Current as of November 1, 2017

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Current as of November 1, 2017"

Transcription

1 Current as of November 1, 2017 ZYTIGA 500 MG ORAL TABLETS Formulary Addition TIER 5 QL = 2 PER DAY BENLYSTA 200 MG/ML AUTO- INJECTOR Formulary Addition TIER 5 BENLYSTA 200 MG/ML PREFILLED SYRINGE Formulary Addition TIER 5 RAYALDEE 0.03 MG EXTENDED ORAL RELEASE CAPSULE Formulary Addition TIER 5 caspogungin acetate 50 mg injection Formulary Addition TIER 5 caspogungin acetate 70 mg injection Formulary Addition TIER 5 VYXEOS 100 MG/44 MG INJECTION Formulary Addition TIER 5 PA/ B VS D DETERMINATION diazepam 5 mg/ml prefilled applicator Formulary Addition TIER 3 diazepam 5 mg/ml prefilled applicator Formulary Addition TIER 3 IDHIFA 100 MG ORAL TABLETS Formulary Addition TIER 5 QL = 1 PER DAY IDHIFA 50 MG ORAL TABLETS Formulary Addition TIER 5 QL = 1 PER DAY

2 estradiol 0.01 mg vaginal tablets Formulary Addition TIER 2 ARMONAIR MG DRY POWDER INHALER Formulary Addition TIER 4 ARMONAIR MG DRY POWDER INHALER Formulary Addition TIER 4 ARMONAIR MG DRY POWDER INHALER Formulary Addition TIER 4 MAVYRET 100 MG/40 MG ORAL TABLETS Formulary Addition TIER 5 PA REQUIRED QL=3 PER DAY NERLYNX 40 MG ORAL TABLETS Formulary Addition TIER 5 LYNPARZA 100 MG ORAL TABLETS Formulary Addition TIER 5 QL=4 PER DAY LYNPARZA 150 MG ORAL TABLETS Formulary Addition TIER 5 QL= 4 PER DAY prasugrel 10 mg oral tablets Formulary Addition TIER 3 prasugrel 5 mg oral tablets Formulary Addition TIER 3 ISENTRESS 600 MG ORAL TABLETS Formulary Addition TIER 3 VOSEVI 400 MG/100 MG/100 MG ORAL TABLETS Formulary Addition TIER 5 PA REQUIRED QL=1 PER DAY vigabatrin 50 mg/ml oral solution Formulary Addition TIER 5 bupremorphine mg/hr transdermal system Formulary Addition Tier 4 desogestrel 0.15 mg/ ethinyl estradil 0.03 mg/inert ingredients 1 mg pack Formulary Addition Tier 3 ISIBLOOM 28 DAY PACK Formulary Addition Tier 3

3 eletriptan 20 mg oral tablet Formulary Addition Tier 4 QL 12 per 30 days eletriptan 40 mg oral tablet Formulary Addition Tier 4 QL 12 per 30 days RENFLEXIS 100 MG INJECTION Formulary Addition Tier 5 AMNESTEEM 10 MG ORAL CAPSULE Formulary Addition Tier 4 AMNESTEEM 20 MG ORAL CAPSULE Formulary Addition Tier 4 AMNESTEEM 40 MG ORAL CAPSULE Formulary Addition Tier 4 meropenem 1000 mg injection Formulary Addition Tier 3 HI DRUG mesalamine 1200 mg delayed release oral tablet Formulary Addition Tier 3 XATMEP 2.5 MG/ML ORAL SOLUTION Formulary Addition Tier 4 PA/B VS. D DETERMINATION moxifloxacin 5 mg/ml ophthalmic solution Formulary Addition Tier 2 sevelamer carbonate 800 mg oral tablet Formulary Addition Tier 2 ALUNBRIG 30 MG TABLET Formulary addition T/5 PA Required IMFINZI 50 MG INJECTION Formulary addition T/5 PA/B vs. D Determination ezetimibe 10mg/simvastatin 10 mg tablets Formulary addition T/2 ezetimibe 10mg/simvastatin 20 mg tablets Formulary addition T/2 ezetimibe 10mg/simvastatin 40 mg tablets Formulary addition T/2 ezetimibe 10mg/simvastatin 80 mg tablets Formulary addition T/2 fluticasone propionate 0.055mg/actuat/salmeterol Formulary addition T/2

4 xinafoate mg/actuat inhaler fluticasone propionate 0.113mg/actuat/salmeterol xinafoate mg/actuat inhaler Formulary addition T/2 fluticasone propionate 0.232mg/actuat/salmeterol xinafoate mg/actuat inhaler Formulary addition T/2 KISQALI FEMARA CO-PACK MG /200 MG PACK Formulary addition T/5 PA Required KISQALI FEMARA CO-PACK MG/200 MG PACK Formulary addition T/5 PA Required KISQUALI FEMARA CO-PACK MG/200 MG PACK Formulary addition T/5 PA Required XATMEP 2.5 MG/ML ORAL SOLUTION Formulary addition T/4 PA/B vs. D Determination RYDAPT 25 MG CAPSULE Formulary addition T/5 PA Required ZEJULA 100 MG CAPSULE Formulary addition T/5 PA Required XADAGO 100 MG CAPSULE Formulary addition T/4 XADAGO 50 MG CAPSULE Formulary addition T/4 ORENCIA Formulary addition T/5 PA Required ARISTADA 273 MG/ML PREFILLED SYRINGE Formulary addition T/5 atomoxetine 10 mg capsule Formulary addition T/3 atomoxetine 100 mg capsule Formulary addition T/3 atomoxetine 18 mg capsule Formulary addition T/3 atomoxetine 25 mg capsule Formulary addition T/3 atomoxetine 40 mg capsule Formulary addition T/3

