2011 Formulary Addendum

Transcription

1 2011 Formulary Addendum This is a listin of the chanes that have occurred in our formulary. Please carefully review these chanes and call Ohana if you have any questions. Date of Chane: 03/01/2011 Formulary File #11203 Formulary Version #8 NAME a-methapred solution 125m Glucocorticoids/ Mineralocorticoids a-methapred solution 40m Glucocorticoids/ Mineralocorticoids anaspaz orally disinteratin Antispasmodics, tablets 0.125m Gastrointestinal ASMANEX 7 METERED DOS- Anti-inflammatories, ES 110MCG/INHALATION Inhaled Corticosteroids ROMDAY SOLUTION 0.09% Ophthalmic Antiinflammatories calcipotriene ointment 0.005% Dermatoloical Aents calcitriol capsules 0.25mc Metabolic one Disease Aents calcitriol capsules 0.5mc Metabolic one Disease Aents RAND NAME PA Prior Authorization LA Limited Access 1 Dru Added 1 Dru Added 1 Tier Decreased to Tier 1 2 Dru Added 3 Dru Added 1 Dru Added 1 PA Removed 1 PA Removed QL Quantity Limit MO Mail-order Available ST Step Therapy Pae 1 of 22

2 NAME calcitriol solution 1mc/ml Metabolic one Disease Aents calcitriol solution 1mc/ml Metabolic one Disease Aents calcitriol solution 2mc/ml Metabolic one Disease Aents carisoprodol tablets 250m Skeletal Muscle Relaxants cimetidine hcl solution 300m/5ml Histamine2 (H2) lockin Aents clorpres tablets 15m; 0.1m Alpha-adreneric Aonists clorpres tablets 15m; 0.2m Alpha-adreneric Aonists clorpres tablets 15m; 0.3m Alpha-adreneric Aonists dexamethasone sodium Glucocorticoids/ phosphate solution 4m/ml Mineralocorticoids donepezil hcl tablets 10m Cholinesterase donepezil hcl tablets 5m Cholinesterase donepezil hcl orally disinteratin tablets 10m donepezil hcl orally disinteratin tablets 5m Cholinesterase Cholinesterase 1 Dru Added 1 PA Removed 1 PA Removed 1 Dru Added 1 Dru Added 1 Tier Decreased to Tier 1 1 Tier Decreased to Tier 1 1 Tier Decreased to Tier 1 1 Dru Added 1 Dru Added 1 Dru Added 1 Dru Added 1 Dru Added RAND NAME Pae 2 of 22

3 NAME DULERA AEROSOL 5MCG/ ACTUATION; 100MCG/AC- Anti-inflammatories, Inhaled Corticosteroids 2 Dru Added TUATION DULERA AEROSOL 5MCG/ ACTUATION; 200MCG/AC- Anti-inflammatories, Inhaled Corticosteroids 2 Dru Added TUATION eliphos tablets 667m Phosphate inders 1 PA Removed enoxaparin sodium solution 100m/ml Anticoaulants 1 Dru Added enoxaparin sodium solution 120m/0.8ml enoxaparin sodium solution 150m/ml enoxaparin sodium solution 30m/0.3ml enoxaparin sodium solution 40m/0.4ml enoxaparin sodium solution 60m/0.6ml enoxaparin sodium solution 80m/0.8ml Anticoaulants 1 Dru Added Anticoaulants 1 Dru Added Anticoaulants 1 Dru Added Anticoaulants 1 Dru Added Anticoaulants 1 Dru Added Anticoaulants 1 Dru Added RAND NAME Pae 3 of 22

