Umpqua Health Alliance (OHP) Formulary Changes January 2018 Umpqua Health Alliance would like to advise you of the following currently monthly changes that have been made to the Umpqua Health Alliance Formulary. Any changes seen below will also be reflected on our latest version of our print formulary which can be located on our website (www.umpquahealth.com) under the members or providers tab. Medication acyclovir 800mg tablet Advair Diskus Advair HFA balsalazide 750mg tablet bisacodyl 5mg tablet bisacodyl 10mg tablet cetirizine 5mg tablet cetirizine 10mg tablet cholecalciferol (vitamin D3) 400u capsules cholecalciferol (vitamin D3) 400u tablets cholecalciferol (vitamin D3) 1,000u chewable tablets cholecalciferol (vitamin D3) 1,000u capsules cholecalciferol (vitamin D3) 1,000u tablets cholecalciferol (vitamin D3) 2,000u capsules Formulary Change Limitations/Changes Changed Quantity Limit from #50 within 30 days to #5 per day. Removed from formulary. Removed from formulary. Changed Quantity Limit from #30 per 365 days to #2 per 1 day. Added a Quantity Limit of #1 per 1 day. Prior Added a Prior Added a
cholecalciferol (vitamin D3) 2,000u tablets cholecalciferol (vitamin D3) 5,000u capsules cholecalciferol (vitamin D3) 5,000u capsules cholecalciferol (vitamin D3) 50,000u capsules cholecalciferol (vitamin D3) 50,000u tablets clotrimazole 1% cream clotrimazole 1% vaginal cream clotrimazole 2% cream clotrimazole 10mg troche cyanocobalamin (vitamin B12) 500mcg tablet cyanocobalamin (vitamin B12) 1,000mcg tablet cyanocobalamin (vitamin B12) 1,000mcg injection solution docusate sodium 100mg docusate sodium 250mg donepezil 5mg tablet donepezil 10mg tablet ergocalciferol (vitamin D2) 50,000u capsules ergocalciferol (vitamin D2) 50,000u capsules Ferrex 150mg (and all generic equivalents) Fiber Powders (dextrin, methylcellulose with sugar, psyllium husk, psyllium husk with aspartame, psyllium husk with sugar, psyllium seed with aspartame, psyllium seed with dextrose, psyllium seed with sugar, and wheat dextrin powders) Fiber capsules and tablets (calcium polycarbophil and psyllium husk) Fish Oils (omega-3 fatty acid 1,000mg, omega-3 fatty acids/fish oil 300/1,000mg, omega-3 fatty acids/fish oil 340/1,000mg, omega-3 fatty acids/fish oil 500/1,000mg, omega-3 fatty Added Quantity Limits of #70/14 days and Fill Limit of 1 fill per 30 days without Prior Authorization. Added Quantity Limits of #2 per day. Added Quantity Limits of #2 per day. Changed Quantity Limits from #1 per 28 days to #4 per 28 days. Changed Quantity Limits from #60 per 30 days to #5 per 1 day. Changed Quantity Limits from #60 per 30 days to #2 per 1 day (will allow member/patient to get quantities less than 30 days at a time). Added Quantity Limit of #2 per 1 day. Added Quantity Limit of #1 per 1 day.
acids/fish oil 600/1,000mg, omega- 3/DHA/EPA/fish oil 1,000mg, and omega- 3/DHA/EPA/fish oil 300/1,000mg) Enema (generic Fleet Enema) lactulose 10g/15mL solution lactulose 20g/30mL solution loratadine 10mg tablet magnesium chloride 60mg DR tablet Mag64 DR tablet magnesium chloride 70mg DR tablet magnesium chloride 71.5mg DR tablet magnesium citrate solution magnesium hydroxide 400mg/5mL solution methocarbamol 500mg tablet methocarbamol 750mg tablet miconazole 2% vaginal cream montelukast 5mg chewable tablet mupirocin 2% topical ointment naratriptan 1mg tablet naratriptan 2.5mg tablet oxybutynin 5mg ER tablet oxybutynin 10mg ER tablet rizatriptan 5mg ODT tablet rizatriptan 10mg ODT tablet rosuvastatin 5mg tablet Prior Added a Removed Quantity Limit restriction. Changed Quantity Limits from #378 in 180 days and #9 per 1 day to #16 per 1 day. Changed Quantity Limits from #252 in 180 days and #6 per 1 day to #10 per 1 day. Changed Age Restriction from members under 6 only to members age 6-14. Removed Quantity Limit restriction. tablets of next highest dose still
rosuvastatin 10mg tablet rosuvastatin 20mg tablet rosuvastatin 40mg tablet sodium chloride 1g tablet sodium chloride 3% nebulizer vial sodium chloride 7% nebulizer vial tizanidine 2mg tablet tizanidine 4mg tablet triamcinolone 0.025% cream triamcinolone 0.025% cream triamcinolone 0.025% ointment triamcinolone 0.1% cream triamcinolone 0.1% ointment triamcinolone 0.5% cream triamcinolone 0.5% ointment valacyclovir 500mg tablet valacyclovir 1,000mg tablet zolmitriptan 2.5mg tablet zolmitriptan 5mg tablet tablets of next highest dose still tablets of next highest dose still tablets of next highest dose still Added Quantity Limits of #18 per day. Added Quantity Limits of #9 per day. Authorization requirements. Authorization requirements. Removed Prior Authorization requirement. Added Quantity Limit of #2 per day. Removed Prior Authorization requirement. Added Quantity Limit of #3 per day with max fill of 7 days and 1 fill per 30 days.
zolpidem 5mg tablet zolpidem 10mg tablet Added Quantity Limit of #2 per day and max fill of 90 days every 180 days. Added Quantity Limit of #1 per day and max fill of 90 days every 180 days. If your office has questions about these changes, please contact: Sara Hrouda, CPhT @ 541-229-8901 or shrouda@umpquahealth.com Kim Karlovich, CPhT @ 541-229-8902 or kkarlovich@umpquahealth.com Jamie Vanassche CPhT @ 541-229-7002 or jvanassche@umpquahealth.com