5 atomoxetine 60 mg capsule Formulary addition T/3 atomoxetine 80 mg capsule Formulary addition T/3 SILIQ 140 MG/ML PREFILLED SYRINGE Formulary addition T/5 buprenorphine mg/hr transdermal system Formulary addition T/4 buprenorphine 0.01 mg/hr transdermal system Formulary addition T/4 buprenorphine mg/hr transdermal system Formulary addition T/4 buprenorphine 0.02 mg/hr transdermal system Formulary addition T/4 JADENU 180 MG ORAL GRANULES Formulary addition T/5 PA Required JADENU 360 MG ORAL GRANULES Formulary addition T/5 PA Required JADENU 90 MG ORAL GRANULES Formulary addition T/5 PA Required lidocaine hydrochloride 10 mg/ml injection Formulary addition T/4 VYVANSE 10 MG CHEWABLE TABLETS Formulary addition T/4 VYVANSE 20 MG CHEWABLE TABLETS Formulary addition T/4 VYVANSE 30 MG CHEWABLE TABLETS Formulary addition T/4 VYVANSE 40 MG CHEWABLE TABLETS Formulary addition T/4 VYVANSE 50 MG CHEWBLE TABLETS Formulary addition T/4 VYVANSE 60 MG CHEWABLE Formulary addition T/4

6 TABLETS olopatadine 2 mg/ml ophthalmic solution Formulary addition T/3 sevelamer carbonate 2400 mg oral suspension Formulary addition T/3 sevelamer carbonate 800 mg oral suspension Formulary addition T/3 ORENITRAM 5 MG ER TABLETS Formulary addition T/5 PA Required gavilyte oral package kit Reduction in Tiered Cost-Sharing Status T/2 7/1/2017 BAVENCIO 20 MG/ML Formulary Addition TIER 5 PA/B VS. D DETERMINATION INJECTION 7/1/2017 FAYOSIM 91 DAY PACK Formulary Addition TIER 4 7/1/2017 GAMMAPLEX 100 MG/ML Formulary Addition TIER 5 PA/B VS. D DETERMINATION INJECTION 7/1/2017 INTRON A 2B 10 MILLION UNIT/ML INJECTABLE SOLUTION Formulary Addition TIER 5 7/1/2017 ROWEEPRA 1000 MG TABLET Formulary Addition TIER 2 7/1/2017 ROWEEPRA 750 MG TABLET Formulary Addition TIER 2 7/1/2017 ESBRIET 267 MG TABLET Formulary Addition TIER 5 PA REQUIRED 7/1/2017 ESBRIET 801 MG TABLET Formulary Addition TIER 5 PA REQUIRED 7/1/2017 tazarotene 1 mg/ml topical Formulary Addition TIER 3 cream 7/1/2017 zileuton 600 mg er tablet Formulary Addition TIER 5 6/1/2017 desvenlafaxine succ 100 mg er tablet Formulary Addition TIER 3 6/1/2017 desvenlafaxine succ 25 mg er tablet Formulary Addition TIER 3 6/1/2017 desvenlafaxine succ 50 mg er tablet Formulary Addition TIER 3 6/1/2017 KISQALI 200 MG DAILY DOSE Formulary Addition TIER 5

7 CARTON KISQALI 400 MG DAILY DOSE 6/1/2017 CARTON Formulary Addition TIER 5 KISQALI 600 MG DAILY DOSE 6/1/2017 CARTON Formulary Addition TIER 5 5/1/2017 calcium acetat 667 mg tablet Formulary Addition TIER 3 5/1/2017 EMFLAZA 18 MG TABLET Formulary Addition TIER 5 PA REQUIRED 5/1/2017 EMFLAZA MG/ ML Formulary Addition TIER 5 PA REQUIRED SUSPENION 5/1/2017 EMFLAZA 30 MG TABLET Formulary Addition TIER 5 PA REQUIRED 5/1/2017 EMFLAZA 36 MG TABLET Formulary Addition TIER 5 PA REQUIRED 5/1/2017 EMFLAZA 6 MG TALBET Formulary Addition TIER 5 PA REQUIRED 5/1/2017 epinephrine 1 mg/ml autoinjector Formulary Addition TIER 3 5/1/2017 LINZESS MG CAPSULE Formulary Addition TIER 4 5/1/2017 SELZENTRY 25 MG TABLET Formulary Addition TIER 4 5/1/2017 SELZENTRY 75 MG TABLET Formulary Addition TIER 5 5/1/2017 MENOMUNE A/C/Y/W-135 Formulary Addition TIER 3 INJECTION 5/1/2017 methylphenicate 20 mg er Formulary Addition TIER 4 capsule 5/1/2017 methylphenicate 40 mg er Formulary Addition TIER 4 capsule 5/1/2017 methylphenicate 60 mg er Formulary Addition TIER 4 capsule 5/1/2017 potassium 10 meq er tablet Formulary Addition TIER 2 5/1/2017 KLOR-CON 10 MEQ ER TABLET Formulary Addition TIER 2 5/1/2017 potassium 20 meq er tablet Formulary Addition TIER 2 5/1/2017 KLOR-CON 20 MEQ ER TABLET Formulary Addition TIER 2

