AgeWell 1-Tier 2017 Formulary Addendum

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1 FORMULARY CHANGES EFFECTIVE 01/01/ ABILIFY MAINT INJ 400MG ADRUCIL INJ 500/10ML NF 1 + BvD Formulary Enhancement N/A AMMONIUM LAC CRE 12% BUPROPION TAB 150MG BUTAL/APAP TAB MG CAZIANT PAK CHOLESTYRAMINE LIGHT POW 4 GM/DOSE COMPRO SUP 25MG EMEND SUS 125MG NF 1 + BvD Formulary Enhancement N/A EPITOL TAB 200MG ERAXIS INJ 50MG GENGRAF CAP 50MG GRISEOFULVIN TAB MICR 500 GRISEOFULVIN TAB ULTR 125 GRISEOFULVIN TAB ULTR 250 HUMIRA PEN INJ PSORIASI KANUMA INJ 20/10ML NF 1 + PA1 Formulary Enhancement N/A LARISSIA TAB MEMANT TITRA PAK 5-10MG MEMANTINE TAB HCL 10MG MEMANTINE TAB HCL 5MG MESALAMINE TAB 800MG DR METHOCARBAM INJ 100MG/ML NF 1 + HR Formulary Enhancement N/A MUPIROCIN CRE 2% NILUTAMIDE TAB 150MG Page 1 of 7

2 FORMULARY CHANGES NORGESTIM-ETH ESTRAD TRIPHASIC TAB 0.18/0.215/0.25 MG- 35 MCG NUCALA INJ 100MG NF 1 + PA1 Formulary Enhancement N/A ORENCIA CLCK INJ 125MG/ML NF 1 + ST2 Formulary Enhancement N/A PANTOPRAZOLE INJ SOD 40MG PRAMIPEXOLE TAB 3.75MG PREDNISONE TAB 10 MG (21) PREDNISONE TAB 10 MG (48) PREDNISONE TAB 5 MG (21) PREDNISONE TAB 5 MG (48) RELISTOR TAB 150MG REPATHA PUSH INJ 420/3.5 NF 1 + PA1 Formulary Enhancement N/A RISEDRONATE SOD TAB 35 MG (12 PACK) RISEDRONATE TAB 150MG RISEDRONATE TAB 30MG RISEDRONATE TAB 5MG SPS SUS 15GM/60 SUMATRIPTAN SUC SOL AUTO-INJ NF 1 + QL 4.5 Formulary Enhancement N/A 4 MG/0.5ML SUBQ TOPOSAR INJ 1GM/50ML NF 1 + BvD Formulary Enhancement N/A VALSARTAN TAB 160MG VALSARTAN TAB 320MG VALSARTAN TAB 40MG VALSARTAN TAB 80MG VINCASAR PFS INJ 1MG/ML NF 1 + BvD Formulary Enhancement N/A Page 2 of 7

3 FORMULARY CHANGES YONDELIS INJ 1MG NF 1 + PA2 Formulary Enhancement N/A ZEBUTAL CAP EFFECTIVE 03/01/ 8-MOP CAP 10MG 1 NF CMS Required Deletion N/A ABACA/LAMIVU TAB ADRIAMYCIN INJ 20MG NF 1 + BvD Formulary Enhancement N/A ALYACEN TAB 1/35 AMLOD/OLMESA TAB 10-20MG AMLOD/OLMESA TAB 10-40MG AMLOD/OLMESA TAB 5-20MG AMLOD/OLMESA TAB 5-40MG APREPITANT CAP 125MG NF 1 + BvD Formulary Enhancement N/A APREPITANT CAP 40MG NF 1 + BvD Formulary Enhancement N/A APREPITANT CAP 80MG NF 1 + BvD Formulary Enhancement N/A APREPITANT PAK 80 & 125 NF 1 + BvD Formulary Enhancement N/A AZITHROMYCIN TAB 500 MG (3 PACK) BUPROBAN TAB 150MG 1 NF CMS Required Deletion N/A CERVARIX INJ 1 NF CMS Required Deletion N/A CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 6000UNIT DAPTOMYCIN INJ 500MG DOCEFREZ INJ 20MG 1 + BvD NF CMS Required Deletion N/A EPCLUSA TAB NF 1 + PA1 Formulary Enhancement N/A Page 3 of 7

