Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative formulary drugs would not be as effective in treating your condition and would have a negative effect on your health. Contact us to ask for an initial coverage decision for a formulary, tier or utilization restriction (specific criteria) exception. When you re requesting an exception, please submit a statement from your physician supporting your request. For more detailed information about your Network Health Insurance Corporation prescription drug coverage, please review your Evidence of Coverage and other plan materials. The following brand name drugs will have a tier increase, with an increase in the member s share of the cost. For each drug, a generic alternative is now available. Drug Name Effective Date New Tier Alternative Drug Alternative Drug Tier Exelon 4.6 mg/24 hour patch July 1, 2016 4 Rivastigmine 4.6 mg/24hr patch Tier 2: Exelon 9.5 mg/24 hour patch July 1, 2016 4 Rivastigmine 9.5 mg/24hr patch Tier 2: Exelon 13.3 mg/24 hour patch July 1, 2016 4 Rivastigmine 13.3 mg/24hr patch Tier 2: Namenda 2 mg/ml solution July 1, 2016 4 Memantine 2 mg/ml solution Tier 2: Lincocin 300 mg/ml vial August 1, 2016 4 Lincomycin 600 mg/2 ml vial Tier 2: Tegretol XR 100mg October 1, 2016 4 Carbamazepine ER 100mg Tier 2: Voltaren 1% gel October 1, 2016 4 Diclofenac 1% gel Tier 2: Abilify Discmelt 10 mg March 1, 2016 Aripiprazole odt 10 mg Tier 2: Cedax 90 mg/5 ml suspension March 1, 2016 Cedax 180 mg/5 ml suspension Tier 4: Non- Cefditoren pivoxil 200 mg tab March 1, 2016 Consult with provider N/A Cortisporin ear solution March 1, 2016 Neomycin-polymyxin-HC ear suspension Tier 2: Demadex 100 mg March 1, 2016 Torsemide 100 mg Tier 2: Dilaudid-HP 10 mg/ml vial March 1, 2016 Hydromorphone HCl 10 mg/ml vial Tier 2: Eloxatin 100 mg/20 ml vial March 1, 2016 Oxaliplatin 100 mg/20 ml vial Tier 5: Specialty Enjuvia 0.625 mg March 1, 2016 Premarin 0.625 mg Tier 3: Updated 6/2016 1
Foscarnet 24 mg/ml infusion bottle March 1, 2016 Consult with provider N/A IPOL single dose syringe March 1, 2016 IPOL vial Tier 3: Lescol 20 mg capsule March 1, 2016 Fluvastatin sodium 20 mg cap Tier 2: Lescol 40 mg capsule March 1, 2016 Fluvastatin sodium 40 mg cap Tier 2: Levaquin 25 mg/ml solution March 1, 2016 Levofloxacin 500 mg/20 mg vial Tier 2: Liptruzet 10-10 mg March 1, 2016 Zetia 10 mg ; Atorvastatin 10 mg Tier 3: ; Tier 2: Liptruzet 10-20 mg March 1, 2016 Zetia 10 mg ; Atorvastatin 20 mg Tier 3: ; Tier 2: Liptruzet 10-40 mg March 1, 2016 Zetia 10 mg ; Atorvastatin 40 mg Tier 3: ; Tier 2: Liptruzet 10-80 mg March 1, 2016 Zetia 10 mg ; Atorvastatin 80 mg Tier 3: ; Tier 2: Lotrel 5-40 mg capsule March 1, 2016 Amlodipine-benazepril 5-40 mg Tier 2: Naftin 1% cream March 1, 2016 Naftifine HCl 1% cream Tier 4: Non- Naprosyn 250 mg March 1, 2016 Naproxen 250 mg Tier 2: Neumega 5 mg vial March 1, 2016 Consult with provider N/A Spectracef 400 mg dose pack tab March 1, 2016 Consult with provider N/A Suclear bowel prep kit March 