8 5/1/2017 CLINDAMYCIN 15 MG/ML Formulary Addition TIER 4 HI Drug INJECTION SOLUTION 5/1/2017 CLINDAMYCIN 15 MG/ML Formulary Addition TIER 4 HI Drug INJECTION SOLUTION 6 ML 5/1/2017 furosemide 10 mg/ml injection Formulary Addition TIER 1 HI Drug solution 5/1/2017 chlorothiazide sod 500 mg vial Formulary Addition TIER 4 HI Drug dexmethylphenidate 25 mg er capsule Formulary Addition Tier 4 dexmethylphenidate 35 mg er capsule Formulary Addition Tier 4 ethinyl estradiol mg/ inert ingredients 1 mg/ norgestimate 0.25 mg pack Formulary Addition Tier 3 lopinavir 80 mg/ ml / ritonavir 20 mg/ml oral solution Formulary Addition Tier 4 ranitidine 25 mg/ml injection Formulary Addition Tier 4 cartia xt 120 mg capsule Reduction in Tiered Cost-Sharing Status Tier 2 cartia xt 180 mg capsule Reduction in Tiered Cost-Sharing Status Tier 2 cartia xt 240 mg capsule Reduction in Tiered Cost-Sharing Status Tier 2 cartia xt 300 mg capsule Reduction in Tiered Cost-Sharing Status Tier 2 GLYXAMBI 10 MG/5 MG Formulary Addition Tier 4 GLYXAMBI 25 MG/5 MG Formulary Addition Tier 4 RIVASTIGMINE 13.3 MG/24 PATCH Formulary Addition Tier 3 RIVASTIGMINE 4.6 MG/24 PATCH Formulary Addition Tier 3 RIVASTIGMINE 9.5 MG/24 PATCH Formulary Addition Tier 3 metadate er 200 mg tablet Formulary Addition Tier 4

9 erythromycin ethylsuccinate 200 mg/ 5ml oral susp Formulary Addition Tier 3 mimvey 1 mg-0.5 mg tablet Formulary Addition Tier 3 mimvey lo 0.5 mg-0.1 mg tablet Formulary Addition Tier 3 estradiol-norethindrone 0.5 mg-0.1 mg tablet Formulary Addition Tier 3 estradiol-norethindrone 1 mg- 0.5 mg tablet Formulary Addition Tier 3 ANORO ELLIPA INHALATION Reduction in Tiered Cost-Sharing Status Tier 3 PROAIR HFA 90 MCG INHALER Reduction in Tiered Cost-Sharing Status Tier 3 GILENYA 0.5 MG CAPSULE Change in Utilization Management Tier 5 abacavir 600 mg/ lamivudine 300 mg tablet Formulary Addition TIER 3 ORENCIA AUTO-INJECTOR Formulary Addition TIER 5 PA REQUIRED HUMIRA PEN - PSORIASIS STARTER PACK Formulary Addition TIER 5 PA REQUIRED/QL = 6 PER 28 DAYS amlopidine 10 mg/ hctz 12.5 mg/ olmesartan 40 mg tablet Formulary Addition TIER 3 amlopidine 10 mg/ hctz 25 mg/ olmesartan 40 mg tablet Formulary Addition TIER 3 amlopidine 10 mg/ olmesartan 20 mg tablet Formulary Addition TIER 2 amlopidine 10 mg/ olmesartan 40 mg tablet Formulary Addition TIER 2 amlopidine 5 mg/ hctz 12.5 mg/ olmesartan 20 mg tablet Formulary Addition TIER 3 amlopidine 5 mg/ hctz 12.5 mg/ olmesartan 40 mg tablet Formulary Addition TIER 3 amlopidine 5 mg/ hctz 25 mg/ Formulary Addition TIER 3

10 olmesartan 40 mg tablet amlopidine 5 mg/ olmesartan 20 mg tablet Formulary Addition TIER 2 amlopidine 5 mg/ olmesartan 40 mg tablet Formulary Addition TIER 2 PANCREAZE UNT/ ENDOPEPTIDASES 6200 UNT/ LIPASE 2600 UNT CAPSULE Formulary Addition TIER 3 EMEND 125 MG POWDER FOR ORAL SUSPENSION Formulary Addition TIER 4 PA/B VS. D DETERMINATION aprepitant 125 mg capsule Formulary Addition TIER 2 PA/B VS. D DETERMINATION aprepitant 125 mg/ aprepitant 80 mg pack Formulary Addition TIER 2 PA/B VS. D DETERMINATION aprepitant 40 mg capsule Formulary Addition TIER 2 PA/B VS. D DETERMINATION aprepitant 80 mg capsule Formulary Addition TIER 2 PA/B VS. D DETERMINATION azithromycin 500 mg pack Formulary Addition TIER 1 BENZOYL PEROXIDE 0.05 MG/MG / CLINDAMYCIN PHOSPHATE MG/MG TOPICAL GEL Formulary Addition TIER 4 bupropion 150 mg er tablet Formulary Addition TIER 1 QL = 2 TABLETS DAILY INVOKAMET 150 MG/ 1000 MG ER TABLET Formulary Addition TIER 3 INVOKAMET 150 MG/ 500 MG ER TABLET Formulary Addition TIER 3 INVOKAMET 50 MG/ 1000 MG ER TABLET Formulary Addition TIER 3 INVOKAMET 50 MG/ 500 MG ER TABLET Formulary Addition TIER 3 cholestyramine 4000 mg Formulary Addition TIER 2

