AgeWell 5-Tier 2017 Formulary Addendum

Transcription

1 EFFECTIVE 01/01/ ABILIFY MAINT INJ 400MG ADRUCIL INJ 500/10ML NF 2 + BvD Formulary Enhancement N/A AMMONIUM LAC CRE 12% NF 1 Formulary Enhancement N/A AMMONIUM LAC LOT 12% 2 1 Formulary Enhancement N/A BUPROPION TAB 150MG BUTAL/APAP TAB MG CAZIANT PAK CHOLESTYRAMINE LIGHT POW 4 GM/DOSE COMPRO SUP 25MG EMEND SUS 125MG NF 4 + BvD Formulary Enhancement N/A EPITOL TAB 200MG ERAXIS INJ 50MG GENGRAF CAP 50MG GRISEOFULVIN TAB MICR 500 NF 1 Formulary Enhancement N/A GRISEOFULVIN TAB ULTR 125 NF 1 Formulary Enhancement N/A GRISEOFULVIN TAB ULTR 250 NF 1 Formulary Enhancement N/A HUMIRA PEN INJ PSORIASI NF 5 Formulary Enhancement N/A KANUMA INJ 20/10ML NF 5 + PA1 Formulary Enhancement N/A LARISSIA TAB MEMANT TITRA PAK 5-10MG MEMANTINE TAB HCL 10MG MEMANTINE TAB HCL 5MG MESALAMINE TAB 800MG DR NF 3 Formulary Enhancement N/A METHOCARBAM INJ 100MG/ML NF 2 + HR Formulary Enhancement N/A MUPIROCIN CRE 2% NILUTAMIDE TAB 150MG NF 5 Formulary Enhancement N/A Page 1 of 14

2 NORGESTIM-ETH ESTRAD TRIPHASIC TAB 0.18/0.215/0.25 MG- 35 MCG NUCALA INJ 100MG NF 5 + PA1 Formulary Enhancement N/A ORENCIA CLCK INJ 125MG/ML NF 5 + ST2 Formulary Enhancement N/A PANTOPRAZOLE INJ SOD 40MG PRAMIPEXOLE TAB 3.75MG PREDNISONE TAB 10 MG (21) NF 1 Formulary Enhancement N/A PREDNISONE TAB 10 MG (48) NF 1 Formulary Enhancement N/A PREDNISONE TAB 5 MG (21) NF 1 Formulary Enhancement N/A PREDNISONE TAB 5 MG (48) NF 1 Formulary Enhancement N/A RELISTOR TAB 150MG REPATHA PUSH INJ 420/3.5 NF 5 + 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 2 + QL 4.5 Formulary Enhancement N/A 4 MG/0.5ML SUBQ TOPOSAR INJ 1GM/50ML NF 2 + BvD Formulary Enhancement N/A VALSARTAN TAB 160MG VALSARTAN TAB 320MG VALSARTAN TAB 40MG VALSARTAN TAB 80MG VINCASAR PFS INJ 1MG/ML NF 2 + BvD Formulary Enhancement N/A YONDELIS INJ 1MG NF 5 + PA2 Formulary Enhancement N/A Page 2 of 14