4 NAME epinephrine device 0.15m/0.15ml epinephrine device 0.3m/0.3ml HECTOROL CAPSULES 0.5MCG ronchodilators, Sympathomimetic ronchodilators, Sympathomimetic Metabolic one Disease Aents HECTOROL CAPSULES 1MCG Metabolic one Disease Aents HECTOROL CAPSULES 2.5MCG HECTOROL SOLUTION 4MCG/2ML HUMAPEN LUXURA HD DE- VICE Metabolic one Disease Aents Metabolic one Disease Aents Miscellaneous Therapeutic Aents HUMAPEN MEMOIR DEVICE Miscellaneous Therapeutic Aents INTRALIPID EMULSION 2.25%; 20% JALYN CAPSULES 0.5MG; 0.4MG Miscellaneous Therapeutic Aents enin Prostatic Hypertrophy Aents 1 Dru Added 1 Dru Added 2 PA Removed 2 PA Removed 2 PA Removed 2 PA Removed 2 Dru Added 2 Dru Added 2 Dru Added 2 Dru Added LATUDA TALETS 40MG Atypicals 3 Dru Added LATUDA TALETS 80MG Atypicals 3 Dru Added RAND NAME Pae 4 of 22

5 NAME LUMIGAN SOLUTION 0.01% Ophthalmic Prostalandin and Prostamide Analos LUMIZYME SOLUTION Enzyme Replacements/ 50MG Modifiers np thyroid 30 tablets 30m Hormonal Aents, Stimulant/ Replacement/ Modifyin (Thyroid) np thyroid 60 tablets 60m Hormonal Aents, Stimulant/ Replacement/ Modifyin (Thyroid) np thyroid 90 tablets 90m Hormonal Aents, Stimulant/ Replacement/ Modifyin (Thyroid) 2 Dru Added 4 Dru Added LA Added 1 Dru Added 1 Dru Added 1 Dru Added oxycodone hcl capsules 5m Opioid Analesics 1 Dru Added phenelzine sulfate tablets 15m pramipexole dihydrochloride tablets 0.75m Monoamine Oxidase Antiparkinson Aents 1 Dru Added 1 Dru Added RENVELA PACKET 0.8GM Phosphate inders 3 Dru Added RAND NAME Pae 5 of 22

6 NAME RENVELA PACKET 2.4GM Phosphate inders 3 Dru Added RENVELA TALETS 800MG Phosphate inders 3 Dru Added SUOXONE SULINGUAL FILM 2MG; 0.5MG Toxicoloic Aents 3 Dru Added SUOXONE SULINGUAL FILM 8MG; 2MG verapamil hcl solution 2.5m/ml verapamil hcl sr capsules 240m verapamil hcl sr capsules 360m Toxicoloic Aents 3 Dru Added Calcium Channel lockin Aents Calcium Channel lockin Aents Calcium Channel lockin Aents 1 Dru Added 1 Dru Added 1 Dru Added zafirlukast tablets 10m Antileukotrienes 1 Dru Added zafirlukast tablets 20m Antileukotrienes 1 Dru Added Date of Chane: 04/01/2011 Formulary File #11203 Formulary Version #9 NAME AFINITOR TALETS 2.5MG Molecular Taret 4 Dru Added RAND NAME Pae 6 of 22

7 NAME amlodipine besylate/benazepril hcl capsules 10m; 40m amlodipine besylate/benazepril hcl capsules 5m; 40m YETTA SOLUTION 10MCG/0.04ML YETTA SOLUTION 5MCG/0.02ML calcitriol capsules 0.25mc Metabolic one Disease Aents calcitriol capsules 0.5mc Metabolic one Disease Aents calcitriol solution 1mc/ml Metabolic one Disease Aents calcitriol solution 1mc/ml Metabolic one Disease Aents calcitriol solution 2mc/ml Metabolic one Disease Aents HECTOROL CAPSULES 0.5MCG Calcium Channel 1 Dru Added lockin Aents Calcium Channel 1 Dru Added lockin Aents Antidiabetic Aents 3 PA Removed Antidiabetic Aents 3 PA Removed Metabolic one Disease Aents HECTOROL CAPSULES 1MCG Metabolic one Disease Aents HECTOROL CAPSULES 2.5MCG Metabolic one Disease Aents RAND NAME Pae 7 of 22