1, 2016 Suprep bowel prep kit Tier 4: Non- Teveten 600 mg March 1, 2016 Eprosartan mesylate 600 mg tab Tier 2: Teveten HCT 600-12.5 mg tab March 1, 2016 Eprosartan mesylate 600 mg tab; Tier 2: ; Tier 2: Hydrochlorothiazide 12.5 mg tab Teveten HCT 600-25 mg tab March 1, 2016 Eprosartan mesylate 600 mg tab; Tier 2: ; Tier 2: Hydrochlorothiazide 25 mg tab Ticlopidine 250 mg March 1, 2016 Consult with provider N/A Viibryd titration pack March 1, 2016 Viibryd 10-20 mg starter pack Tier 3: Voltaren-XR 100 mg March 1, 2016 Diclofenac sod ER 100 mg tab Tier 2: Apexicon 0.05% ointment April 1, 2016 Diflorasone 0.05% ointment Tier 2: Auvi-Q 0.15 mg auto-injector April 1, 2016 Epipen JR 2-pak 0.15 mg injctr Tier 3: Auvi-Q 0.3 mg auto-injector April 1, 2016 Epipen 2-pak 0.3 mg auto-injct Tier 3: Updated 6/2016 2
Avandia 8 mg April 1, 2016 Avandia 4 mg Tier 4: Non- Demadex 20 mg April 1, 2016 Torsemide 20 mg Tier 2: Endodan 4.8355-325 mg April 1, 2016 Oxycodone-aspirin 4.8355-325 mg Tier 2: Factive 320 mg April 1, 2016 Consult with provider N/A Flagyl ER 750 mg April 1, 2016 Metronidazole 500 mg Tier 2: Lomustine 10 mg capsule April 1, 2016 Gleostine 10 mg capsule Tier 4: Non- Lomustine 100 mg capsule April 1, 2016 Gleostine 100 mg capsule Tier 4: Non- Lomustine 40 mg capsule April 1, 2016 Gleostine 40 mg capsule Tier 4: Non- Naprosyn 375 mg April 1, 2016 Naproxen 375 mg Tier 2: Ortho-cept 28 day April 1, 2016 Apri 28 day Tier 2: Percodan 4.8355-325 mg April 1, 2016 Oxycodone-aspirin 4.8355-325 mg Tier 2: Pletal 100 mg April 1, 2016 Cilostazol 100 mg Tier 2: Pletal 50 mg April 1, 2016 Cilostazol 50 mg Tier 2: Prandimet 1 mg-500 mg April 1, 2016 Repaglinide-metformin 1-500 mg Tier 2: Prandimet 2 mg-500 mg April 1, 2016 Repaglinide-metformin 2-500 mg Tier 2: Roxicet 5-325 mg oral solution April 1, 2016 Oxycodone HCl 5 mg/5 ml soln Tier 2: Sprix 15.75 mg nasal spray April 1, 2016 Consult with provider N/A Tobramycin 80 mg/100 ml NS April 1, 2016 Tobramycin 10 mg/ml vial Tier 2: Triamcinolone 55 mcg nasal spray April 1, 2016 Fluticasone Prop 50 mcg spray Tier 2: Ultressa DR 13,800 unit capsule April 1, 2016 Zenpep DR capsule Tier 4: Non- Ultressa DR 20,700 unit capsule April 1, 2016 Zenpep DR capsule Tier 4: Non- Ultressa DR 23,000 unit capsule April 1, 2016 Zenpep DR capsule Tier 4: Non- Xylocaine 4% solution April 1, 2016 Lidocaine HCl 4% solution Tier 2: Anaprox 275mg May 1, 2016 Naproxen sodium 275mg Tier 2: Androgel 1% gel pump May 1, 2016 Androgel 1% gel packet Tier 3: Arzerra 100mg/5ml vial May 1, 2016 Consult with provider N/A Lopressor 5mg/5ml ampule May 1, 2016 Metoprolol tartrate 1mg/ml amp Tier 2: Norpramin 75mg May 1, 2016 Desipramine 75mg Tier 2: Prilosec DR 10mg capsule May 1, 2016 Omeprazole DR 10mg capsule Tier 1: Preferred Updated 6/2016 3
