Medicare Part D 017 Formulary s OC Preferred 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 017. VERSION: 18 017 FORMULARY ADDITIONS UPDATE AS OF AUGUST 1, 017: FORMULARY ID: 00017407 Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of Utilization Management to an existing formulary drug Covered Drug Name ALUNBRIG TAB 30MG BRIGATINIB ADDITION 8/1/017 5 PA CLOFARABINE INJ 0/0ML CLOLAR ADDITION 8/1/017 5 PA EZETIM/SIMVA TAB 10-10MG VYTORIN ADDITION 8/1/017 QL (30 PER 30 DAYS), (90) EZETIM/SIMVA TAB 10-0MG VYTORIN ADDITION 8/1/017 QL (30 PER 30 DAYS), (90) EZETIM/SIMVA TAB 10-80MG VYTORIN ADDITION 8/1/017 QL (30 PER 30 DAYS), (90) IMFINZI INJ 10/.4 DURVALUMAB ADDITION 8/1/017 5 PA IMFINZI INJ 500/10 DURVALUMAB ADDITION 8/1/017 5 PA KISQALI 00 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/017 5 PA KISQALI 400 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/017 5 PA 1
KISQALI 600 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/017 5 PA RYDAPT CAP 5MG MIDOSTAURIN ADDITION 8/1/017 5 PA XATMEP SOL.5MG/ML METHOTREXATE ADDITION 8/1/017 5 PA ZEJULA CAP 100MG NIRAPARIB ADDITION 8/1/017 5 PA GARDASIL INJ PAPILLOMAVIRUS VACCINE DELETION 8/1/017 4 PA PEG-INTRON KIT 150 RP PEGINTERFERON ALFA-b DELETION 8/1/017 5 QL (4 PER 8 DAYS), PA PEG-INTRON KIT 50MCG RP PEGINTERFERON ALFA-b DELETION 8/1/017 5 QL (4 PER 8 DAYS), PA PEG-INTRON KIT 80MCG RP PEGINTERFERON ALFA-b DELETION 8/1/017 5 QL (4 PER 8 DAYS), PA BAVENCIO INJ 0MG/ML AVELUMAB ADDITION 7/1/017 5 PA PRISTIQ DESVENLAFAX TAB 100MG ER ADDITION 7/1/017 QL (30 PER 30 DAYS) DESVENLAFAX TAB 5MG ER PRISTIQ ADDITION 7/1/017 QL (40 PER 30 DAYS) DESVENLAFAX TAB 50MG ER PRISTIQ ADDITION 7/1/017 QL (40 PER 30 DAYS) PIRFENIDONE 5 ESBRIET TAB 67MG ADDITION 7/1/017 QL (70 PER 30 DAYS), PA ESBRIET TAB 801MG PIRFENIDONE ADDITION 7/1/017 5 QL (90 PER 30 DAYS), PA LEVOLEUCOVOR INJ 50MG FUSILEV ADDITION 7/1/017 4 PA NITROGLYCERN SUB 0.3MG NITROSTAT ADDITION 7/1/017 OSELTAMIVIR CAP 30MG TAMIFLU ADDITION 7/1/017 QL (84 PER 180 DAYS) OSELTAMIVIR CAP 45MG TAMIFLU ADDITION 7/1/017 QL (4 PER 180 DAYS) OSELTAMIVIR CAP 75MG TAMIFLU ADDITION 7/1/017 QL (4 PER 180 DAYS) VIRAZOLE INH 6GM RIBAVIRIN DELETION 7/1/017 5 PA BUTRANS DIS 10MCG/HR BUPRENORPHINE ADDITION 6/1/017 3 QL (4 PER 8 DAYS) BUTRANS DIS 15MCG/HR BUPRENORPHINE ADDITION 6/1/017 3 QL (4 PER 8 DAYS) BUTRANS DIS 0MCG/HR BUPRENORPHINE ADDITION 6/1/017 3 QL (4 PER 8 DAYS) BUTRANS DIS 5MCG/HR BUPRENORPHINE ADDITION 6/1/017 3 QL (4 PER 8 DAYS) BUTRANS DIS 7.5/HR BUPRENORPHINE ADDITION 6/1/017 3 QL (4 PER 8 DAYS)
BYDUREON INJ BYDUREON INJ EXENATIDE EXTENDED RELEASE EXENATIDE EXTENDED RELEASE REDUCTION 6/1/017 3 QL (4 PER 8 DAYS) REDUCTION 6/1/017 3 QL (4 PER 8 DAYS) FARXIGA TAB 10MG DAPAGLIFLOZIN ADDITION 6/1/017 3 FARXIGA TAB 5MG DAPAGLIFLOZIN ADDITION 6/1/017 3 FLECTOR DIS 1.3% DICLOFENAC ADDITION 6/1/017 3 HYSINGLA ER TAB 100 MG HYSINGLA ER TAB 10 MG HYSINGLA ER TAB 0 MG HYSINGLA ER TAB 30 MG HYSINGLA ER TAB 40 MG HYSINGLA ER TAB 60 MG HYSINGLA ER TAB 80 MG KISQALI TAB 00DOSE RIBOCICLIB ADDITION 6/1/017 5 PA KISQALI TAB 400DOSE RIBOCICLIB ADDITION 6/1/017 5 PA KISQALI TAB 600DOSE RIBOCICLIB ADDITION 6/1/017 5 PA OXYCONTIN TAB 10MG CR OXYCONTIN TAB 15MG CR 3