8 NAME HECTOROL SOLUTION 4MCG/2ML Metabolic one Disease Aents INTELENCE TALETS 200MG Anti-HIV Aents, Nucleoside and Nucleotide Reverse Transcriptase 2 4 Dru Added MOXEZA SOLUTION 0.5% Quinolones 2 Dru Added pantoprazole sodium enteric-coated tablets 20m pantoprazole sodium enteric-coated tablets 40m potassium chloride liquid 10% Proton Pump Proton Pump Electrolytes/Minerals 1 SPRYCEL TALETS 140MG Molecular Taret SPRYCEL TALETS 80MG Molecular Taret vancomycin hcl solution 1000m vancomycin hcl solution 10m 1 Dru Added 1 Dru Added Dru Added 4 Dru Added 4 Dru Added Antibacterials, Other 1 Antibacterials, Other 1 RAND NAME Pae 8 of 22

9 Date of Chane: 05/01/2011 Formulary File #11203 Formulary Version #10 NAME ALPHAGAN P SOLUTION 0.1% ALPHAGAN P SOLUTION 0.15% Ophthalmic Antilaucoma Aents Ophthalmic Antilaucoma Aents AMITIZA CAPSULES 24MCG Gastrointestinal Aents, Other AMITIZA CAPSULES 8MCG Gastrointestinal Aents, Other DEXILANT DELAYED-RE- LEASE CAPSULES 30MG DEXILANT DELAYED-RE- LEASE CAPSULES 60MG DIOVAN HCT TALETS 12.5MG; 160MG DIOVAN HCT TALETS 12.5MG; 80MG Proton Pump Proton Pump Renin-aniotensinaldosterone System Renin-aniotensinaldosterone System DIOVAN TALETS 160MG Renin-aniotensinaldosterone System DIOVAN TALETS 40MG Renin-aniotensinaldosterone System 3 Dru Added 3 Dru Added 3 Dru Added ST Added 3 Dru Added ST Added 3 Dru Added 3 Dru Added 3 QL Increased 3 QL Increased 3 QL Increased 3 QL Increased RAND NAME Pae 9 of 22

10 NAME DIOVAN TALETS 80MG Renin-aniotensinaldosterone System DUETACT TALETS 2MG; 30MG DUETACT TALETS 4MG; 30MG abapentin solution 250m/5ml 3 QL Increased Antidiabetic Aents 3 Dru Added Antidiabetic Aents 3 Dru Added Gamma-aminobutyric Acid (GAA) Aumentin Aents 1 Dru Added jinteli tablets 5mc; 1m Estroens 1 Dru Added PATADAY SOLUTION 0.2% Ophthalmic Antiallery Aents PATANOL SOLUTION 0.1% Ophthalmic Antiallery Aents SPIRIVA HANDIHALER CAP- SULES 18MCG TORADEX ST SUSPENSION 0.05%; 0.3% ronchodilators, Anticholineric Ophthalmic Antiinflammatories 3 Dru Added 3 Dru Added 3 ST Removed 3 Dru Added voriconazole tablets 200m Antifunals 1 Dru Added RAND NAME Pae 10 of 22

11 NAME voriconazole tablets 50m Antifunals 1 Dru Added ZYMAXID SOLUTION 0.5% Quinolones 3 Dru Added Date of Chane: 07/01/2011 Formulary File #11203 Formulary Version #12 NAME alendronate sodium tablets 10m Metabolic one Disease Aents 1 Dru Added alendronate sodium tablets 5m ANZEL SUSPENSION 40MG/ML Metabolic one Disease Aents Anticonvulsants, Other 1 Dru Added 4 Dru Added briellyn tablets 35mc; 0.4m Estroens 1 Dru Added CIPRODEX SUSPENSION 0.3%; 0.1% Ophthalmic Antiinflammatories 3 Dru Added disulfiram tablets 250m Deterrents 1 Dru Added DUREZOL EMULSION 0.05% Ophthalmic Antiinflammatories ENREL KIT 25MG Immune Suppressants 3 Dru Added 4 Dru Added RAND NAME Pae 11 of 22