11 powder for oral suspension gengraf 50 mg capsule Formulary Addition TIER 3 PA/B VS. D DETERMINATION daptomycin 500 mg injection Formulary Addition TIER 4 HI DRUG VIEKIRA XR PAK Formulary Addition TIER 5 PA REQUIRED CAZIANT 28 DAY PACK Formulary Addition TIER 3 drospirenone 3 mg/ ethinyl estradiol 0.02 mg/ levomefolate mg pack Formulary Addition TIER 3 zarah pack Formulary Addition TIER 3 epinephrine 0.5 mg/ ml autoinjector Formulary Addition TIER 2 epirubicin 2 mg/ ml injection Formulary Addition TIER 4 yuvafem vaginal tablet Formulary Addition TIER 2 AMABELZ 0.5/ DAY Formulary Addition TIER 3 AMABELZ 1/ DAY Formulary Addition TIER 3 ethacrynic 25 mg tablet Formulary Addition TIER 3 AMETHIA LO 91 DAY Formulary Addition TIER 3 CAMRESELO 91 DAY Formulary Addition TIER 3 LARISSIA 28 DAY PACK Formulary Addition TIER 3 ethinyl estradiol 0.02 mg/ norethindrone 1 mg Formulary Addition TIER 3 LOW-OGESTREL 28 DAY Formulary Addition TIER 3 ethinyl estradiol mg/ ferrous fumarate 75 mg/ norethindrone 0.4 mg pack Formulary Addition TIER 3 ALYACEN 1/35 Formulary Addition TIER 3 ethinyl estradiol mg/ inert 1 mg/ norgestimate 0.18 mg/ norgestimate mg/ Formulary Addition TIER 3

12 norgestimate 0.25 mg pack FEMYNOR 28 DAY Formulary Addition TIER 3 ethinyl estradiol 0.05 mg/ ethynodiol 1 mg/ inert 1 mg Formulary Addition TIER 3 REPATHA 120 MG/ ML CARTIRIDGE Formulary Addition TIER 5 PA REQUIRED ezetimibe 10 mg tablet Formulary Addition TIER 2 fluocinonide 0.5 mg/ml topical cream Formulary Addition TIER 3 BEVESPI METERED DOSE INHALER Formulary Addition TIER 4 olmesartan 20 mg/ hctz 12.5 tablet Formulary Addition TIER 2 olmesartan 40 mg/ hctz 12.5 tablet Formulary Addition TIER 2 olmesartan 40 mg/ hctz 25 tablet Formulary Addition TIER 2 VASCEPA 500 MG CAPSULE Formulary Addition TIER 4 GAMMAGARD MG INJECTION Formulary Addition TIER 5 PA/B VS. D DETERMINATION GAMASTAN 180 UNT/ML INJECTION Formulary Addition TIER 3 PA/B VS. D DETERMINATION GAMMAGARD 5000 MG INJECTION Formulary Addition TIER 5 PA/B VS. D DETERMINATION BASAGLAR PEN INJECTOR Formulary Addition TIER 3 ORKAMBI 125 MG/ 100 MG TABLET Formulary Addition TIER 5 PA REQUIRED levalbuterol mg/actuat metered dose inhaler Formulary Addition TIER 3 levalbuterol 2.5 mg/ml Formulary Addition TIER 4 PA/B VS. D DETERMINATION

13 inhalant solution XIIDRA OPHTHAL SOLUTION Formulary Addition TIER 4 ADLYXIN STARTER KIT PACK Formulary Addition TIER 4 ADLYXIN 0.1 MG/ML PEN INJECTOR Formulary Addition TIER 4 mesalamine 800 mg er tablet Formulary Addition TIER 3 methotrexate 25 mg/ ml injection Formulary Addition TIER 4 methylphenidate 20 mg er capsule Formulary Addition TIER 4 methylphenidate 40 mg er capsule Formulary Addition TIER 4 mycophenolate 500 mg injection Formulary Addition TIER 4 PA/B VS. D DETERMINATION nifedipine 30 mg er tablet Formulary Addition TIER 2 nifedipine 60 mg er tablet Formulary Addition TIER 2 nifedipine 90 mg er tablet Formulary Addition TIER 2 nilutamide 150 mg tablet Formulary Addition TIER 5 nitroglycerin 0.3 mg sublingual tablet Formulary Addition TIER 2 nitroglycerin 0.4 mg sublingual tablet Formulary Addition TIER 2 nitroglycerin 0.6 mg sublingual tablet Formulary Addition TIER 2 ofloxacin 300 mg tablet Formulary Addition TIER 3 LARTRUVO 10 MG/ML INJECTION Formulary Addition TIER 5 olmesartan 20 mg tablet Formulary Addition TIER 2 olmesartan 40 mg tablet Formulary Addition TIER 2

