Provider Partners Pennsylvania Advantage Plan Offered by Provider Partners Health Plan April 2019 Formulary Addendum

Transcription

1 Provider Partners Pennsylvania Advantage Plan Offered by Provider Partners Health Plan April 2019 Formulary Addendum Below is a list formulary changes for the benefit year This is not a complete list of drugs covered by the Part D plan. The formulary changes are reflected in the 2019 downloadable formulary on the Provider Partners Health Plan website. For a complete list of drugs covered by Provider Partners Health Plan, please visit our Web site or call Member Services at , 8 am - 8 pm, 7 days a week. TTY/TDD users should call 711. EFFECTIVE 01/01/2019 Auryxia TABLET 1 GM 210 MG(Fe) ORAL PA1 Formulary Update N/A BromSite SOLUTION % OPHTHALMIC Cimduo Tablet MG Estropipate TABLET 1.5 MG ORAL 1 + PA2 CMS Required Deletion N/A Humira Pen-CD/UC/HS Starter Pen-Injector Kit 80 MG/0.8ML Subcutaneous 1 + PA1 Formulary Enhancement N/A Page 1 of 12

2 Humira Pen-Ps/UV Starter Pen- Injector Kit 80 MG/0.8ML & 40MG/0.4ML Subcutaneous 1 + PA1 Formulary Enhancement N/A Incassia Tablet 0.35 MG Ketoprofen CAPSULE 75 MG Trelegy Ellipta Aerosol Powder Breath Activated MCG/INH Inhalation 1 + ST1 Formulary Enhancement N/A Vestura TABLET MG ORAL Xeljanz Tablet 10 MG 1 + PA1 Formulary Enhancement N/A Page 2 of 12

3 Zenpep CAPSULE DELAYED RELEASE PARTICLES UNIT ORAL Zenpep Capsule Delayed Release Particles UNIT Zenpep CAPSULE DELAYED RELEASE PARTICLES UNIT ORAL Zenpep CAPSULE DELAYED RELEASE PARTICLES UNIT ORAL Zenpep Capsule Delayed Release Particles UNIT Zenpep CAPSULE DELAYED RELEASE PARTICLES 5000 UNIT ORAL EFFECTIVE 02/01/2019 Abiraterone Acetate Tablet 250 MG Adapalene Solution 0.1 % External Afeditab CR Tablet Extended Release 24 Hour 60 MG 1 + QL PA2 Formulary Enhancements N/A Ampyra Tablet Extended Release 12 Hour 10 MG 1 + QL 60 + PA2 + LA Formulary Update dalfampridine 10mg, 1 + QL 60 + PA2 AndroGel GEL MG/1.25GM (1.62%) TRANSDERMAL 1 + PA2 Formulary Update testosterone mg/mg, 1 + PA2 Page 3 of 12

4 AndroGel GEL 40.5 MG/2.5GM (1.62%) TRANSDERMAL AndroGel Pump GEL MG/ACT (1.62%) TRANSDERMAL 1 + PA2 Formulary Update 1 + PA2 Formulary Update testosterone mg/mg, 1 + PA2 testosterone 20.25mg/actuat, 1 + PA2 Arikayce Suspension 590 MG/8.4ML Inhalation Braftovi Capsule 50 MG 1 + PA2 + LA Formulary Enhancements N/A Braftovi Capsule 75 MG 1 + PA2 + LA Formulary Enhancements N/A BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 450 MG Cefotaxime Sodium Solution Reconstituted 2 GM Injection Clindamycin Phos-Benzoyl Perox Gel % External Clinimix/Dextrose (2.75/5) SOLUTION 2.75 % Intravenous Clinimix/Dextrose (4.25/20) SOLUTION 4.25 % Intravenous CloBAZam Suspension 2.5 MG/ML 1 + QL 30 + ST2 Formulary Enhancements N/A 1 Formulary Enhancements N/A 1 + BvD CMS Required Deletion N/A 1 + BvD CMS Required Deletion N/A 1 + PA2 Formulary Enhancements N/A Page 4 of 12

5 CloBAZam Tablet 10 MG 1 + QL 60 + PA2 Formulary Enhancements N/A CloBAZam Tablet 20 MG 1 + QL 60 + PA2 Formulary Enhancements N/A Colesevelam HCl Packet 3.75 GM 1 Formulary Enhancements N/A Copiktra Capsule 15 MG 1 + QL 60 + PA2 + LA Formulary Enhancements N/A Copiktra Capsule 25 MG 1 + QL 60 + PA2 + LA Formulary Enhancements N/A Cyred EQ Tablet MG- MCG DAPTOmycin Solution Reconstituted 350 MG Intravenous Delstrigo Tablet MG Epidiolex Solution 100 MG/ML Ertapenem Sodium Solution Reconstituted 1 GM Injection 1 Formulary Enhancements N/A 1 Formulary Enhancements N/A 1 + PA2 Formulary Enhancements N/A 1 Formulary Enhancements N/A Forfivo XL Tablet Extended Release 24 Hour 450 MG 1 + QL 30 + ST2 Formulary Update bupropion hydrochloride, 1 + QL 30 + ST2 Page 5 of 12

