Medicare Part D 2017 Formulary s Service To Senior 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 2017. VERSION: 22 2017 FORMULARY ADDITIONS UPDATE AS OF AUGUST 1, 2017: FORMULARY ID: 00017195 Formulary additions, reductions in preferred or tiered cost-sharing status, or removal of Utilization Management to an existing formulary drug Covered Drug Name of Tier Utilization Management Notes ALUNBRIG TAB 30MG BRIGATINIB ADDITION 8/1/2017 5 PA CLOFARABINE INJ 20/20ML CLOLAR ADDITION 8/1/2017 5 PA EZETIM/SIMVA TAB 10-10MG VYTORIN ADDITION 8/1/2017 2 QL (30 PER 30 DAYS), (90) EZETIM/SIMVA TAB 10-20MG VYTORIN ADDITION 8/1/2017 2 QL (30 PER 30 DAYS), (90) EZETIM/SIMVA TAB 10-80MG VYTORIN ADDITION 8/1/2017 2 QL (30 PER 30 DAYS), (90) IMFINZI INJ 120/2.4 DURVALUMAB ADDITION 8/1/2017 5 PA IMFINZI INJ 500/10 DURVALUMAB ADDITION 8/1/2017 5 PA KISQALI 200 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/2017 5 PA KISQALI 400 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/2017 5 PA KISQALI 600 PAK FEMARA RIBOCICLIB AND LETROZOLE ADDITION 8/1/2017 5 PA RYDAPT CAP 25MG MIDOSTAURIN ADDITION 8/1/2017 5 PA XATMEP SOL 2.5MG/ML METHOTREXATE ADDITION 8/1/2017 5 PA ZEJULA CAP 100MG NIRAPARIB ADDITION 8/1/2017 5 PA GARDASIL INJ PAPILLOMAVIRUS VACCINE DELETION 8/1/2017 4 PA 1
of Tier Utilization Management Notes PEG-INTRON KIT 150 RP PEGINTERFERON ALFA-2b DELETION 8/1/2017 5 QL (4 PER 28 DAYS), PA PEG-INTRON KIT 50MCG RP PEGINTERFERON ALFA-2b DELETION 8/1/2017 5 QL (4 PER 28 DAYS), PA PEG-INTRON KIT 80MCG RP PEGINTERFERON ALFA-2b DELETION 8/1/2017 5 QL (4 PER 28 DAYS), PA BAVENCIO INJ 20MG/ML AVELUMAB ADDITION 7/1/2017 5 PA DESVENLAFAX TAB 100MG ER PRISTIQ ADDITION 7/1/2017 2 QL (30 PER 30 DAYS) DESVENLAFAX TAB 25MG ER PRISTIQ ADDITION 7/1/2017 2 QL (240 PER 30 DAYS) DESVENLAFAX TAB 50MG ER PRISTIQ ADDITION 7/1/2017 2 QL (240 PER 30 DAYS) ESBRIET TAB 267MG PIRFENIDONE ADDITION 7/1/2017 5 QL (270 PER 30 DAYS), PA ESBRIET TAB 801MG PIRFENIDONE ADDITION 7/1/2017 5 QL (90 PER 30 DAYS), PA LEVOLEUCOVOR INJ 50MG FUSILEV ADDITION 7/1/2017 4 PA NITROGLYCERN SUB 0.3MG NITROSTAT ADDITION 7/1/2017 6 OSELTAMIVIR CAP 30MG TAMIFLU ADDITION 7/1/2017 2 QL (84 PER 180 DAYS) OSELTAMIVIR CAP 45MG TAMIFLU ADDITION 7/1/2017 2 QL (42 PER 180 DAYS) OSELTAMIVIR CAP 75MG TAMIFLU ADDITION 7/1/2017 2 QL (42 PER 180 DAYS) VIRAZOLE INH 6GM RIBAVIRIN DELETION 7/1/2017 5 PA BUTRANS DIS 10MCG/HR BUPRENORPHINE ADDITION 6/1/2017 3 QL (4 PER 28 DAYS) BUTRANS DIS 15MCG/HR BUPRENORPHINE ADDITION 6/1/2017 3 QL (4 PER 28 DAYS) BUTRANS DIS 20MCG/HR BUPRENORPHINE ADDITION 6/1/2017 3 QL (4 PER 28 DAYS) BUTRANS DIS 5MCG/HR BUPRENORPHINE ADDITION 6/1/2017 3 QL (4 PER 28 DAYS) BUTRANS DIS 7.5/HR BUPRENORPHINE ADDITION 6/1/2017 3 QL (4 PER 28 DAYS) BYDUREON INJ EXENATIDE EXTENDED TIER RELEASE REDUCTION 6/1/2017 3 QL (4 PER 28 DAYS) BYDUREON INJ EXENATIDE EXTENDED TIER RELEASE REDUCTION 6/1/2017 3 QL (4 PER 28 DAYS) FARXIGA TAB 10MG DAPAGLIFLOZIN ADDITION 6/1/2017 3 FARXIGA TAB 5MG DAPAGLIFLOZIN ADDITION 6/1/2017 3 FLECTOR DIS 1.3% DICLOFENAC ADDITION 6/1/2017 3 HYSINGLA ER TAB 100 MG 2