3 ZEBUTAL CAP EFFECTIVE 03/01/ 8-MOP CAP 10MG 4 NF CMS required deletion N/A ABACA/LAMIVU TAB ADRIAMYCIN INJ 20MG NF 2 + 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 4 + BvD Formulary Enhancement N/A APREPITANT CAP 40MG NF 4 + BvD Formulary Enhancement N/A APREPITANT CAP 80MG NF 4 + BvD Formulary Enhancement N/A APREPITANT PAK 80 & 125 NF 4 + BvD Formulary Enhancement N/A AZITHROMYCIN TAB 500 MG (3 PACK) BUPROBAN TAB 150MG 2 NF CMS required deletion N/A CERVARIX INJ 4 NF CMS required deletion N/A CREON CAP 12000UNT NF 3 Formulary Enhancement N/A CREON CAP 24000UNT NF 3 Formulary Enhancement N/A CREON CAP 3000UNIT NF 3 Formulary Enhancement N/A CREON CAP 6000UNIT NF 3 Formulary Enhancement N/A DAPTOMYCIN INJ 500MG DOCEFREZ INJ 20MG 5 + BvD NF CMS required deletion N/A EPCLUSA TAB NF 5 + PA1 Formulary Enhancement N/A EPINEPHRINE SOL AUTO-INJ 0.15 MG/0.3ML INJ NF 3 Formulary Enhancement N/A EPIRUBICIN INJ 200MG NF 4 + BvD Formulary Enhancement N/A Page 3 of 14

4 ERGOMAR SUB 2MG 4 NF CMS required deletion N/A ERGOT/CAFFEN TAB 1-100MG NF 2 + QL 40/28 Formulary Enhancement N/A ETHYNODIOL TAB 1-50 EZETIMIBE TAB 10MG FEMYNOR TAB GAMMAGARD SD INJ 10GM HU NF 5 + BvD Formulary Enhancement N/A GAMMAGARD SD INJ 5GM HU NF 5 + BvD Formulary Enhancement N/A INVOKAMET XR TAB NF 3 Formulary Enhancement N/A INVOKAMET XR TAB NF 3 Formulary Enhancement N/A INVOKAMET XR TAB NF 3 Formulary Enhancement N/A INVOKAMET XR TAB MG NF 3 Formulary Enhancement N/A KETEK TAB 300MG 4 NF CMS required deletion N/A KETEK TAB 400MG 4 NF CMS required deletion N/A KINRIX INJ KYPROLIS SOL 30MG NF 5 + BvD Formulary Enhancement N/A KYPROLIS SOL 60MG NF 5 + BvD Formulary Enhancement N/A LARTRUVO INJ 10MG/ML NF 4 + PA2 Formulary Enhancement N/A LEVALBUTEROL HCL NEB SOL 1.25 MG/0.5ML INH (2.5MG/ML) NF 2 + BvD Formulary Enhancement N/A LOW-OGESTREL TAB MELOXICAM SUS 7.5/5ML 2 NF CMS required deletion N/A MENEST TAB 2.5MG 2 + HR NF CMS required deletion N/A METFORMIN HCL ER (OSM) TAB ER 24H 1000 MG (OSMOTIC) METFORMIN HCL ER (OSM) TAB ER 24H 500 MG NF 1 Formulary Enhancement N/A METHOTREXATE INJ 25MG/ML NF 2 + BvD Formulary Enhancement N/A MYCOPHENOLAT INJ 500MG NF 2 + BvD Formulary Enhancement N/A Page 4 of 14

5 NAMZARIC CAP NF 3 Formulary Enhancement N/A NAMZARIC CAP 21-10MG NF 3 Formulary Enhancement N/A NAMZARIC CAP 7-10MG NF 3 Formulary Enhancement N/A NAPHAZOLINE SOL 0.1% OP 1 NF CMS required deletion N/A NIFEDICAL XL TAB 30MG 2 NF CMS required deletion N/A NIFEDICAL XL TAB 60MG 2 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 OLMESA MEDOX TAB 5MG OLMESARTAN-AMLODIPINE-HCTZ TAB MG OLMESARTAN-AMLODIPINE-HCTZ TAB MG Page 5 of 14