4 FORMULARY CHANGES EPINEPHRINE SOL AUTO-INJ 0.15 MG/0.3ML INJ EPIRUBICIN INJ 200MG NF 1 + BvD Formulary Enhancement N/A ERGOMAR SUB 2MG 1 NF CMS Required Deletion N/A ERGOT/CAFFEN TAB 1-100MG NF 1 + QL 40/28 Formulary Enhancement N/A ETHYNODIOL TAB 1-50 EZETIMIBE TAB 10MG FEMYNOR TAB GAMMAGARD SD INJ 10GM HU NF 1 + BvD Formulary Enhancement N/A GAMMAGARD SD INJ 5GM HU NF 1 + BvD Formulary Enhancement N/A INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB MG KETEK TAB 300MG 1 NF CMS Required Deletion N/A KETEK TAB 400MG 1 NF CMS Required Deletion N/A KINRIX INJ KYPROLIS SOL 30MG NF 1 + BvD Formulary Enhancement N/A KYPROLIS SOL 60MG NF 1 + BvD Formulary Enhancement N/A LARTRUVO INJ 10MG/ML NF 1 + PA2 Formulary Enhancement N/A LEVALBUTEROL HCL NEB SOL 1.25 NF 1 + BvD Formulary Enhancement N/A MG/0.5ML INH (2.5MG/ML) LOW-OGESTREL TAB MELOXICAM SUS 7.5/5ML 1 NF CMS Required Deletion N/A MENEST TAB 2.5MG 1 + HR NF CMS Required Deletion N/A METFORMIN HCL ER (OSM) TAB ER 24H 1000 MG (OSMOTIC) Page 4 of 7

5 FORMULARY CHANGES METFORMIN HCL ER (OSM) TAB ER 24H 500 MG METHOTREXATE INJ 25MG/ML NF 1 + BvD Formulary Enhancement N/A MYCOPHENOLAT INJ 500MG NF 1 + BvD Formulary Enhancement N/A MYTESI TAB 125MG NAMZARIC CAP NAMZARIC CAP 21-10MG NAMZARIC CAP 7-10MG NAPHAZOLINE SOL 0.1% OP 1 NF CMS Required Deletion N/A NIFEDICAL XL TAB 30MG 1 NF CMS Required Deletion N/A NIFEDICAL XL TAB 60MG 1 NF CMS Required Deletion N/A NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 30 MG NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 60 MG NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 90 MG NITROGLYCERI SUB 0.6MG NITROGLYCERN SUB 0.3MG NITROGLYCERN SUB 0.4MG NORETH/ETHIN TAB 1/20 OFLOXACIN TAB 300MG OLM MED/HCTZ TAB OLM MED/HCTZ TAB OLM MED/HCTZ TAB 40-25MG OLMESA MEDOX TAB 20MG OLMESA MEDOX TAB 40MG Page 5 of 7

6 FORMULARY CHANGES OLMESA MEDOX TAB 5MG TAB MG TAB MG TAB MG TAB MG TAB MG ORKAMBI TAB NF 1 + PA1 Formulary Enhancement N/A OSELTAMIVIR CAP 30MG OSELTAMIVIR CAP 45MG OSELTAMIVIR CAP 75MG PEDIARIX INJ 0.5ML PLASMA-LYTE INJ 56/D5W 1 NF CMS Required Deletion N/A PRIMSOL SOL 50MG/5ML QUETIAPINE TAB 150MG ER QUETIAPINE TAB 200MG ER QUETIAPINE TAB 300MG ER QUETIAPINE TAB 400MG ER QUETIAPINE TAB 50MG ER RANITIDINE INJ 50MG/2ML 1 NF CMS Required Deletion N/A RASAGILINE TAB 0.5MG RASAGILINE TAB 1MG RESERPINE TAB 0.1MG 1 + HR NF CMS Required Deletion N/A RHEUMATREX TAB 2.5MG 4X6 1 + BvD NF CMS Required Deletion N/A Page 6 of 7

7 FORMULARY CHANGES RUBRACA TAB 200MG NF 1 + PA2 Formulary Enhancement N/A RUBRACA TAB 300MG NF 1 + PA2 Formulary Enhancement N/A STAVUDINE SOL 1MG/ML 1 NF CMS Required Deletion N/A TRAVOPROST DRO 0.004% 1 NF CMS Required Deletion N/A TYZEKA TAB 600MG 1 NF CMS Required Deletion N/A VALGANCICLOV SOL 50MG/ML VARIZIG INJ 125UNIT 1 NF CMS Required Deletion N/A VEMLIDY TAB 25MG NF 1 + PA2 Formulary Enhancement N/A VITEKTA TAB 150MG 1 NF CMS Required Deletion N/A VITEKTA TAB 85MG 1 NF CMS Required Deletion N/A YUVAFEM TAB 10MCG ZERIT SOL 1MG/ML Page 7 of 7

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