6 Hexalen CAPSULE 50 MG ORAL 1 + PA2 CMS Required Deletion N/A INVanz Solution Reconstituted 1 GM Injection 1 Formulary Update ertapenem 1000mg, 1 Itraconazole Solution 10 MG/ML Ketoprofen Capsule 25 MG 1 Formulary Enhancements N/A Kimidess Tablet /0.01 MG (21/5) Lenvima 12 MG Daily Dose Capsule Therapy Pack 4 (3) MG Lenvima 4 MG Daily Dose Capsule Therapy Pack 4 MG 1 + PA2 Formulary Enhancements N/A 1 + PA2 Formulary Enhancements N/A Lorbrena Tablet 100 MG 1 + PA2 Formulary Enhancements N/A Lorbrena Tablet 25 MG 1 + PA2 Formulary Enhancements N/A Mektovi Tablet 15 MG 1 + PA2 + LA Formulary Enhancements N/A Molindone HCl Tablet 10 MG Molindone HCl Tablet 25 MG 1 Formulary Enhancements N/A 1 Formulary Enhancements N/A Molindone HCl Tablet 5 MG 1 Formulary Enhancements N/A Page 6 of 12

7 Morphine Sulfate ER Capsule Extended Release 24 Hour 40 MG Nafcillin Sodium Solution Reconstituted 2 GM Injection Necon 7/7/7 Tablet 0.5/0.75/1-35 MG-MCG 1 Formulary Enhancements N/A 1 Formulary Enhancements N/A Norvir CAPSULE 100 MG ORAL Onfi SUSPENSION 2.5 MG/ML ORAL 1 + PA2 Formulary Update clobazam 2.5mg/ml, 1 + PA2 Onfi TABLET 10 MG 1 + QL 60 + PA2 Formulary Update clobazam 10mg, 1 + QL 60 + PA2 Onfi TABLET 20 MG 1 + QL 60 + PA2 Formulary Update clobazam 20mg, 1 + QL 60 + PA2 Orilissa Tablet 150 MG Orilissa Tablet 200 MG Orkambi Packet MG 1 + PA1 + LA Formulary Enhancements N/A Orkambi Packet MG 1 + PA1 + LA Formulary Enhancements N/A Periogard Solution 0.12 % Mouth/Throat Pifeltro Tablet 100 MG 1 Formulary Enhancements N/A Page 7 of 12

8 Sodium Chloride Solution 2.5 MEQ/ML Injection Symtuza Tablet MG Takhzyro Solution 300 MG/2ML Subcutaneous 1 Formulary Enhancements N/A 1 + PA1 + LA Formulary Enhancements N/A Talzenna Capsule 0.25 MG 1 + PA2 + LA Formulary Enhancements N/A Talzenna Capsule 1 MG 1 + PA2 + LA Formulary Enhancements N/A Testosterone Gel MG/1.25GM (1.62%) Transdermal Testosterone Gel MG/ACT (1.62%) Transdermal Testosterone Gel 40.5 MG/2.5GM (1.62%) Transdermal 1 + PA2 Formulary Enhancements N/A 1 + PA2 Formulary Enhancements N/A 1 + PA2 Formulary Enhancements N/A Tibsovo Tablet 250 MG 1 + PA2 + LA Formulary Enhancements N/A Tiglutik Suspension 50 MG/10ML Triamcinolone Acetonide Aerosol 55 MCG/ACT Nasal Vancomycin HCl Solution Reconstituted 250 MG Intravenous 1 + BvD Formulary Enhancements N/A Page 8 of 12

9 Versacloz Suspension 50 MG/ML 1 + PA2 CMS Required Deletion N/A Vizimpro Tablet 15 MG 1 + QL 30 + PA2 Formulary Enhancements N/A Vizimpro Tablet 30 MG 1 + QL 30 + PA2 Formulary Enhancements N/A Vizimpro Tablet 45 MG 1 + QL 30 + PA2 Formulary Enhancements N/A Welchol Packet 3.75 GM 1 Formulary Update colesevelam hydrochloride 3750mg, 1 Xarelto Tablet 2.5 MG 1 Formulary Enhancements N/A Xofluza Tablet Therapy Pack 20 (2) MG Xofluza Tablet Therapy Pack 40 (2) MG 1 Formulary Enhancements N/A 1 Formulary Enhancements N/A Xolair Solution Prefilled Syringe 150 MG/ML Subcutaneous 1 + QL 6/28 + PA1 + LA Formulary Enhancements N/A Xolair Solution Prefilled Syringe 75 MG/0.5ML Subcutaneous 1 + QL 6/28 + PA1 + LA Formulary Enhancements N/A Zortress Tablet 1 MG 1 + PA2 Formulary Enhancements N/A Zytiga TABLET 250 MG ORAL 1 + QL PA2 Formulary Update abiraterone acetate 250mg, 1 + QL PA2 EFFECTIVE 03/01/2019 Page 9 of 12