12 NAME ENREL SOLUTION 25MG/0.5ML ENREL SOLUTION 50MG/ ML ENREL SURECLICK SOLU- TION 50MG/ML erythromycin ethylsuccinate tablets 400m Immune Suppressants Immune Suppressants Immune Suppressants exemestane tablets 25m Aromatase, 3rd Generation fortical solution 200unit/actuation hydrocodone bitartrate/ acetaminophen tablets 300m; 10m hydrocodone bitartrate/ acetaminophen tablets 300m; 5m hydrocodone bitartrate/ acetaminophen tablets 300m; 7.5m klor-con m10 controlledrelease tablets 10meq 4 Dru Added 4 Dru Added 4 Dru Added Macrolides 1 Dru Added Metabolic one Disease Aents 1 Dru Added 1 Dru Added Opioid Analesics 1 Dru Added Opioid Analesics 1 Dru Added Opioid Analesics 1 Dru Added Electrolytes/Minerals 1 Dru Added RAND NAME Pae 12 of 22

13 NAME latanoprost solution 0.005% Ophthalmic Prostalandin and Prostamide Analos 1 Dru Added loryna tablets 3m; 0.02m Estroens 1 Dru Added methylphenidate hydrochloride solution 10m/5ml methylphenidate hydrochloride solution 5m/5ml NEUPOGEN SOLUTION 300MCG/ML Non-amphetamines, ADHD Non-amphetamines, ADHD lood Formation Products NEVANAC SUSPENSION 0.1% Ophthalmic Antiinflammatories 1 Dru Added 1 Dru Added 4 Dru Added 3 Dru Added pacerone tablets 200m Antiarrhythmics 1 Dru Added PROLIA SOLUTION 60MG/ ML propantheline bromide tablets 15m Metabolic one Disease Aents Antispasmodics, Gastrointestinal SARIL PACK 500MG Gamma-aminobutyric Acid (GAA) Aumentin Aents SUOXONE SULINGUAL FILM 2MG; 0.5MG 3 Dru Added 1 Dru Added 4 Dru Added LA Added Toxicoloic Aents 2 Tier Decreased to Tier 2 RAND NAME Pae 13 of 22

14 NAME SUOXONE SULINGUAL FILM 8MG; 2MG SYLATRON KIT 296MCG Antineoplastics, Other SYLATRON KIT 444MCG Antineoplastics, Other SYLATRON KIT 888MCG Antineoplastics, Other VANDETANI TALETS 100MG VANDETANI TALETS 300MG Toxicoloic Aents 2 Tier Decreased to Tier 2 Antianioenic Aents Antianioenic Aents ZYTIGA TALETS 250MG Antineoplastics, Other 4 Dru Added 4 Dru Added 4 Dru Added 4 Dru Added 4 Dru Added 4 Dru Added Date of Chane: 08/01/2011 Formulary File #11203 Formulary Version #13 NAME AZILECT TALETS 0.5MG Antiparkinson Aents 3 Dru Added AZILECT TALETS 1MG Antiparkinson Aents 3 Dru Added RAND NAME Pae 14 of 22