14 olmesartan 5 mg tablet Formulary Addition TIER 2 oseltamivir 30 mg capsule Formulary Addition TIER 2 oseltamivir 45 mg capsule Formulary Addition TIER 2 oseltamivir 75 mg capsule Formulary Addition TIER 2 quetiapine 150 mg er tablet Formulary Addition TIER 3 quetiapine 200 mg er tablet Formulary Addition TIER 3 quetiapine 300 mg er tablet Formulary Addition TIER 3 quetiapine 400 mg er tablet Formulary Addition TIER 3 quetiapine 50 mg er tablet Formulary Addition TIER 3 rasagiline 0.5 mg tablet Formulary Addition TIER 3 rasagiline 1 mg tablet Formulary Addition TIER 3 RUBRACA 200 MG TABLET Formulary Addition TIER 5 RUBRACA 300 MG TABLET Formulary Addition TIER 5 SPS 250 MG/ ML ORAL SUSPENSION Formulary Addition TIER 3 EPCLUSA 400 MG/ 100 MG TABLET Formulary Addition TIER 5 PA REQUIRED sumatriptan 8 mg/ml autoinjector Formulary Addition TIER 4 QL = 8 MLS IN 30 DAYS VEMLIDY 25 MG TABLET Formulary Addition TIER 5 YONDELIS 1 MG INJECTION Formulary Addition TIER 5 triamcinolone mg/actuat metered dose nasal spray Formulary Addition TIER 3 valganciclovir 50 mg/ml oral solution Formulary Addition TIER 4

15

AgeWell 5-Tier 2017 Formulary Addendum

AgeWell 5-Tier 2017 Formulary Addendum 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

More information

Care Wisconsin 2017 Formulary Addendum

Care Wisconsin 2017 Formulary Addendum - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, EFFECTIVE 01/01/ ABILIFY MAINT INJ 400 1/26 + ST2 Formulary Enhancement N/A ABILIFY MAINT SUSP 300 1/26

More information

AgeWell 1-Tier 2017 Formulary Addendum

AgeWell 1-Tier 2017 Formulary Addendum 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 50-325MG CAZIANT PAK CHOLESTYRAMINE

More information

Care Wisconsin 2018 Formulary Addendum

Care Wisconsin 2018 Formulary Addendum pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy EFFECTIVE 01/01/ 0.5 ML SUMATRIPTAN 4 MG CARTRIDGE 0.5 ML SUMATRIPTAN 6 MG Last Updated: 03/24/ Effective

More information

Memorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum

Memorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum Memorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum Changes may have occurred since the printing of your current Memorial Hermann Advantage HMO & PPO Formulary. Medications that may have

More information

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

Provider Partners Pennsylvania Advantage Plan Offered by Provider Partners Health Plan April 2019 Formulary Addendum 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 2019. This is not a complete

More information

Upcoming Changes to Retiree RxCare s 5 Tier Formulary

Upcoming Changes to Retiree RxCare s 5 Tier Formulary Upcoming Changes to Retiree RxCare s 5 Tier Formulary Retiree RxCare may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, [or] add prior authorization, quantity

More information

ATRIO Health Plans 2018 SNP Plans Formulary Change Notice

ATRIO Health Plans 2018 SNP Plans Formulary Change Notice Formulary ID: 18007 ATRIO Special Needs Plan ATRIO Special Needs Plan (Rogue) ATRIO Special Needs Plan (Willamette) ATRIO Health Plans 2018 SNP Plans Formulary Change Notice ATRIO Health Plans may remove

More information

ATRIO Health Plans 2018 PPO Plans Formulary Change Notice

ATRIO Health Plans 2018 PPO Plans Formulary Change Notice Formulary ID: 18032 ATRIO Bronze Rx (Basin) ATRIO Silver Rx ATRIO Gold Rx ATRIO Bronze Rx (Umpqua) ATRIO Bronze Rx (Rogue) ATRIO Silver Rx (Rogue) ATRIO Gold Rx (Willamette) ATRIO Silver Rx (Willamette)

More information

BCN Advantage Formulary Updates: April, 2018

BCN Advantage Formulary Updates: April, 2018 Attention BCN Advantage members: This is a list of changes made to the BCN Advantage formulary since its initial release in October, 2017 BCN Advantage may add or remove drugs from our formulary during

More information

Quarterly pharmacy formulary change notice

Quarterly pharmacy formulary change notice Provider Bulletin December 2017 Quarterly pharmacy formulary notice The formulary s listed in the table below apply to all Anthem HealthKeepers Plus members. These s were reviewed and approved at the third

More information

Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health New Jersey Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil

More information

Acyclovir Ointment. Aetna Better Health Kentucky. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health Kentucky. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Kentucky Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca ADCIRCA TABLET 20 MG ORAL Use of sildenafil in previous

More information

Acyclovir Ointment. Aetna Better Health Louisiana. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health Louisiana. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Louisiana Use of oral acyclovir in the previous 130 days 1 Adcirca ADCIRCA TABLET 20 MG ORAL Use of sildenafil in previous 30 days

More information

Acyclovir Ointment. Aetna Better Health Virginia Medallion/FAMIS 3.0. Products Affected. acyclovir ointment 5 % external Details.

