITUX INJ 100MG CETUXIMAB Deletion 10/1/15 4 FOSCARNET INJ 24MG/ML FOSCARNET Deletion 10/1/15 4 HYPERRAB S/D INJ 150/ML RABIES IMMUNE GLOBULIN Addition 10/1/15 4 KADCYLA INJ 100MG ADO-TRASTUZUMAB EMTANSINE Deletion 10/1/15 5 2
Tier KEYTRUDA INJ 100MG/4M PEMBROLIZUMAB Addition 10/1/15 5 OFLOXACIN TAB 300MG FLOXIN Deletion 10/1/15 2 REXULTI TAB 0.25MG BREXPIPRAZOLE Addition 10/1/15 4 QL (480 per 30 days) REXULTI TAB 0.5MG BREXPIPRAZOLE Addition 10/1/15 4 QL (240 per 30 days) REXULTI TAB 1MG BREXPIPRAZOLE Addition 10/1/15 4 QL (120 per 30 days) REXULTI TAB 2MG BREXPIPRAZOLE Addition 10/1/15 4 QL (60 per 30 days) REXULTI TAB 3MG BREXPIPRAZOLE Addition 10/1/15 4 QL (30 per 30 days) REXULTI TAB 4MG BREXPIPRAZOLE Addition 10/1/15 4 QL (30 per 30 days) TEKAMLO TAB 150-10MG ALISKIREN AND AMOLODIPINE Deletion 10/1/15 3 QL (30 per 30 days) TEKAMLO TAB 150-5MG ALISKIREN AND AMOLODIPINE Deletion 10/1/15 3 QL (30 per 30 days) TEKAMLO TAB 300-10MG ALISKIREN AND AMOLODIPINE Deletion 10/1/15 3 QL (30 per 30 days) TEKAMLO TAB 300-5MG ALISKIREN AND AMOLODIPINE Deletion 10/1/15 3 QL (30 per 30 days) TETANUS TOX INJ 5LF ADS TETANUS TOXOID Deletion 10/1/15 3 U-CORT CRE 1% HYDROCORTISONE AND UREA Deletion 10/1/15 2 VECTIBIX INJ 100MG PANITUMUMAB Deletion 10/1/15 4 YERVOY INJ 50MG IPILIMUMAB Deletion 10/1/15 5 ABILIFY DISC TAB 10MG ARIPIPRAZOLE Deletion 9/1/2015 4 QL (90 per 30 days) ABILIFY DISC TAB 15MG ARIPIPRAZOLE Deletion 9/1/2015 4 QL (60 per 30 days) 3
Tier AVONEX PEN KIT 30MCG INTERFERON BETA-1A Addition 9/1/2015 5 QL (4 per 28 days), BREO ELLIPTA INH 200-25 FLUTICASONE AND VILANTEROL Addition 9/1/2015 3 QL (60 per 30 days) DULOXETINE CAP 40MG CYMBALTA Addition 9/1/2015 2 QL (90 per 30 days) ENBREL SRCLK INJ 50MG/ML ETANERCEPT Addition 9/1/2015 5 QL (8 per 28 days), HUMALOG KWIK INJ 100/ML INSULIN LISPRO Addition 9/1/2015 3 HUMALOG KWIK INJ 200/ML INSULIN LISPRO Addition 9/1/2015 3 HUMALOG INJ 100/ML INSULIN LISPRO Addition 9/1/2015 3 HYPERRAB S/D INJ 150/ML RABIES IMMUNE GLOBULIN Addition 9/1/2015 4 IRENKA CAP 40MG DULOXETINE Addition 9/1/2015 2 QL (90 per 30 days) NOVOLOG INJ PENFILL INSULIN ASPART Addition 9/1/2015 4 QL (30 per 30 days) PEGASYS INJ PROCLICK VARIZIG INJ 125 UNIT PEGINTERFERON ALFA- 2A Addition 9/1/2015 5 VARICELLA ZOSTER IMMUNE GLOBULIN Addition 9/1/2015 4 QL (2 per 28 days), ABILIFY 9.75MG INJ ARIPIPAZOLE Deletion 8/1/2015 4 ABILIFY SOL 1MG/ML ARIPIPAZOLE Deletion 8/1/2015 4 QL (900 per 30 days) AMTURNIDE 150-5-12.5 TABLETS ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE Deletion 8/1/2015 3 QL (30 per 30 days) 4