of Tier Utilization Management Notes HYSINGLA ER TAB 120 MG HYSINGLA ER TAB 20 MG HYSINGLA ER TAB 30 MG HYSINGLA ER TAB 40 MG HYSINGLA ER TAB 60 MG HYSINGLA ER TAB 80 MG KISQALI TAB 200DOSE RIBOCICLIB ADDITION 6/1/2017 5 PA KISQALI TAB 400DOSE RIBOCICLIB ADDITION 6/1/2017 5 PA KISQALI TAB 600DOSE RIBOCICLIB ADDITION 6/1/2017 5 PA OXYCONTIN TAB 10MG CR OXYCODONE TIER 6/1/2017 3 QL (90 PER 30 DAYS) OXYCONTIN TAB 15MG CR OXYCODONE TIER 6/1/2017 3 QL (90 PER 30 DAYS) OXYCONTIN TAB 20MG CR OXYCODONE TIER 6/1/2017 3 QL (90 PER 30 DAYS) OXYCONTIN TAB 30MG CR OXYCODONE TIER 6/1/2017 3 QL (90 PER 30 DAYS) OXYCONTIN TAB 40MG CR OXYCODONE TIER 6/1/2017 3 QL (90 PER 30 DAYS) OXYCONTIN TAB 60MG CR OXYCODONE TIER 6/1/2017 3 QL (90 PER 30 DAYS) OXYCONTIN TAB 80MG CR OXYCODONE TIER 6/1/2017 3 QL (90 PER 30 DAYS) TRULICITY INJ 0.75/0.5 DULAGLUTIDE ADDITION 6/1/2017 3 QL (2 PER 28 DAYS) TRULICITY INJ 1.5/0.5 DULAGLUTIDE ADDITION 6/1/2017 3 QL (2 PER 28 DAYS) XIGDUO XR TAB 10-1000 DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/2017 3 XIGDUO XR TAB 10-500MG DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/2017 3 3
of Tier Utilization Management Notes XIGDUO XR TAB 5-1000MG XIGDUO XR TAB 5-500MG DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/2017 3 DAPAGLIFLOZIN AND METFORMIN EXTENDED- RELEASE ADDITION 6/1/2017 3 SELZENTRY TAB 25MG MARAVIROC ADDITION 5/1/2017 5 SELZENTRY TAB 75MG MARAVIROC ADDITION 5/1/2017 5 APREPITANT CAP 40MG EMEND ADDITION 5/1/2017 2 QL (30 PER 30 DAYS), PA APREPITANT CAP 80MG EMEND ADDITION 5/1/2017 2 QL (30 PER 30 DAYS), PA APREPITANT CAP 125MG EMEND ADDITION 5/1/2017 2 QL (30 PER 30 DAYS), PA RASAGILINE TAB 0.5MG AZILECT TIER REDUCTION 5/1/2017 2 RASAGILINE TAB 1MG AZILECT TIER REDUCTION 5/1/2017 2 MIRCERA INJ 50MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/2017 4 PA MIRCERA INJ 75MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/2017 4 PA MIRCERA INJ 100MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/2017 4 PA MIRCERA INJ 200MCG METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA ADDITION 5/1/2017 4 PA ASA/DIPYRIDA CAP 25-200MG AGGRENOX ADDITION 5/1/2017 2 QL (60 PER 30 DAYS) AMIFOSTINE INJ 500MG AMIFOSTINE DELETION 4/1/2017 5 PA AMIODARONE TAB 100MG PACERONE ADDITION 4/1/2017 2 DOXYCYCL HYC INJ 100MG DOXY DELETION 4/1/2017 2 PA LOPIN/RITON SOL 80-20/ML KALETRA ADDITION 4/1/2017 2 QL (480 PER 30 DAYS) 4