15 NAME ROMDAY SOLUTION 0.09% Ophthalmic Antiinflammatories bromfenac solution 0.09% Ophthalmic Antiinflammatories EDURANT TALETS 25MG Anti-HIV Aents, Non-nucleoside Reverse Transcriptase HALDOL DECANOATE 100 SOLUTION 100MG/ML HALDOL DECANOATE 50 SOLUTION 50MG/ML letrozole tablets 2.5m Aromatase, 3rd Generation matzim la tablets 180m Calcium Channel lockin Aents matzim la tablets 240m Calcium Channel lockin Aents matzim la tablets 300m Calcium Channel lockin Aents matzim la tablets 360m Calcium Channel lockin Aents matzim la tablets 420m Calcium Channel lockin Aents 3 QL Increased 1 Dru Added 4 Dru Added Conventional 2 Dru Added Conventional 2 Dru Added 1 Dru Added 1 Dru Added 1 Dru Added 1 Dru Added 1 Dru Added 1 Dru Added next choice tablets 0.75m Proestins 1 Dru Added RAND NAME Pae 15 of 22

16 NAME ocudox kit 50m Tetracyclines 1 Dru Added PAXIL SUSPENSION 10MG/5ML Serotonin/ Norepinephrine Reuptake 3 Dru Added proctozone-hc cream 2.5% Glucocorticoids/ Mineralocorticoids PROLASTIN-C SOLUTION 1000MG Respiratory Tract Aents, Other RAPAFLO CAPSULES 4MG enin Prostatic Hypertrophy Aents RAPAFLO CAPSULES 8MG enin Prostatic Hypertrophy Aents 1 Dru Added 4 Dru Added LA Added 3 Dru Added 3 Dru Added syeda tablets 3m; 0.03m Estroens 1 Dru Added VIIRYD TALETS 10MG Serotonin/ Norepinephrine Reuptake VIIRYD TALETS 20MG Serotonin/ Norepinephrine Reuptake VIIRYD TALETS 40MG Serotonin/ Norepinephrine Reuptake 3 Dru Added ST Added 3 Dru Added ST Added 3 Dru Added ST Added RAND NAME Pae 16 of 22

17 NAME VIRAMUNE XR TALETS 400MG Anti-HIV Aents, Non-nucleoside Reverse Transcriptase 3 Dru Added Date of Chane: 09/01/2011 Formulary File #11203 Formulary Version #14 NAME budesonide capsules 3m Glucocorticoids 1 Dru Added HIERIX SOLUTION Vaccines 2 Dru Added levofloxacin solution 25m/ ml Quinolones 1 Dru Added levofloxacin tablets 250m Quinolones 1 Dru Added levofloxacin tablets 500m Quinolones 1 Dru Added levofloxacin tablets 750m Quinolones 1 Dru Added LUPRON DEPOT KIT 45MG Hormonal Aents, Suppressant (Pituitary) naproxen tablets 500m Nonsteroidal Antiinflammatory Drus 4 Dru Added 1 Dru Added PENTACEL SUSPENSION Vaccines 3 Dru Added RAND NAME Pae 17 of 22

18 NAME ROTARIX SUSPENSION Vaccines 3 Dru Added venlafaxine hcl er capsules 150m venlafaxine hcl er capsules 37.5m venlafaxine hcl er capsules 75m Serotonin/ Norepinephrine Reuptake Serotonin/ Norepinephrine Reuptake Serotonin/ Norepinephrine Reuptake 1 Dru Added 1 Dru Added 1 Dru Added Date of Chane: 10/01/2011 Formulary File #11203 Formulary Version #15 NAME OOSTRIX SUSPEN- SION 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML CAPRELSA TALETS 100MG Antianioenic Aents CAPRELSA TALETS 300MG Antianioenic Aents ceftazidime/dextrose solution 1m/50ml; 5% ceftazidime/dextrose solution 2m/50ml; 5% Vaccines 2 Dru Added eta-lactam, Cephalosporins eta-lactam, Cephalosporins 4 Dru Added 4 Dru Added 1 Dru Added 1 Dru Added RAND NAME Pae 18 of 22