Prilosec DR 20mg capsule May 1, 2016 Omeprazole DR 20mg capsule Tier 1: Preferred Prilosec DR 40mg capsule May 1, 2016 Omeprazole DR 40mg capsule Tier 1: Preferred Reprexain 2.5-200mg May 1, 2016 Hydrocodone-ibuprofen 5-200mg Tier 2: Advicor 1,000-20mg June 1, 2016 Niacin ER ; Altoprev 20mg Tier 2: ; Tier 4: Non- Advicor 1,000-40mg June 1, 2016 Niacin ER ; Altoprev 40mg Tier 2: ; Tier 4: Non- Advicor 500-20mg June 1, 2016 Niacin ER 500mg; Altoprev 20mg Tier 2: ; Tier 4: Non- Advicor 750-20mg June 1, 2016 Niacin ER 750mg; Altoprev 20mg Tier 2: ; Tier 4: Non- Alsuma 6mg/0.5ml auto-inject June 1, 2016 Sumatriptan 6mg/0.5ml injection Tier 2: Amnesteem 10mg capsule June 1, 2016 Claravis 10mg capsule Tier 2: Amnesteem 20mg capsule June 1, 2016 Claravis 20mg capsule Tier 2: Amnesteem 40mg capsule June 1, 2016 Claravis 40mg capsule Tier 2: Avandamet 2mg- June 1, 2016 Metformin ; Avandia 2mg Tier 1: Preferred ; Tier 4: Non- Coly-mycin S ear drops June 1, 2016 Cortisporin-TC ear suspension Tier 4: Non- Comvax vaccine vial June 1, 2016 Consult with provider N/A Dilaudid 2mg/ml ampule June 1, 2016 Dilaudid 4mg/ml ampule Tier 4: Non- Fulyzaq 125 mg DR June 1, 2016 Consult with provider N/A Simcor 1,000-20mg June 1, 2016 Simvastatin 20mg ; Niacin ER Simcor 1,000-40mg June 1, 2016 Simvastatin 40mg ; Niacin ER Simcor 500-20mg June 1, 2016 Simvastatin 20mg ; Niacin ER 500mg Simcor 500-40mg June 1, 2016 Simvastatin 40mg ; Niacin ER Tier 1: Preferred ; Tier 2: Tier 1: Preferred ; Tier 2: Tier 1: Preferred ; Tier 2: Tier 1: Preferred ; Tier 2: Updated 6/2016 4
Simcor 750-20mg June 1, 2016 Simvastatin 20mg ; Niacin ER 750mg Tier 1: Preferred ; Tier 2: Tofranil-PM 100mg capsule June 1, 2016 Imipramine pamoate 100 mg capsule Tier 2: Tofranil-PM 125mg capsule June 1, 2016 Imipramine pamoate 125 mg capsule Tier 2: Tofranil-PM 150mg capsule June 1, 2016 Imipramine pamoate 150 mg capsule Tier 2: Tofranil-PM 75mg capsule June 1, 2016 Imipramine pamoate 75 mg capsule Tier 2: Treanda 45mg/0.5ml vial June 1, 2016 Treanda 100 mg/vial Tier 5: Specialty Wellbutrin 75mg June 1, 2016 Buproprion HCl 75mg Tier 2: Zolpimist 5mg oral spray June 1, 2016 Zolpidem 5mg ; Edluar 5mg SL Tier 2: ; Tier 4: Non- Cantil 25 mg July 1, 2016 Consult with provider N/A Daunoxome 50 mg (2mg/ml) vial July 1, 2016 Consult with provider N/A Flo-pred 16.7(15) mg/5 ml susp July 1, 2016 Prednisolone 15 mg/5 ml solution Tier 2: Garamycin 0.3% eye drops July 1, 2016 Gentamicin 0.3% eye drops Tier 2: Gelnique 3% gel July 1, 2016 Gelnique 10% gel sachets Tier 4: Non- Keflex 250 mg capsule July 1, 2016 Cephalexin 250 mg capsule Tier 2: Keflex 500 mg capsule July 1, 2016 Cephalexin 500 mg capsule Tier 2: Keflex 750 mg capsule July 1, 2016 Cephalexin 750 mg capsule Tier 2: Lotrel 2.5-10 mg capsule July 1, 2016 Amlodipine-benazepril 2.5-10 mg Tier 2: Otezla starter pack July 1, 2016 Otezla 28 day starter pack Tier 5: Specialty Primsol 50 mg/5 ml oral solution July 1, 2016 Trimethoprim 100mg Tier 2: Promacta 75 mg July 1, 2016 Promacta 25 mg ; 50 mg Tier 5: Specialty Uceris 2 mg rectal foam July 1, 2016 Consult with provider N/A Zazole vaginal 0.4% cream July 1, 2016 Zazole vaginal 0.8% cream Tier 4: Non- Updated 6/2016 5