Tier AMTURNIDE 300-10-12.5 TABLETS AMTURNIDE 300-10-25MG TABLETS ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE Deletion 8/1/2015 3 QL (30 per 30 days) Deletion 8/1/2015 3 QL (30 per 30 days) AMTURNIDE 300-5-12.5 TABLETS ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE Deletion 8/1/2015 3 QL (30 per 30 days) AMTURNIDE 300-5-25MG TABLETS ALISKIREN,AMLODIPINE AND HYDROCHLOROTHIAZIDE Deletion 8/1/2015 3 QL (30 per 30 days) ANDROXY 10MG TABLETS FLUOXYMESTERONE Deletion 8/1/2015 3 GAMUNEX-C 1GM/10ML INJ IMMUNE GLOBULIN Addition 8/1/2015 5 HARVONI 90-400MG TABLETS LEDIPASVIR AND SOFOSBUVIR Addition 8/1/2015 5 HYDROXYZINE HCL 25MG/ML HYDROXYZINE Deletion 8/1/2015 4 HYDROXYZINE HCL 50MG/ML HYDROXYZINE Deletion 8/1/2015 4 LUFYLLIN 200MG TABLETS DYPHYLLINE Deletion 8/1/2015 2 PANTOPRAZOLE 40MG INJ PROTONIX Deletion 8/1/2015 4, QL (28 per 28 days) 5
Tier PEDI-DRI 100000 POW NYSTATIN Deletion 8/1/2015 1 PRISTIQ 25MG TABLETS DESVENLAFAXINE Addition 8/1/2015 4 QL (480 per 30 days) QUADRACEL INJ DIPTHERIA,TETANUS TOXOIDS,ACELLULAR PERTUSSIS AND Addition 8/1/2015 4 POLIOVIRUS VACCINE QUINIDINE SULF 300MG ER TABLETS QUINIDINE Deletion 8/1/2015 1 ADRUCIL INJ 500/10ML FLUOROURACIL Addition 6/1/2015 2 Prior AMP-SULBACTA INJ 1.5GM UNASYN Addition 6/1/2015 4 Prior BEXSERO INJ MENINGOCOCCAL GROUP B VACCINE Addition 6/1/2015 4 DAUNOXOME INJ 2MG/ML DAUNORUBICIN Addition 6/1/2015 4 Prior FARYDAK CAP 20MG PANOBINOSTAT Addition 6/1/2015 5 QL (6 per 21 days) FARYDAK CAP 10MG PANOBINOSTAT Addition 6/1/2015 5 QL (6 per 21 days) FARYDAK CAP 15MG PANOBINOSTAT Addition 6/1/2015 5 QL (6 per 21 days) FENTANYL DIS 37.5MCG FENTANYL Addition 6/1/2015 2 QL (30 per 30 days) FENTANYL DIS 62.5MCG FENTANYL Addition 6/1/2015 2 QL (30 per 30 days) FENTANYL DIS 87.5MCG FENTANYL Addition 6/1/2015 2 QL (30 per 30 days) FRAGMIN INJ 7500/0.3 DALTEPARIN Deletion 6/1/2015 5 QL (20 per 30 days), Prior ICLUSIG TAB 45MG PONATINIB Addition 6/1/2015 5 QL (30 per 30 days) LENVIMA CAP 10MG LENVATINIB Addition 6/1/2015 5 QL (30 per 30 days) LENVIMA CAP 14MG LENVATINIB Addition 6/1/2015 5 QL (60 per 30 days) LENVIMA CAP 20MG LENVATINIB Addition 6/1/2015 5 QL (60 per 30 days) LENVIMA CAP 24MG LENVATINIB Addition 6/1/2015 5 QL (90 per 30 days) LEVETIRACETAM INJ 10MG/ML LEVETIRACETAM Addition 6/1/2015 4 6