of Tier Utilization Management Notes MENOMUNE INJ A/C/Y/W NECON TAB 1/35 MENINGOCOCCAL POLYSACCHARIDE VACCINE DELETION 4/1/2017 4 ETHINYL ESTRADIOL AND NORETHINDRONE DELETION 4/1/2017 1 8-MOP CAP 10MG METHOXSALEN DELETION 3/1/2017 3 PA ABACA/LAMIVU TAB 600-300 EPZICOM ADDITION 3/1/2017 2 QL (30 PER 30 DAYS) A-HYDROCORT INJ 100MG CORTEF DELETION 3/1/2017 4 PA BUPROBAN TAB 150MG BUPROPION DELETION 3/1/2017 2 QL (90 PER 30 DAYS) CERVARIX INJ HUMAN PAPILLOMAVIRUS (HPV) BIVALENT(TYPES 16,18) RECMB VAC DELETION 3/1/2017 4 DOCEFREZ INJ 20MG DOCETAXEL DELETION 3/1/2017 5 PA ERGOMAR SUB 2MG ERGOTAMINE DELETION 3/1/2017 2 EZETIMIBE TAB 10MG ZETIA ADDITION 3/1/2017 2 QL (30 PER 30 DAYS) GENGRAF CAP 50MG NEORAL ADDITION 3/1/2017 4 PA HUMALOG INJ 100/ML INSULIN LISPRO ADDITION 3/1/2017 6 QL (30 PER 30 DAYS), (90) HUMALOG INJ 100/ML INSULIN LISPRO TIER REDUCTION 3/1/2017 6 QL (30 PER 30 DAYS), (90) HUMALOG KWIK INJ 100/ML INSULIN LISPRO ADDITION 3/1/2017 6 QL (30 PER 30 DAYS), (90) TIER KLOR-CON M20 TAB 20MEQ ER MICRO-K/KLOR-CON/K-TAB REDUCTION 3/1/2017 1 (90) KYPROLIS SOL 30MG CARFILZOMB ADDITION 3/1/2017 5 PA KYPROLIS SOL 60MG CARFILZOMB ADDITION 3/1/2017 5 PA LANTUS INJ SOLOSTAR INSULIN GLARGINE ADDITION 3/1/2017 4 QL (30 PER 30 DAYS) LARTRUVO INJ 10MG/ML OLARATUMAB ADDITION 3/1/2017 5 PA MENEST TAB 2.5MG ESTERIFIED ESTROGENS DELETION 3/1/2017 2 METHOTREXATE INJ 25MG/ML METHOTREXATE ADDITION 3/1/2017 1 PA 5
of Tier Utilization Management Notes NAPHAZOLINE SOL 0.1% OP NAPHAZOLINE DELETION 3/1/2017 1 NIFEDICAL XL TAB 30MG PROCARDIA XL, ADALAT CC DELETION 3/1/2017 2 NIFEDICAL XL TAB 60MG PROCARDIA XL, ADALAT CC DELETION 3/1/2017 2 NILUTAMIDE TAB 150MG NILANDRON ADDITION 3/1/2017 2 QL (30 PER 30 DAYS) RANITIDINE INJ 150/6ML ZANTAC DELETION 3/1/2017 2 PA RASAGILINE TAB 0.5MG AZILECT ADDITION 3/1/2017 4 RASAGILINE TAB 1MG AZILECT ADDITION 3/1/2017 4 ROSUVASTATIN TAB 10MG CRESTOR ADDITION 3/1/2017 2 QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 20MG CRESTOR ADDITION 3/1/2017 2 QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 40MG CRESTOR ADDITION 3/1/2017 2 QL (30 PER 30 DAYS), (90) ROSUVASTATIN TAB 5MG CRESTOR ADDITION 3/1/2017 2 QL (30 PER 30 DAYS), (90) RUBRACA TAB 200MG RUCAPARIB ADDITION 3/1/2017 5 PA RUBRACA TAB 300MG RUCAPARIB ADDITION 3/1/2017 5 PA STAVUDINE SOL 1MG/ML ZERIT DELETION 3/1/2017 2 QL (2400 PER 30 DAYS) TRAVOPROST DRO 0.004% TRAVATAN DELETION 3/1/2017 2 TYZEKA TAB 600MG TELBIVUDINE DELETION 3/1/2017 5 PA VITEKTA TAB 150MG ELVITEGRAVIR DELETION 3/1/2017 5 QL (30 PER 30 DAYS) VITEKTA TAB 85MG ELVITEGRAVIR DELETION 3/1/2017 5 QL (30 PER 30 DAYS) XIIDRA DRO 5% LIFITEGRAST ADDITION 3/1/2017 4 QL (60 PER 30 DAYS) YONDELIS INJ 1MG TRABECTEDIN ADDITION 3/1/2017 5 PA ZERIT SOL 1MG/ML STAVUDINE ADDITION 3/1/2017 4 QL (2400 PER 30 DAYS) 6
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