Pharmacy Formulary Updates for January 2019 To offer a pharmacy benefit that is clinically appropriate and cost effective, we constantly review how we cover prescription medications. Periodic adjustments are made to meet these goals. The changes below are reflected in our online drug list. The following is a list of drugs that changed formulary status in January 2019: Coagadex Drug Name Large Group 3-Tier Formulary Tufts Health Plan Commercial Formularies Massachusetts Small Group/ Small Group/ Large Group Individual Individual Large Group 3-3-Tier Tier Formulary Formulary (Exchange (Exchange Formularies) Formularies) MB;PA;SI Rhode Island Large Group Formulary Zydelig ;PA;SP T4;PA;SP ;PA;SP T4;PA;SP ;PA;SP T4;PA;SP Kanuma amphetamine/ dextroamphetamine ER dextroamphetamine ER capsules (CD) capsules (LA) tablets solution clonidine ER methamphetamine 5 mg guanfacine ER amitriptyline/ perphenazine amitriptyline amoxapine bupropion HCL SR bupropion ER MB;PA;SI ;PA(25 and older) (25 and older);ql Small Group/ Individual (Exchange Formularies) 1 Tufts Health Plan Formulary Updated for January 2019
bupropion clomipramine desipramine duloxetine duloxetine 40 mg doxepin fluoxetine 90 mg fluvoxamine ER imipramine pamoate maprotiline mirtazapine ODT mirtazapine nefazodone nortriptyline paroxetine ER paroxetine tranylcypromine trazodone venlafaxine ER tablets venlafaxine 225 mg ER tablets desvenlafaxine succinate ER trimipramine Surmontil Aplenzin Desvenlafaxine ER Khedezla Desvenlafaxine fumarate ER Emsam bupropion ER (Forfivo XL) Forfivo XL Pexeva Trintellix ;PA(12 and younger) ;PA(12 and younger) ;PA(12 and younger) ;PA(12 and younger) T3 ;PA(12 and younger);stpa (12 and younger) (no (no ;PA(12 and younger) (no (no (no (no 2 Tufts Health Plan Formulary Updated for January 2019
Viibryd phenelzine Nardil Marplan protriptyline / caffeine/ dihydrocodone capsules Trezix / caffeine/ dihydrocodone tablets Panlor codeine/ solution and suspension codeine/ tablets Tylenol w/codeine tablets hydrocodone/apap solution (12 and younger) (no (12 and younger) (12 and younger) ;QL ;QL (no Lortab 10-300mg elixir T3;QL T3;QL hydrocodone/ 7.5/300 tablets Xodol T3;QL T3;QL hydrocodone/ tablets Norco hydrocodone/ ibuprofen tablets Vicoprofen oxycodone/ 5/325/5 ml solution Roxicet solution T3;QL T3;QL 3 Tufts Health Plan Formulary Updated for January 2019
oxycdone/ capsules oxycodone/ tablets Percocet tablets oxycdone/aspirin Percodan tablets oxycodone/ibuprofen pentazocine/ tramadol/ Ultracet Renova 0.2% cream Tradjenta Jentadueto Jentadueto XR Invokamet Invokamet XR Invokana Movantik Relistor Symproic Proventil HFA Ventolin HFA Xopenex HFA Arnuity Ellipta Pulmicort Flexhaler Breo Ellipta Symbicort Stiolto Respimat Xiidra Restasis Lunesta Intermezzo Excluded (no ;QL ;QL ;QL ;QL ;QL ;PA ;PA (no (no (no (no (no 4 Tufts Health Plan Formulary Updated for January 2019
Belbuca buprenorphine transdermal Butrans isotretinoin Praluent Otrexup ;QL ;PA;QL (no ;SP;QL H.P. Acthar gel ;PA;SP T4;PA;SP ;PA;SP T4;PA;SP ;PA;SP T4;PA;SP Ortho Micronor Yaz Yasmin Ortho-Novum 1/35 Norinyl 1+35 Loestrin Ortho-Cyclen Beyaz Safyral Generess Fe Loestrin Fe Minastrin 24 Fe Mircette Ortho-Novum 7/7/7 Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Estrostep Fe LoSeasonique Seasonique Quartette Tri-Norinyl Desogen Ovcon 35 Brevicon Modicon Nor-QD Cyclessa Femcon Fe Necon 10/11 T3 (no 5 Tufts Health Plan Formulary Updated for January 2019
Sporanox solution Ampyra ;SP;QL (no T4;PA;SP;QL (no ;SP;QL (no ;SP;QL Zyclara 3.75% pump cream (no Dexpak Dose Pak Eurax 10% lotion Welchol 3.75 g packet Uceris 9 mg tablets Clindagel 1% gel vardenafil estradiol transdermal patches (generic Minivelle) (no (no (no (no (no T4;PA;SP; QL (no (no ;SP;QL (no Minivelle patches T3 (no T3 (no miconazole-zinc oxidewhite petrolatum ointment Palynziq ;PA;QL T4;PA;QL ;PA;QL T4;PA;QL ;PA;QL T4;PA;QL Altreno lotion Siklos Nuplazid 34 mg capsules ;PA;QL;SP T4;PA;QL;SP ;PA;QL;SP T4;PA;QL;SP ;PA;QL;SP T4;PA;QL;SP Orilissa ;QL ;PA ;QL Galafold ;PA T4;PA ;PA T4;PA ;PA T4;PA Xofluza Arikayce T3 T4 T3 T4 T3 T4 Tiglutik T3 T4 T3 T4 T3 T4 Delstrigo Perseris Retacrit ;QL;SP T4;QL;SP ;QL;SP T4;QL;SP ;QL;SP T4;QL;SP naloxone cartridges Drysol T3;QL MB $0 copay T1 (no (no (no (no (no (no 6 Tufts Health Plan Formulary Updated for January 2019
Key: MM Managed Mail must fill at mail order pharmacy SP Specialty Pharmacy Not covered ST PA Step Therapy Prior Authorization PA Prior Authorization MB Medical Benefit QL Quantity Limitation SI Specialty Infusion 7 Tufts Health Plan Formulary Updated for January 2019