Acyclovir Ointment. Aetna Better Health Virginia Medallion/FAMIS 3.0. Products Affected. acyclovir ointment 5 % external Details. Aetna Better Health Virginia Medallion/FAMIS 3.0 Acyclovir Ointment acyclovir ointment 5 % external Use of oral acyclovir in the previous 130 days 1 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil

More information

2018 Formulary Addendum 2018 FORMULARY CHANGES

2018 Formulary Addendum 2018 FORMULARY CHANGES Below is a list formulary changes for the benefit year 2018. This is not a complete list of drugs covered by the Part D plan. The formulary changes are reflected in the 2018 downloadable formulary on the

More information

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective New Jersey Department of Human Services State Upper Limit () List - PROPOSED Effective 07-01-2018 New ABACAVIR FATE ORAL TABLET 300 MG ABACAVIR FATE/LAMIVUDINE ORAL TABLET 600-300MG ABACAVIR FATE/LAMIVUDINE/ZIDOVUDINE

More information

3. This solution retains potency for 2 8 hours at room temperature after reconstitution.

3. This solution retains potency for 2 8 hours at room temperature after reconstitution. 1 CHAPTER 10 Reconstitution of Powdered Drugs Problems 10.1 (page 124) 1. The drug should be stored at or below 86 F (30 C). 2. This drug is administered IM or IV. 3. This solution retains potency for

More information

Information for Vermont Prescribers of Prescription Drugs (Long Form)

Information for Vermont Prescribers of Prescription Drugs (Long Form) Information for Vermont Prescribers of Prescription Drugs (Long Form) Beyaz (Drospirenone-Ethinyl Estradiol-Levomefolate Calcium) This list does not imply that the products on this chart are interchangeable

More information

PRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO)

PRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO) PRESCRIPTION DRUGS FORMULARY 1 2018 I ~~ [ tl-i I Classicare (HMO) MCS Classicare 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS

More information

PHP Centennial Care Formulary/Preferred Drug Listing

PHP Centennial Care Formulary/Preferred Drug Listing PHP Centennial Care Formulary/Preferred Drug Listing The Centennial Care Preferred Drug List is subject to change. Presbyterian Centennial Care This list is in alphabetical order. To find a specific drug,

More information

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective Generic_Name Current NJ SUL New NJ SUL Proposed ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-30MG 0.12455 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-60MG 0.25688 ALBUTEROL SULFATE

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) MEDICARE ADVANTAGE PLANS 2018 Formulary (List of Covered Drugs) Presbyterian Dual Plus (HMO SNP) Please Read: This document contains information about the drugs we cover in this plan. HPMS Approved Formulary

More information

Partnership 2017 Formulary. List of Covered Drugs

Partnership 2017 Formulary. List of Covered Drugs Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 26 This formulary was updated on 0/24/207.

More information

2019 Formulary (List of Covered Drugs)

2019 Formulary (List of Covered Drugs) MEDICARE ADVANTAGE PLANS 2019 Formulary (List of Covered Drugs) Presbyterian Senior Care (HMO) Presbyterian Senior Care (HMO-POS) Presbyterian MediCare PPO Please Read: This document contains information

More information

HealthPartners PreferredRx

HealthPartners PreferredRx HealthPartners PreferredRx 2018 Formulary (List of covered drugs) For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2018 2018 HealthPartners

More information

Alphabetical Listing. This list is subject to change. For an up-to-date listing please visit Pg. 2

Alphabetical Listing. This list is subject to change. For an up-to-date listing please visit  Pg. 2 898/7 A abacavir oral tablet 00 mg abacavir-lamivudine oral tablet 600-00 mg abacavir-lamivudine-zidovudine oral tablet 00-50-00 mg ABREVA TOPICAL CREAM 0 % acarbose oral tablet 00 mg, 5 mg, 50 mg acebutolol

More information

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER 209 2 Tier Standard- Keystone First VIP Choice Document: 209 Formulary Formulary ID: 9393 Updated: 03/209 Effective Date: 04-0-209 ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine

More information

Health First Health Plans 2018 Formulary (List of Covered Drugs)

Health First Health Plans 2018 Formulary (List of Covered Drugs) Updated: July 1, 2018 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Employer Group Plus A Plan (HMO) Employer Group Plus B Plan (HMO) Employer Group POS Plan (HMO-POS) Health First Health

More information

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs)

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs) Memorial Hermann Advantage H 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 19563,

More information

Alphabetical Listing. PA = Prior Authorization QL = Quantity Limits Per Prescription Days Supply ST = Step Therapy

Alphabetical Listing. PA = Prior Authorization QL = Quantity Limits Per Prescription Days Supply ST = Step Therapy 899/17 A abacavir oral tablet 300 mg abacavir-lamivudine oral tablet 600-300 mg abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg ABREVA TOPICAL CREAM 10 % acarbose oral tablet 100 mg, 25 mg,

More information

2018 List of Covered Drugs (Formulary)

2018 List of Covered Drugs (Formulary) 208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect

More information

OPTIMA HEALTH OPTIMA FAMILY CARE (JANUARY MARCH 2019) PRESCRIPTION DRUG FORMULARY WITH MEDICAID EXPANSION (XP) Effective: January 1, 2019