OXYCONTIN TAB 0MG CR OXYCONTIN TAB 30MG CR OXYCONTIN TAB 40MG CR OXYCONTIN TAB 60MG CR OXYCONTIN TAB 80MG CR TRULICITY INJ 0.75/0.5 DULAGLUTIDE ADDITION 6/1/017 3 QL ( PER 8 DAYS) TRULICITY INJ 1.5/0.5 DULAGLUTIDE ADDITION 6/1/017 3 QL ( PER 8 DAYS) XIGDUO XR TAB 10-1000 DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/017 3 XIGDUO XR TAB 10-500MG DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/017 3 XIGDUO XR TAB 5-1000MG DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/017 3 XIGDUO XR TAB 5-500MG DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/017 3 SELZENTRY TAB 5MG MARAVIROC ADDITION 5/1/017 5 SELZENTRY TAB 75MG MARAVIROC ADDITION 5/1/017 5 APREPITANT CAP 40MG EMEND ADDITION 5/1/017 QL (30 PER 30 DAYS), PA APREPITANT CAP 80MG EMEND ADDITION 5/1/017 QL (30 PER 30 DAYS), PA 4
APREPITANT CAP 15MG EMEND ADDITION 5/1/017 QL (30 PER 30 DAYS), PA MIRCERA INJ 50MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/017 4 PA MIRCERA INJ 75MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/017 4 PA MIRCERA INJ 100MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/017 4 PA MIRCERA INJ 00MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/017 4 PA ASA/DIPYRIDA CAP 5-00MG AGGRENOX ADDITION 5/1/017 QL (60 PER 30 DAYS) AMIFOSTINE INJ 500MG AMIFOSTINE DELETION 4/1/017 5 PA AMIODARONE TAB 100MG PACERONE ADDITION 4/1/017 DOXYCYCL HYC INJ 100MG DOXY DELETION 4/1/017 PA LOPIN/RITON SOL 80-0/ML KALETRA ADDITION 4/1/017 QL (480 PER 30 DAYS) MENOMUNE INJ A/C/Y/W MENINGOCOCCAL POLYSACCHARIDE VACCINE DELETION 4/1/017 4 NECON TAB 1/35 ETHINYL ESTRADIOL AND NORETHINDRONE DELETION 4/1/017 1 8-MOP CAP 10MG METHOXSALEN DELETION 3/1/017 3 PA ABACA/LAMIVU TAB 600-300 EPZICOM ADDITION 3/1/017 QL (30 PER 30 DAYS) A-HYDROCORT INJ 100MG CORTEF DELETION 3/1/017 PA BUPROBAN TAB 150MG BUPROPION DELETION 3/1/017 QL (90 PER 30 DAYS) CERVARIX INJ HUMAN PAPILLOMAVIRUS (HPV) BIVALENT(TYPES 16,18) RECMB VAC DELETION 3/1/017 4 DOCEFREZ INJ 0MG DOCETAXEL DELETION 3/1/017 5 PA ERGOMAR SUB MG ERGOTAMINE DELETION 3/1/017 5
EZETIMIBE TAB 10MG ZETIA ADDITION 3/1/017 QL (30 PER 30 DAYS) GENGRAF CAP 50MG NEORAL ADDITION 3/1/017 PA KYPROLIS SOL 30MG CARFILZOMB ADDITION 3/1/017 5 PA KYPROLIS SOL 60MG CARFILZOMB ADDITION 3/1/017 5 PA LANTUS INJ SOLOSTAR INSULIN GLARGINE ADDITION 3/1/017 3 QL (30 PER 30 DAYS) LARTRUVO INJ 10MG/ML OLARATUMAB ADDITION 3/1/017 5 PA MENEST TAB.5MG ESTERIFIED ESTROGENS DELETION 3/1/017 METHOTREXATE INJ 5MG/ML METHOTREXATE ADDITION 3/1/017 PA NAPHAZOLINE SOL 0.1% OP NAPHAZOLINE DELETION 3/1/017 1 NIFEDICAL XL TAB 30MG PROCARDIA XL, ADALAT CC DELETION 3/1/017 NIFEDICAL XL TAB 60MG PROCARDIA XL, ADALAT CC DELETION 3/1/017 NILUTAMIDE TAB 150MG NILANDRON ADDITION 3/1/017 QL (30 PER 30 DAYS) RANITIDINE INJ 150/6ML ZANTAC DELETION 3/1/017 PA RASAGILINE TAB 0.5MG AZILECT ADDITION 3/1/017 RASAGILINE TAB 1MG AZILECT ADDITION 3/1/017 ROSUVASTATIN TAB 10MG CRESTOR ADDITION 3/1/017 QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 0MG CRESTOR ADDITION 3/1/017 QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 40MG CRESTOR ADDITION 3/1/017 QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 5MG CRESTOR ADDITION 3/1/017 QL (30 PER 30 DAYS), (90) RUBRACA TAB 00MG RUCAPARIB ADDITION 3/1/017 5 PA RUBRACA TAB 300MG RUCAPARIB ADDITION 3/1/017 5 PA STAVUDINE SOL 1MG/ML ZERIT DELETION 3/1/017 QL (400 PER 30 DAYS) TRAVOPROST DRO 0.004% TRAVATAN DELETION 3/1/017 TYZEKA TAB 600MG TELBIVUDINE DELETION 3/1/017 5 PA 6
VITEKTA TAB 150MG ELVITEGRAVIR DELETION 3/1/017 5 QL (30 PER 30 DAYS) VITEKTA TAB 85MG ELVITEGRAVIR DELETION 3/1/017 5 QL (30 PER 30 DAYS) XIIDRA DRO 5% LIFITEGRAST ADDITION 3/1/017 4 QL (60 PER 30 DAYS) YONDELIS INJ 1MG TRABECTEDIN ADDITION 3/1/017 5 PA ZERIT SOL 1MG/ML STAVUDINE ADDITION 3/1/017 4 QL (400 PER 30 DAYS) 7
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