Tier LEVETIRACETAM INJ 15MG/ML LEVETIRACETAM Addition 6/1/2015 4 LEVETIRACETAM INJ 5MG/ML LEVETIRACETAM Addition 6/1/2015 4 MOVANTIK TAB 12.5MG NALOXEGOL OXALATE Addition 6/1/2015 4 QL (30 per 30 days) MOVANTIK TAB 25MG NALOXEGOL OXALATE Addition 6/1/2015 4 QL (30 per 30 days) OTEZLA TAB 10/20/30 APREMILAST Addition 6/1/2015 4 QL (60 per 30 days) RELISTOR INJ 8/0.4ML METHYLNALTREXONE Addition 6/1/2015 4 Prior RELISTOR INJ 12/0.6ML METHYLNALTREXONE Addition 6/1/2015 4 Prior SAIZEN INJ 8.8MG SOMATROPIN Addition 6/1/2015 5 Prior SUPRAX TAB 400MG CEFIXIME Deletion 6/1/2015 4 TARGRETIN GEL 1% BEXAROTENE Deletion 6/1/2015 5 QL (60 per 30 days) TYPHIM VI INJ TYPHOID VI POLYSACCHARIDE VACCINE Addition 6/1/2015 4 ZENATANE CAP 30MG ISOTRETINOIN Addition 6/1/2015 2 ZYPREXA RELP INJ 210MG OLANZAPINE Addition 6/1/2015 4 ABILIFY MAIN INJ 300MG ARIPIPRAZOLE Addition 5/1/2015 5 ABILIFY MAIN INJ 400MG ARIPIPRAZOLE Addition 5/1/2015 5 COUMADIN INJ 5 MG WARFARIN Deletion 5/1/2015 4 Prior ATAZANAVIR AND EVOTAZ TAB 300-150MG COBICISTAT Addition 5/1/2015 5 QL (30 per 30 days) FRAGMIN INJ 25000/ML DALTEPARIN Deletion 5/1/2015 4 Prior, QL (20 per 30 days) GLEOSTINE CAP 100MG LOMUSTINE Addition 5/1/2015 4 GLEOSTINE CAP 10MG LOMUSTINE Addition 5/1/2015 4 GLEOSTINE CAP 40MG LOMUSTINE Addition 5/1/2015 4 IBRANCE CAP 100MG PALBOCICLIB Addition 5/1/2015 5 QL (30 per 30 days) IBRANCE CAP 125MG PALBOCICLIB Addition 5/1/2015 5 QL (30 per 30 days) 7
Tier IBRANCE CAP 75MG PALBOCICLIB Addition 5/1/2015 5 QL (30 per 30 days) LAMOTRIGINE TAB ODT 25MG LAMICTAL Addition 5/1/2015 2 LAMOTRIGINE TAB ODT 50MG LAMICTAL Addition 5/1/2015 2 LAMOTRIGINE TAB ODT/100MG LAMICTAL Addition 5/1/2015 2 LAMOTRIGINE TAB ODT/200MG LAMICTAL Addition 5/1/2015 2 DARUNAVIR AND PREZCOBIX TAB 800-150MG COBICISTAT Addition 5/1/2015 5 QL (30 per 30 days) RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/2015 4 RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/2015 4 RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/2015 4 RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/2015 4 RHEUMATREX TAB 2.5MG METHOTREXATE Addition 5/1/2015 4 VITEKTA TAB 150MG ELVITEGRAVIR Addition 5/1/2015 5 QL (30 per 30 days) VITEKTA TAB 85MG ELVITEGRAVIR Addition 5/1/2015 5 QL (30 per 30 days) ANDROGEL GEL1.62% TESTOSTERONE Addition 4/1/2015 3 QL (300 per 30 days) ANDROGEL GEL1.62% TESTOSTERONE Addition 4/1/2015 3 QL (300 per 30 days) AUBRA TAB0.1-0.02 LEVONORGESTREL