6 OLMESARTAN-AMLODIPINE-HCTZ TAB MG OLMESARTAN-AMLODIPINE-HCTZ TAB MG OLMESARTAN-AMLODIPINE-HCTZ TAB MG ORKAMBI TAB NF 5 + PA1 Formulary Enhancement N/A OSELTAMIVIR CAP 30MG OSELTAMIVIR CAP 45MG OSELTAMIVIR CAP 75MG PEDIARIX INJ 0.5ML PLASMA-LYTE INJ 56/D5W 3 NF CMS required deletion N/A PRIMSOL SOL 50MG/5ML QUETIAPINE TAB 150MG ER NF 3 Formulary Enhancement N/A QUETIAPINE TAB 200MG ER NF 3 Formulary Enhancement N/A QUETIAPINE TAB 300MG ER NF 3 Formulary Enhancement N/A QUETIAPINE TAB 400MG ER NF 3 Formulary Enhancement N/A QUETIAPINE TAB 50MG ER NF 3 Formulary Enhancement N/A RANITIDINE INJ 50MG/2ML 2 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 4 + BvD NF CMS required deletion N/A RUBRACA TAB 200MG NF 5 + PA2 Formulary Enhancement N/A RUBRACA TAB 300MG NF 5 + PA2 Formulary Enhancement N/A STAVUDINE SOL 1MG/ML 2 NF CMS required deletion N/A TRAVOPROST DRO 0.004% 1 NF CMS required deletion N/A TYZEKA TAB 600MG 4 NF CMS required deletion N/A Page 6 of 14

7 VALGANCICLOV SOL 50MG/ML VARIZIG INJ 125UNIT 4 NF CMS required deletion N/A VEMLIDY TAB 25MG NF 5 + PA2 Formulary Enhancement N/A VITEKTA TAB 150MG 5 NF CMS required deletion N/A VITEKTA TAB 85MG 5 NF CMS required deletion N/A YUVAFEM TAB 10MCG NF 3 Formulary Enhancement N/A ZERIT SOL 1MG/ML NF 3 Formulary Enhancement N/A EFFECTIVE 04/01/ AMIFOSTINE SOL 500 MG IV 5 + BvD NF CMS Required Deletion N/A AMIODARONE HCL TAB 100 MG DEXMETHYLPHENIDATE HCL ER CAP 24 HR 25 MG DEXMETHYLPHENIDATE HCL ER CAP 24 HR 35 MG DOXYCYCLINE HYC SOL 100 MG IV 2 NF CMS Required Deletion N/A LOPINAVIR-RITONAVIR SOL MG/5ML MENOMUNE INJECTABLE SUBQ 4 NF CMS Required Deletion N/A MYTESI TABLET DELAYED RELEASE 125 MG ORAL NORGESTIMATE-ETH ESTRADIOL TAB MG-MCG PRALUENT SOL PFS 150 MG/ML SUBQ 5 + PA1 NF CMS Required Deletion N/A RANITIDINE HCL SOL 50 MG/2ML INJ Page 7 of 14

8 RIBASPHERE RIBAPAK TAB 200 & 400 MG EFFECTIVE 05/01/ AZILECT TAB 0.5 MG 4 NF Formulary Update AZILECT TAB 1 MG 4 NF Formulary Update AZOR TAB MG 4 NF Formulary Update AZOR TAB MG 4 NF Formulary Update AZOR TAB 5-20 MG 4 NF Formulary Update AZOR TAB 5-40 MG 4 NF Formulary Update BENICAR HCT TAB MG 4 NF Formulary Update BENICAR HCT TAB MG 4 NF Formulary Update rasagiline mes tab 0.5 mg, 4 rasagiline mes tab 1 mg, 4 amlodipineolmesartan tab mg, 2 amlodipineolmesartan tab mg, 2 amlodipineolmesartan tab 5-20 mg, 2 amlodipineolmesartan tab 5-40 mg, 2 olmesartan medoxomilhctz tab mg, 4 olmesartan medoxomilhctz tab mg, 4 Page 8 of 14