19 NAME CREON CAPSULES 15000UNIT; 3000UNIT; 9500UNIT Enzyme Replacements/ Modifiers 3 Dru Added disulfiram tablets 500m Deterrents 1 Dru Added fondaparinux sodium solution 10m/0.8ml fondaparinux sodium solution 2.5m/0.5ml fondaparinux sodium solution 5m/0.4ml fondaparinux sodium solution 7.5m/0.6ml levofloxacin in d5w solution 5%; 250m/50ml levofloxacin in d5w solution 5%; 500m/100ml levofloxacin in d5w solution 5%; 750m/150ml Anticoaulants 1 Dru Added Anticoaulants 1 Dru Added Anticoaulants 1 Dru Added Anticoaulants 1 Dru Added Quinolones 1 Dru Added Quinolones 1 Dru Added Quinolones 1 Dru Added LIDODERM PATCH 5% Local Anesthetics 3 PA Removed NULOJIX SOLUTION 250MG Immune Suppressants 4 Dru Added RAND NAME Pae 19 of 22

20 NAME orsythia tablets 20mc; 0.1m piperacillin/tazobactam solution 3m; 0.375m piperacillin/tazobactam solution 4m; 0.5m Estroens 1 Dru Added eta-lactam, Penicillins eta-lactam, Penicillins 1 Dru Added 1 Dru Added prenatal plus/iron tablets Vitamins 1 Dru Added PRIMAXIN IV ADD-VANTAGE SOLUTION 250MG; 250MG PRIMAXIN IV ADD-VANTAGE SOLUTION 500MG; 500MG eta-lactam, Other 2 Dru Added eta-lactam, Other 2 Dru Added RANEXA TALETS 1000MG Cardiovascular 3 PA Removed Aents, Other RANEXA TALETS 500MG Cardiovascular 3 PA Removed Aents, Other SAVELLA TALETS 100MG Analesics 3 Dru Added SAVELLA TALETS 12.5MG Analesics 3 Dru Added SAVELLA TALETS 25MG Analesics 3 Dru Added SAVELLA TALETS 50MG Analesics 3 Dru Added SAVELLA TITRATION PACK Analesics 3 Dru Added RAND NAME Pae 20 of 22

21 NAME sumatriptan succinate solution 6m/0.5ml TAMIFLU SUSPENSION 6MG/ML Abortive 1 Dru Added Anti-influenza Aents 2 Dru Added Date of Chane: 11/01/2011 Formulary File #11203 Formulary Version #16 NAME clindamycin hcl capsules 75m Antibacterials, Other 1 Dru Added COMPLERA TALETS 200MG; 25MG; 300MG cyclobenzaprine hcl tablets 7.5m Anti-HIV Aents, Non-nucleoside Reverse Transcriptase Skeletal Muscle Relaxants TASIGNA CAPSULES 150MG Molecular Taret ZELORAF TALETS 240MG Molecular Taret ZOMETA SOLUTION 4MG/100ML Metabolic one Disease Aents 4 Dru Added 1 Dru Added 4 Dru Added 4 Dru Added 3 Dru Added RAND NAME Pae 21 of 22

22 If you need more information, visit or call Customer Service at the toll-free number listed. For Liberty (HMO SNP/HMOPOS SNP) plans, call toll-free: Hawai i: TTY/TDD: Monday Sunday, 8am to 8pm HST. Or visit us anytime at For all other Ohana plans, call toll-free: Hawai i: TTY/TDD: Monday Sunday, 8am to 8pm HST. Or visit us anytime at This document is available in alternate formats or lanuaes. For information on the availability of alternate formats or lanuaes in your service area, please call Customer Service at the number listed in this document. Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare is a health plan with a Medicare contract. Ohana uses a formulary. You may be able to et Extra Help to pay for your prescription dru premiums and costs. To see if you qualify for ettin Extra Help, call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users can call You can also call the Social Security Administration at (TTY ) between 7am and 7pm, Monday Friday; or call your state Medicaid office. eneficiaries must use network pharmacies to access their prescription dru benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. enefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may chane on January 1, P.O. ox Tampa, FL Pae 22 of 22