and Addition 4/1/2015 2 BELEODAQ INJ500MG BELINOSTA Addition 4/1/2015 5 Prior BREO ELLIPTAINH100-25 FLUTICASONE and VILANTEROL Addition 4/1/2015 3 QL (60 per 30 days) CELECOXIB CAP100MG CELEBREX Addition 4/1/2015 3 QL (60 per 30 days) CELECOXIB CAP200MG CELEBREX Addition 4/1/2015 3 QL (60 per 30 days) CELECOXIB CAP400MG CELEBREX Addition 4/1/2015 3 QL (60 per 30 days) 8
Tier CELECOXIB CAP50MG CELEBREX Addition 4/1/2015 3 QL (60 per 30 days) COLY-MYCIN SSUSOTIC NEOMYCIN, COLISTIN, HYDROCORTISONE, and THONZONIUM Deletion 4/1/2015 4 CRINONE GEL4% VAG PROGESTERONE Deletion 4/1/2015 4 CRINONE GEL8% VAG PROGESTERONE Deletion 4/1/2015 4 CYCLOPHOSPH TAB25MG CYCLOPHOSPHAMIDE Deletion 4/1/2015 2 Prior CYCLOPHOSPH TAB50MG CYCLOPHOSPHAMIDE Deletion 4/1/2015 2 Prior DELYLA TAB0.1-0.02 LEVONORGESTREL and Addition 4/1/2015 2 DOCEFREZ INJ80MG DOCETAXEL Deletion 4/1/2015 5 Prior CONJUGATED DUAVEE TAB0.45-20 ESTROGENS and Addition 4/1/2015 3 QL (30 per 30 days) BAZEDOXIFENE ELIQUIS TAB2.5MG APIXABAN Addition 4/1/2015 3 QL (60 per 30 days) ELIQUIS TAB5MG APIXABAN Addition 4/1/2015 3 QL (60 per 30 days) FALMINA TAB LEVONORGESTREL and Addition 4/1/2015 2 FYCOMPA TAB10MG PERAMPANEL Addition 4/1/2015 4 QL (30 per 30 days) FYCOMPA TAB12MG PERAMPANEL Addition 4/1/2015 4 QL (30 per 30 days) HUMAN GARDASIL 9 INJ PAPILLOMAVIRUS (HPV) Addition 4/1/2015 4 Prior VACCINE GARDASIL INJ HUMAN PAPILLOMAVIRUS (HPV) VACCINE Addition 4/1/2015 4 Prior GILDESS TAB1.5/30 LEVONORGESTREL and Addition 4/1/2015 2 9
GRANISOL SOL2MG/10ML GRANISETRON Deletion 4/1/2015 1 Tier QL (30 per 30 days), Prior HEP SOD/NACLINJ1000UNIT HEPARIN and SODIUM CHLORIDE Deletion 4/1/2015 4 Prior HUMIRA INJ10MG/0.2 ADALIMUMAB Addition 4/1/2015 5 QL (6 per 30 days), Prior ICLUSIG TAB15MG PONATINIB Addition 4/1/2015 5 QL (90 per 30 days) INCIVEK TAB375MG TELAPREVIR Deletion 4/1/2015 5 INTRON A INJ18MU INTERFERON ALFA-2b Addition 4/1/2015 4 INTRON A INJ50MU INTERFERON ALFA-2b Addition 4/1/2015 5 KEYTRUDA SOL50MG PEMBROLIZUMAB Addition 4/1/2015 5 Prior LAMIVUDINE SOL10MG/ML EPIVIR Addition 4/1/2015 2 LARIN TAB1.5/30 NORETHINDRONE and Addition 4/1/2015 2 LIDOCAINE INJ1% XYLOCAINE Deletion 4/1/2015 4 Prior LUFYLLIN TAB400MG DYPHYLLINE Deletion 4/1/2015 2 LYNPARZA CAP50MG OLAPARIB Addition 4/1/2015 5 QL (480 per 30 days) MYCOPHENOLATSUS200MG/ ML CELLCEPT Addition 4/1/2015 2 Prior NAMENDA TAB5-10MG MEMANTINE Addition 4/1/2015 3 QL (60 per 30 days) NAMENDA TAB10MG