OPTIMA HEALTH OPTIMA FAMILY CARE (JANUARY MARCH 2019) PRESCRIPTION DRUG FORMULARY WITH MEDICAID EXPANSION (XP) Effective: January 1, 2019 OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA FAMILY CARE WITH MEDICAID EXPANSION (XP) (JANUARY MARCH 2019) Revised: 1/2/2019 Table of Contents Analgesics - Drugs for Pain... 3 Analgesics - Drugs for

More information

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Health Plan of Ohio (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19582, Version 5

More information

Provider Partners Pennsylvania Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Pennsylvania Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Pennsylvania Advantage Plan (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19548, Version

More information

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS)

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) 208 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) This formulary was updated on 05/0/208. For more recent information or other questions, please

More information

Health First Health Plans 2019 Formulary (List of Covered Drugs)

Health First Health Plans 2019 Formulary (List of Covered Drugs) Updated: March 1, 2019 Health First Health Plans 2019 Formulary (List of Covered Drugs) SunSaver (HMO) Employer Group Plus C Plan (HMO) Employer Group Plus D Plan (HMO) Employer Group POS B Plan (HMO-POS)

More information

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Illinois Advantage Plan (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19547, Version

More information

PRESCRIPTION DRUG FORMULARY

PRESCRIPTION DRUG FORMULARY OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA FAMILY CARE (FAMIS) (April June 2019) Revised: 3/27/2019 Table of Contents Analgesics - Drugs for Pain... 3 Analgesics - Drugs for Pain and Inflammation...

More information

SIGNATURE ADVANTAGE Formulary. (List of Covered Drugs)

SIGNATURE ADVANTAGE Formulary. (List of Covered Drugs) SIGNATURE ADVANTAGE 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19552, Version Number 5 This formulary was

More information

2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans

2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans 018 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) Please Read: This document contains information about

More information

QUALIFIED HEALTH PLAN FORMULARY Effective January 2018

QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians,

More information

2018 List of Covered Drugs (Formulary)

2018 List of Covered Drugs (Formulary) 208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect

More information

Health First Health Plans 2019 Formulary (List of Covered Drugs)

Health First Health Plans 2019 Formulary (List of Covered Drugs) Updated: 10/2018 Health First Health Plans 2019 Formulary (List of Covered Drugs) Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Employer Group Plus A Plan (HMO) Employer Group Plus B Plan

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) Tribute Health Plan of Arkansas (H POS SNP) H1587 001 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 17384, Version

More information

EnvisionRxPlus Formulary. (List of Covered Drugs)

EnvisionRxPlus Formulary. (List of Covered Drugs) EnvisionRxPlus 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission 18365, Version Number

More information

Notice of Negative Formulary Changes (List of Covered Drugs)

Notice of Negative Formulary Changes (List of Covered Drugs) Care1st Health Plan 601 Potrero Grande Drive Monterey Park, CA 91755 www.care1stmedicare.com Notice of Negative Formulary Changes (List of Covered Drugs) Care1st Health Plan may add/remove drugs from the

More information

COMPREHENSIVE FORMULARY

COMPREHENSIVE FORMULARY COMPREHENSIVE FORMULARY HEALTHTEAM ADVANTAGE PLAN I (PPO) HEALTHTEAM ADVANTAGE PLAN II (PPO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

More information

(List of Covered Drugs)

(List of Covered Drugs) Superior Select Health Plans H-POS SNP 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19550, Version Number 5

More information

QL (0.5 per 365 days); AGE (Min 7 Years) ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML

QL (0.5 per 365 days); AGE (Min 7 Years) ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML Tier 1 Zero Cost Share Preventive Drugs 2018 Marketplace Plans Drug Name Requirements/Limits ADACEL(TDAP ADOLESDULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESDULT)(PF)

More information

Partnership 2017 Formulary. List of Covered Drugs

Partnership 2017 Formulary. List of Covered Drugs Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 9 This formulary was updated on 5/23/207. For

More information

2019 Formulary Annual Notice of Change

2019 Formulary Annual Notice of Change Updated: October 1, 2018 2019 Formulary Annual Notice of Change Medicare Advantage Plans (MAPD) This is a listing of the changes that have occurred to the 2019 MAPD formulary. For a complete list, please

More information

LEGEND. Tier 1: Covered Medications

LEGEND. Tier 1: Covered Medications LEGEND : Covered Medications BvD: Part B vs. Part D-This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. HRM: High Risk Medication (PA required for ages 65

More information

COMPREHENSIVE FORMULARY

COMPREHENSIVE FORMULARY 08 COMPREHENSIVE FORMULARY CARE N CARE CHOICE PREMIUM (PPO) CARE N CARE CHOICE PLUS (PPO) CARE N CARE CHOICE (PPO) CARE N CARE CLASSIC (HMO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS

More information

Senior Preferred (HMO) 2019 Formulary (List of Covered Drugs)

Senior Preferred (HMO) 2019 Formulary (List of Covered Drugs) Senior Preferred (HMO) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary ID: 19116, Version 5 This formulary

More information

HealthPartners GenericsPlusRx

HealthPartners GenericsPlusRx HealthPartners GenericsPlusRx 2018 Formulary (List of covered drugs) For current information on the GenericsPlusRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2018 2018 HealthPartners

More information

Superior Select Health Plans Formulary. (List of Covered Drugs)