10 Actemra ACTPen Solution Auto- Injector 162 MG/0.9ML Subcutaneous Afeditab CR Tablet Extended Release 24 Hour 30 MG Clinimix E/Dextrose (5/25) Solution 5 % Intravenous 1 + BvD CMS Required Deletion N/A Daurismo Tablet 100 MG 1 + PA2 Formulary Enhancements N/A Daurismo Tablet 25 MG 1 + PA2 Formulary Enhancements N/A Hailey 24 Fe Tablet 1-20 MG- MCG(24) 1 Formulary Enhancements N/A Invirase CAPSULE 200 MG Lokelma Packet 10 GM 1 Formulary Enhancements N/A Lokelma Packet 5 GM 1 Formulary Enhancements N/A Lynparza Capsule 50 MG 1 + PA2 + LA CMS Required Deletion N/A Mesalamine Suppository 1000 MG Rectal 1 Formulary Enhancements N/A Metipranolol Solution 0.3 % Ophthalmic Moderiba 800 Dose Pack Tablet 400 MG Nocdurna Tablet Sublingual 27.7 MCG Sublingual 1 Formulary Enhancements N/A Nocdurna Tablet Sublingual 55.3 MCG Sublingual 1 Formulary Enhancements N/A Oxervate Solution % Ophthalmic Polyethylene Glycol 3350 Powder Potassium Chloride PACKET 20 MEQ 1 Formulary Enhancements N/A Retacrit Solution UNIT/ML Injection Page 10 of 12

11 Retacrit Solution 2000 UNIT/ML Injection Retacrit Solution 3000 UNIT/ML Injection Retacrit Solution 4000 UNIT/ML Injection Retacrit Solution UNIT/ML Injection Silodosin Capsule 4 MG 1 Formulary Enhancements N/A Silodosin Capsule 8 MG 1 Formulary Enhancements N/A Sofosbuvir-Velpatasvir Tablet MG SUMAtriptan Succinate Solution Prefilled Syringe 6 MG/0.5ML 1 Formulary Enhancements N/A Subcutaneous Tecfidera 120 & 240 MG ORAL 1 + QL 60 + PA2 1 + PA2 Formulary Enhancement N/A Tecfidera CAPSULE DELAYED 1 + QL 60 + RELEASE 120 MG ORAL PA2 1 +PA2 Formulary Enhancement N/A Tecfidera CAPSULE DELAYED 1 + QL 60 + RELEASE 240 MG ORAL PA2 1 + PA2 Formulary Enhancement N/A Tegsedi Solution Prefilled Syringe 1 + QL 6/ MG/1.5ML Subcutaneous PA1 Formulary Enhancements N/A Tri-Estarylla Tablet 0.18/0.215/0.25 MG-35 MCG 1 Formulary Enhancements N/A Vitrakvi Capsule 100 MG 1 + PA2 Formulary Enhancements N/A Vitrakvi Capsule 25 MG 1 + PA2 Formulary Enhancements N/A Vitrakvi Solution 20 MG/ML 1 + PA2 Formulary Enhancements N/A Xospata Tablet 40 MG 1 + PA2 Formulary Enhancements N/A Xtandi CAPSULE 40 MG ORAL 1 + QL QL PA2 + PA2 + LA Formulary Enhancement + LA + ST2 N/A Zenchent Tablet MG-MCG Page 11 of 12

12 Zerit Solution Reconstituted 1 MG/ML EFFECTIVE 04/01/2019 Albendazole Tablet 200 MG BCG Vaccine INJECTABLE INJECTION 1 + BvD 1 Formulary Enhancement N/A Clobetasol Propionate Emulsion Foam 0.05 % External Firdapse Tablet 10 MG 1 + QL PA1 Formulary Enhancement N/A Moderiba 1200 Dose Pack Tablet 600 MG Moderiba TABLET 200 MG ORAL Nevirapine Suspension 50 MG/5ML Perseris Prefilled Syringe 120 MG Subcutaneous 1 + PA2 Formulary Enhancement N/A Perseris Prefilled Syringe 90 MG Subcutaneous 1 + PA2 Formulary Enhancement N/A Pimecrolimus Cream 1 % External 1 + ST1 Formulary Enhancement N/A Promacta Packet 12.5 MG 1 + QL PA1 Formulary Enhancement N/A Rapaflo Capsule 4 MG 1 Formulary Update silodosin 4 mg, 1 Rapaflo Capsule 8 MG 1 Formulary Update silodosin 8 mg, 1 Shingrix Suspension Reconstituted 50 MCG/0.5ML Intramuscular 1 + BvD 1 Formulary Enhancement N/A Sympazan Film 10 MG 1 + QL 60 + PA2 Formulary Enhancement N/A Sympazan Film 20 MG 1 + QL 60 + PA2 Formulary Enhancement N/A Sympazan Film 5 MG 1 + QL 60 + PA2 Formulary Enhancement N/A Terbinafine HCl Tablet 250 MG 1 + QL 84/168 1 Formulary Enhancement N/A Tri-VyLibra Lo Tablet 0.18/0.215/0.25 MG-25 MCG Page 12 of 12