MEMANTINE Addition 4/1/2015 3 QL (60 per 30 days) NAMENDA TAB5MG MEMANTINE Addition 4/1/2015 3 QL (60 per 30 days) NEVIRAPINE TAB400MG ER VIRAMUNE XR Addition 4/1/2015 2 OFLOXACIN TAB200MG FLOXIN Deletion 4/1/2015 2 OPDIVO INJ40MG/4ML NIVOLUMAB Addition 4/1/2015 5 Prior ORSYTHIA TAB LEVONORGESTREL and Addition 4/1/2015 2 ORTHO EVRA DISWEEK NORELGESTROMIN and Deletion 4/1/2015 4 10
PEG-INTRON KIT120MCG PEGINTERFERON ALFA-2b Addition 4/1/2015 5 PEG-INTRON KIT150MCG PEGINTERFERON ALFA-2b Addition 4/1/2015 5 PEG-INTRON KIT80MCG PEGINTERFERON ALFA-2b Addition 4/1/2015 5 Tier QL (4 per 30 days), Prior QL (4 per 30 days), Prior QL (4 per 30 days), Prior POT CITRATE TAB1620MG UROCIT-K Addition 4/1/2015 2 PRIFTIN TAB150MG RIFAPENTINE Deletion 4/1/2015 4 PURIXAN SUS20MG/ML MERCAPTOPURINE Addition 4/1/2015 4 QVAR AER80MCG BECLOMETHASONE Deletion 4/1/2015 4 QL (21.9 per 30 days) RECOMBIVA HBINJ10MCG/ML HEPATITIS B VACCINE RECOMBINANT Addition 4/1/2015 4 Prior RECOMBIVA HBINJ5MCG/0.5 HEPATITIS B VACCINE RECOMBINANT Addition 4/1/2015 4 Prior REYATAZ POW50MG ATAZANAVIR Addition 4/1/2015 3 SIROLIMUS TAB1MG RAPAMUNE Addition 4/1/2015 2 Prior SIROLIMUS TAB2MG RAPAMUNE Addition 4/1/2015 2 Prior SOMAVERT INJ25MG PEGVISOMANT Addition 4/1/2015 5 Prior SOMAVERT INJ30MG PEGVISOMANT Addition 4/1/2015 5 Prior SUTENT CAP37.5MG SUNITINIB Addition 4/1/2015 5 SYMBICORT AER80-4.5 BUDESONIDE and FORMOTEROL Deletion 4/1/2015 3 QL (6.9 per 30 days) TREANDA INJ45/0.5ML BENDAMUSTINE Addition 4/1/2015 5 Prior TRIUMEQ TAB ABACAVIR, DOLUTEGRAVIR and LAMIVUDINE Addition 4/1/2015 5 QL (30 per 30 days) TRUMENBA INJ MENINGOCOCCAL GROUP B VACCINE Addition 4/1/2015 4 TYBOST TAB150MG COBICISTAT Addition 4/1/2015 3 QL (30 per 30 days) 11
Tier VALACYCLOVIRTAB1GM VALTREX Removed Quantity Limits 4/1/2015 2 VALACYCLOVIRTAB500MG VALTREX Removed Quantity Limits 4/1/2015 2 VAQTA INJ25/0.5ML HEPATITIS A VACCINE Addition 4/1/2015 4 VAQTA INJ50UNT/ML HEPATITIS A VACCINE Addition 4/1/2015 4 DASABUVIR,OMBITASVIR VIEKIRA PAK TAB,PARITAPREVIR and Addition 4/1/2015 5 RITONAVIR ZENPEP CAP40000UNT PANCRELIPASE Addition 4/1/2015 4 ZENZEDI TAB2.5MG DEXTROAMPHETAMINE Addition 4/1/2015 2 ZENZEDI TAB7.5MG DEXTROAMPHETAMINE Addition 4/1/2015 2 ZYDELIG TAB100MG IDELALISIB Addition 4/1/2015 5 QL (90 per 30 days) ZYDELIG TAB150MG IDELALISIB Addition 4/1/2015 5 QL (60 per 30 days) VALCHLOR GEL 0.016% MECHLORETHAMINE Addition 3/1/2015 5 QL (112 per 30 days), Prior 12