9 BENICAR HCT TAB MG 4 NF Formulary Update BENICAR TAB 20 MG 4 NF Formulary Update BENICAR TAB 40 MG 4 NF Formulary Update BENICAR TAB 5 MG 4 NF Formulary Update olmesartan medoxomilhctz tab mg, 4 olmesartan medoxomil tab 20 mg, 4 olmesartan medoxomil tab 40 mg, 4 olmesartan medoxomil tab 5 mg, 4 CALCIUM ACETATE TAB 667 MG NF 2 Formulary Enhancements N/A CELLCEPT IV SOL 500 MG IV 3 + BvD NF Formulary Update CUBICIN SOL 500 MG IV 4 NF Formulary Update EMEND CAP 40 MG 4 + BvD NF Formulary Update EMEND CAP 80 & 125 MG 4 + QL 12 + BvD NF Formulary Update mycophenolat e mofetil hcl sol 500 mg iv, 2 +BvD daptomycin sol 500 mg iv, 4 aprepitant cap 40 mg, 4 + BvD aprepitant cap 80 & 125 mg, 4 + BvD Page 9 of 14

10 EPINEPHRINE SOL AUTO-INJ 0.3 MG/0.3ML INJ NF 3 Formulary Enhancements N/A EPZICOM TAB MG 5 NF Formulary Update abacavir sullamivudine tab mg, 4 KLOR-CON M10 TAB ER 10 MEQ NF 1 Formulary Enhancements N/A KLOR-CON M20 TAB ER 20 MEQ NF 2 Formulary Enhancements N/A LINZESS CAP 72 MCG NF 3 Formulary Enhancements N/A MENOMUNE INJ SUBQ NF 4 Formulary Enhancements N/A METFORMIN HCL ER (OSM) TAB ER 24H 1000 MG METHYLPHENIDATE HCL ER (CD) CAP 20 MG METHYLPHENIDATE HCL ER (CD) CAP 40 MG METHYLPHENIDATE HCL ER (LA) CAP 24HR 60 MG 2 NF CMS Required Deletion N/A NF 1 Formulary Enhancements N/A NF 1 Formulary Enhancements N/A NF 1 Formulary Enhancements N/A NILANDRON TAB 150 MG 5 NF Formulary Update NITROSTAT TAB SL 0.3 MG SL 4 NF Formulary Update NITROSTAT TAB SL 0.4 MG SL 4 NF Formulary Update NITROSTAT TAB SL 0.6 MG SL 4 NF Formulary Update nilutamide tab 150 mg, 5 nitroglycerin tab sl 0.3 mg sl, 2 nitroglycerin tab sl 0.4 mg sl, 2 nitroglycerin tab sl 0.6 mg sl, 2 Page 10 of 14

11 POTASSIUM CHLORIDE CRYS ER TAB 10 MEQ NF 1 Formulary Enhancements N/A POTASSIUM CHLORIDE CRYS ER TAB 20 MEQ NF 2 Formulary Enhancements N/A RIVASTIGMINE PAT 24H 13.3 MG/24HR TD NF 3 Formulary Enhancements N/A RIVASTIGMINE PAT 24H 4.6 MG/24HR TD NF 3 Formulary Enhancements N/A RIVASTIGMINE PAT 24H 9.5 MG/24HR TD NF 3 Formulary Enhancements N/A SELZENTRY TAB 25 MG NF 4 Formulary Enhancements N/A SELZENTRY TAB 75 MG NF 4 Formulary Enhancements N/A SEROQUEL XR TAB ER 24H 150 MG 3 NF Formulary Update SEROQUEL XR TAB ER 24H 200 MG 3 NF Formulary Update SEROQUEL XR TAB ER 24H 300 MG 3 NF Formulary Update SEROQUEL XR TAB ER 24H 400 MG 3 NF Formulary Update SEROQUEL XR TAB ER 24H 50 MG 3 NF Formulary Update quetiapine fum er tab er 24h 150 mg, 3 quetiapine fum er tab er 24h 200 mg, 3 quetiapine fum er tab er 24h 300 mg, 3 quetiapine fum er tab er 24h 400 mg, 3 quetiapine fum er tab er 24h 50 mg, 3 Page 11 of 14