Superior Select Health Plans Formulary. (List of Covered Drugs) Superior Select Health Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 18379, Version Number 14 This formulary

More information

HealthPartners Minnesota Health Care Programs

HealthPartners Minnesota Health Care Programs HealthPartners Minnesota Health Care Programs 2018 Formulary (List of covered drugs) For current information on the Minnesota Health Care Programs Drug List, visit healthpartners.com/pharmacy. Effective:

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare Health Plans Please Read: Plans in the following states: AR, FL, GA, KY, MS, NC, NY, SC, TN WellCare Access (HMO SNP),

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following states: AR, CT, FL, IL, KY, LA, NJ, NY, TX, TN

More information

2018 Year-to-date Formulary Additions and Deletions

2018 Year-to-date Formulary Additions and Deletions Health Choice Generations may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on

More information

OPTIMA MEDICARE. OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs

OPTIMA MEDICARE. OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs OPTIMA MEDICARE OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) 018 Formulary (List of Covered Drugs) UCare for Seniors Essentials Rx (HMO-POS) UCare for Seniors Value Plus (HMO-POS) UCare for Seniors Classic (HMO-POS) This formulary was updated on 11/01/018. For more

More information

ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet 300-5, 300-30, 300-60 ASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG BUTALBITAL

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO) WellCare Rx (HMO) Plans in the following

More information

Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs)

Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs) Updated: November 1, 2017 Explorer Plan (HMO-POS) SunSaver Plan (HMO-POS) Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE

More information

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 0 - /5 ml (5 ml), 300-30 /.5

More information

Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs)

Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs) Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans Easy Choice Health Plan Plans in the following state: CA Easy Choice Best Plan(HMO)

More information

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS)

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS) 08 Formulary (List of Covered Drugs) Group UCare for Seniors (HMO-POS) This formulary was updated on 0/0/08. For more recent information or other questions, please contact UCare for Seniors Customer Services

More information

2019 HAP Formulary. List of covered drugs, cost tiers and how it all works

2019 HAP Formulary. List of covered drugs, cost tiers and how it all works HAP Empowered Duals (HMO SNP) 209 HAP Formulary List of covered drugs, cost tiers and how it all works PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS. This formulary

More information

Step Therapy Criteria Last Updated 6/1/2018

Step Therapy Criteria Last Updated 6/1/2018 Step Therapy Last Updated 6/1/2018 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740

More information

FRESENIUS TOTAL HEALTH (PPO SNP)

FRESENIUS TOTAL HEALTH (PPO SNP) FRESENIUS TOTAL HEALTH (PPO SNP) 07 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN H9 7444, V This formulary was updated on 07/0/07.

More information

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS)

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS) 08 Formulary (List of Covered Drugs) Group UCare for Seniors (HMO-POS) This formulary was updated on 0/0/08. For more recent information or other questions, please contact UCare for Seniors Customer Services

More information

OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY

OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY SMALL GROUP STANDARD FORMULARY (50 or Less Employees) (January March 09) Effective: January, 09 Revised: //09 Table of Contents Analgesics - Drugs for Pain...

More information

PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing

PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing Presbyterian Health Plan Presbyterian Insurance Company, Inc. PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing This list is in order by therapeutic class. To find

More information

Information for Vermont Prescribers of Prescription Drugs (Long Form)

Information for Vermont Prescribers of Prescription Drugs (Long Form) Information for Vermont Prescribers of Prescription Drugs (Long Form) Beyaz (Drospirenone-Ethinyl Estradiol-Levomefolate Calcium) This list does not imply that the products on this chart are interchangeable

More information

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HealthPartners UnityPoint Health Align (PPO) HealthPartners UnityPoint Health Symmetry (PPO) (Collectively known as HealthPartners UnityPoint Health) 017 Formulary (List of Covered Drugs) PLEASE READ:

More information

Drug - Brand Name (Generic Name) Oseni (alogliptin / pioglitazone) - PA. Obizur (antihemophilic factor, recombinant, porcine sequence-obizur)

Drug - Brand Name (Generic Name) Oseni (alogliptin / pioglitazone) - PA. Obizur (antihemophilic factor, recombinant, porcine sequence-obizur) Orencia (abatacept) - PA Oseni (alogliptin / pioglitazone) - PA Obizur (antihemophilic factor, recombinant, porcine sequence-obizur) Otezla (apremilast) - PA Olumiant (baricitinib) - PA Omnaris (ciclesonide

More information

3 Tier Formulary (List of Covered Drugs)

3 Tier Formulary (List of Covered Drugs) Effective: September 11, 2017 Large Group Non-Qualified Health Plans Small Group Non-Qualified Health Plans 3 Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors

More information

Advance Notification of Amendments to the March 2015 Drug Tariff

Advance Notification of Amendments to the March 2015 Drug Tariff Advance Notification of Amendments to the March 2015 Drug Tariff ADDITIONS Zero Discount Amiodarone 300mg/10ml solution for injection pre-filled syringes Ampicillin 500mg powder for solution for injection

More information

2017 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans

2017 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Extra (PDP) Plans in the

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) 08 Formulary (List of Covered Drugs) UCare for Seniors Essentials Rx (HMO-POS) UCare for Seniors Value Plus (HMO-POS) UCare for Seniors Classic (HMO-POS) This formulary was updated on 04/0/08. For more

More information