Notice of Negative Formulary Changes (List of Covered Drugs)

Transcription

1 Care1st Health Plan 601 Potrero Grande Drive Monterey Park, CA Notice of Negative Formulary Changes (List of Covered Drugs) Care1st Health Plan may add/remove drugs from the formulary (list of covered drugs) or add rules about whether and when certain drugs are covered during the year. The chart below contains upcoming changes to the Care1st Health Plan formulary. Formulary Notification Effective ID Date Date Drug Name /1/2016 6/1/2016 ABILIFY DISCMELT 10 MG ORAL TAB RAPDIS /1/2016 6/1/2016 ABILIFY DISCMELT 15 MG ORAL TAB RAPDIS /1/2016 6/1/2016 AGGRENOX 25MG- 200MG Change Description Reason Description Other Possible Drugs (if applicable)* ARIPIPRAZOLE ODT - ARIPIPRAZOLE ODT - ASPIRIN- DIPYRIDAMOLE ER TIER 4

2 /1/2016 6/1/2016 ANDROID 10 MG ORAL CAPSULE /1/2016 6/1/2016 CITRIC ACID/SODIUM CITRATE MG SOLUTION /1/2016 6/1/2016 CYTRA MG SOLUTION /1/2016 6/1/2016 EXELON 13.3MG/24H TRANSDERM. PATCH TD /1/2016 6/1/2016 EXELON 4.6MG/24HR TRANSDERM. PATCH TD24 NON PART D DRUG NON PART D DRUG METHYLTESTOSTERO NE - TIER 2 RIVASTIGMINE - TIER 4 RIVASTIGMINE - TIER 4

3 /1/2016 6/1/2016 EXELON 9.5MG/24HR TRANSDERM. PATCH TD /1/2016 6/1/2016 NAMENDA 10 MG /1/2016 6/1/2016 NAMENDA 2 MG/ML ORAL SOLUTION /1/2016 6/1/2016 NAMENDA 5 MG /1/2016 6/1/2016 NAMENDA 5 MG-10 MG ORAL TAB DS PK RIVASTIGMINE - TIER 4

4 /1/2016 6/1/2016 RELADOR PAK 2.5 %-2.5% TOPICAL KIT /1/2016 6/1/2016 VIRAMUNE XR 100 MG ORAL TAB ER 24H /1/2016 6/1/2016 XENAZINE 12.5 MG /1/2016 6/1/2016 XENAZINE 25 MG LIDOCAINE- PRILOCAINE - TIER 2 NEVIRAPINE ER - TIER 3 TETRABENAZINE - TETRABENAZINE -

5 /1/2016 6/1/2016 ZYVOX 100 MG/5ML ORAL SUSP RECON /1/2016 6/1/2016 ZYVOX 600 MG /1/2016 8/1/2016 GLEEVEC 100 MG GENERIC DRUG AVAILABLE LINEZOLID - LINEZOLID /1/2016 8/1/2016 GLEEVEC 400 MG GENERIC DRUG AVAILABLE /1/2016 8/1/2016 PRENATABS RX 29 MG-1 MG ORAL TABLET NDC REMOVED FROM NOT A PART D COVERED DRUG PRENATABS RX - TIER /1/2016 8/1/2016 BRINTELLIX 10 MG DRUG REMOVED FROM PRODUCT WITHDRAWN FROM MARKET TRINTELLIX - TIER 4

6 /1/2016 8/1/2016 BRINTELLIX 20 MG DRUG REMOVED FROM PRODUCT WITHDRAWN FROM MARKET TRINTELLIX - TIER /1/2016 8/1/2016 BRINTELLIX 5 MG DRUG REMOVED FROM PRODUCT WITHDRAWN FROM MARKET TRINTELLIX - TIER 4 *These drugs are on our drug list (formulary). Please talk with your doctor to find out if these drugs are right for you. Note: The amount you will pay for these drugs depends on which coverage period you are in. You can call Member Services to find out how much you will pay for these drugs. [Tier increase\decrease The amount you will pay for the drugs listed above that have tier changes in the Change Description column depends on which coverage period you are in. Call our Member Services number to find out how much you will pay for these drugs.] [Prior authorization This means your doctor must contact the plan before the plan will cover the drugs listed above that require Prior Authorization as indicated in the Change Description column. Your doctor must show that these drugs are medically necessary for them to be covered.] [Quantity limits This means there is a limit to how many pills/tablets/capsules/solution/etc you can get at a time.] [Step therapy This means one or more similar lower cost drugs must be tried before the drugs with Step-Therapy indicated in the Change Description column are covered.] This information is not a complete description of benefits. Contact the plan for more information. Benefits, premiums and/or co-payments/coinsurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. The Formulary may change at any time. You will receive notice when necessary. Care1st Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8a.m. 8p.m., 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY: 711), de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. 這項免費資訊以其它語言提供 懇請聯絡會員服務處 : 免費熱線 ( 聽障及語障人士專線 : 711) 每週七天辦公, 早上 8:00 點至晚上 8:00 點

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