12 TAMIFLU CAP 30 MG 4 NF Formulary Update TAMIFLU CAP 45 MG 4 NF Formulary Update TAMIFLU CAP 75 MG 4 NF Formulary Update TRIBENZOR TAB MG 4 NF Formulary Update TRIBENZOR TAB MG 4 NF Formulary Update TRIBENZOR TAB MG 4 NF Formulary Update TRIBENZOR TAB MG 4 NF Formulary Update oseltamivir phos cap 30 mg, 4 oseltamivir phos cap 45 mg, 4 oseltamivir phos cap 75 mg, 4 olmesartanamlodipinehctz tab mg, 4 olmesartanamlodipinehctz tab mg, 4 olmesartanamlodipinehctz tab mg, 4 olmesartanamlodipinehctz tab mg, 4 Page 12 of 14

13 TRIBENZOR TAB MG 4 NF Formulary Update ZETIA TAB 10 MG 4 NF Formulary Update EFFECTIVE 06/01/ DESVENLAFAXINE SUCC ER TAB 24HR 100 MG DESVENLAFAXINE SUCC ER TAB 24HR 25 MG DESVENLAFAXINE SUCC ER TAB 24HR 50 MG KALETRA SOL MG/5ML 5 NF Formulary Update olmesartanamlodipinehctz tab mg, 4 ezetimibe tab 10 mg, 4 lopinavirritonavir sol mg/5ml, 4 KISQALI 200 DOSE TAB 200 MG NF 5 + PA2 Formulary Enhancement N/A KISQALI 400 DOSE TAB 200 MG NF 5 + PA2 Formulary Enhancement N/A KISQALI 600 DOSE TAB 200 MG NF 5 + PA2 Formulary Enhancement N/A PRALUENT SOL PFS 75 MG/ML 5 + PA1 NF CMS Required Deletion N/A SUBQ EFFECTIVE 07/01/ BAVENCIO SOL 200 MG/10ML IV NF 4 + BvD Formulary Enhancement N/A BUSULFAN SOL 6 MG/ML IV NF 4 + BvD Formulary Enhancement N/A ESBRIET TAB 267 MG NF 5 + PA1 Formulary Enhancement N/A ESBRIET TAB 801 MG NF 5 + PA1 Formulary Enhancement N/A Page 13 of 14

14 EXELON PAT 24H 13.3 MG/24HR TD 3 NF Formulary Update EXELON PAT 24H 4.6 MG/24HR TD 3 NF Formulary Update EXELON PAT 24H 9.5 MG/24HR TD 3 NF Formulary Update rivastigmine pat 24h 13.3 mg/24hr td, 3 rivastigmine pat 24h 4.6 mg/24hr td, 3 rivastigmine pat 24h 9.5 mg/24hr td, 3 FLUOCINONIDE-E CRM 0.05 % EX GAMMAPLEX SOL 10 GM/100ML IV NF 5 + BvD Formulary Enhancement N/A GAMMAPLEX SOL 20 GM/200ML IV NF 5 + BvD Formulary Enhancement N/A GAMMAPLEX SOL 5 GM/50ML IV NF 5 + BvD Formulary Enhancement N/A INTRON A SOL UNIT/ML INJ NF 5 Formulary Enhancement N/A KINRIX SUSP IM INJ 0.5 ML LEVOLEUCOVORIN CALC SOL 50 MG IV NF 2 + BvD Formulary Enhancement N/A ROWEEPRA TAB 1000 MG ROWEEPRA TAB 750 MG TAZAROTENE CR 0.1 % EXT UVADEX SOL 20 MCG/ML INJ 4 + BvD NF CMS Required Deletion N/A VIRAZOLE SOL 6 GM INH 5 NF CMS Required Deletion N/A ZILEUTON ER TAB 12 HOUR 600 MG NF 5 Formulary Enhancement N/A Page 14 of 14