Memorial Hermann Advantage HMO November 2015 Formulary Addendum Changes may have occurred since the printing of your current Medicare Advantage HMO Formulary. Medications may have been added or removed from the Formulary are listed below. This is not a complete list of all formulary drugs covered by the Part D plan. For a complete listing, please call Customer Service at 844-550-6896, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 711) 7 days a week or visit the Memorial Hermann Advantage website at http://healthplan.memorialhermann.org. Please retain this with your copy of the Formulary., EFFECTIVE 01/01/2015 AMINOSYN 7% INJ /LYTES NF 4 + PA Formulary Enhancement N/A AMINOSYN-RF INJ 5.2% NF 4 + PA Formulary Enhancement N/A AMLOD/VALSAR TAB /HCTZ 10-160-12.5MG AMLOD/VALSAR TAB /HCTZ 10-160-25MG AMLOD/VALSAR TAB /HCTZ 10-320-25MG AMLOD/VALSAR TAB /HCTZ 5-160-12.25MG AMLOD/VALSAR TAB /HCTZ 5-160-25MG Page 1 of 13
, AMLOD/VALSAR TAB 10-160MG AMLOD/VALSAR TAB 10-320MG AMLOD/VALSAR TAB 5-160MG AMLOD/VALSAR TAB 5-320MG ANORO ELLIPT AER 62.5-25 NF 3 Formulary Enhancement N/A BELEODAQ INJ 500MG NF 5 + PA Formulary Enhancement N/A CLINIMIX E INJ 4.25/D10 NF 4 + PA Formulary Enhancement N/A DEBLITANE TAB 0.35MG DEXMETHYLPHE CAP 5MG FARXIGA TAB 10MG NF 3 + ST Formulary Enhancement N/A FARXIGA TAB 5MG NF 3 + ST Formulary Enhancement N/A FLUOROMETHOL SUS 0.1% OP NF 1 Formulary Enhancement N/A FREAMINE HBC INJ 6.9% NF 4 + PA Formulary Enhancement N/A GARDASIL INJ NF 4 Formulary Enhancement N/A HYDROCO/APAP TAB 2.5-325 NF 1 + QL 370 Formulary Enhancement N/A INTRON A INJ 18MU INTRON A INJ 50MU INVOKAMET TAB 150-1000 NF 3 Formulary Enhancement N/A INVOKAMET TAB 150-500 NF 3 Formulary Enhancement N/A INVOKAMET TAB 50-1000 NF 3 Formulary Enhancement N/A INVOKAMET TAB 50-500MG NF 3 Formulary Enhancement N/A LITHOSTAT TAB 250MG MAGNESIUM SU INJ 50% NF 1 Formulary Enhancement N/A PROMETHAZINE SUP 50MG PURIXAN SUS 20MG/ML NF 5 Formulary Enhancement N/A RECOMBIVA HB INJ 10MCG/ML NF 4 + PA Formulary Enhancement N/A RECOMBIVA HB INJ 5MCG/0.5 NF 4 + PA Formulary Enhancement N/A SUTENT CAP 37.5MG NF 5 Formulary Enhancement N/A TYBOST TAB 150MG NF 4 Formulary Enhancement N/A VALGANCICLOV TAB 450MG NF 5 Formulary Enhancement N/A VALSARTAN TAB 160MG VALSARTAN TAB 320MG Page 2 of 13
, VALSARTAN TAB 40MG VALSARTAN TAB 80MG VAQTA INJ 25/0.5ML NF 4 Formulary Enhancement N/A VAQTA INJ 50UNT/ML NF 4 Formulary Enhancement N/A ZYDELIG TAB 100MG NF 5 Formulary Enhancement N/A ZYDELIG TAB 150MG NF 5 Formulary Enhancement N/A Effective 03/01/2015 ATROPINE SUL SOL 1% OP AURYXIA TAB 210MG NF 4 Formulary Enhancement N/A CELECOXIB CAP 100MG CELECOXIB CAP 200MG CELECOXIB CAP 400MG CELECOXIB CAP 50MG CLOZAPINE TAB 100/ODT CLOZAPINE TAB 12.5/ODT CLOZAPINE TAB 25MG ODT CYCLOPHOSPH TAB 25MG 2 + PA NF CMS Required Deletion N/A CYCLOPHOSPH TAB 50MG 2 + PA NF CMS Required Deletion N/A DIGITEK TAB 0.125MG NF 1 Formulary Enhancement N/A DIGITEK TAB 0.25MG NF 1 Formulary Enhancement N/A DOCEFREZ INJ 80MG 5 + PA NF CMS Required Deletion N/A DOXY 100 INJ 100MG ENTECAVIR TAB 0.5MG NF 5 Formulary Enhancement N/A ENTECAVIR TAB 1MG NF 5 Formulary Enhancement N/A GARDASIL 9 INJ NF 4 Formulary Enhancement N/A GARDASIL 9 INJ NF 4 Formulary Enhancement N/A GUANFACINE TAB 1MG ER NF 2 + PA Formulary Enhancement N/A GUANFACINE TAB 2MG ER NF 2 + PA Formulary Enhancement N/A GUANFACINE TAB 3MG ER NF 2 + PA Formulary Enhancement N/A GUANFACINE TAB 4MG ER NF 2 + PA Formulary Enhancement N/A HARVONI TAB 90-400MG NF 5 + PA Formulary Enhancement N/A HEP SOD/NACL INJ 1000UNIT 1 NF CMS Required Deletion N/A Page 3 of 13
, HUMIRA INJ 10MG/0.2 NF 5 Formulary Enhancement N/A HYDROMORPHON TAB 32MG NF 5 Formulary Enhancement N/A ICLUSIG TAB 15MG NF 5 + PA Formulary Enhancement N/A INCIVEK TAB 375MG 5 + PA NF CMS Required Deletion N/A IPOL INJ INACTIVE NF 4 Formulary Enhancement N/A IVERMECTIN TAB 3MG KEYTRUDA SOL 50MG NF 5 + PA Formulary Enhancement N/A LIDOCAINE INJ 1% 2 NF CMS Required Deletion N/A MIRCERA INJ 100MCG NF 4 + PA Formulary Enhancement N/A MIRCERA INJ 50MCG NF 4 + PA Formulary Enhancement N/A MIRCERA INJ 75MCG NF 4 + PA Formulary Enhancement N/A MYCOPHENOLAT SUS NORTHERA CAP 100MG NF 5 + PA Formulary Enhancement N/A NORTHERA CAP 200MG NF 5 + PA Formulary Enhancement N/A NORTHERA CAP 300MG NF 5 + PA Formulary Enhancement N/A PARICALCITOL INJ 5MCG/ML POT CHLORIDE TAB 8MEQ ER NF 1 Formulary Enhancement N/A POT CITRATE TAB 1620MG PREDNISOLONE TAB 10MG ODT PREDNISOLONE TAB 15MG ODT PREDNISOLONE TAB 30MG ODT PRIFTIN TAB 150MG 4 NF CMS Required Deletion N/A QVAR AER 80MCG NF 3 Formulary Enhancement N/A SIROLIMUS TAB 1MG NF 2 + PA Formulary Enhancement N/A SIROLIMUS TAB 2MG NF 5 + PA Formulary Enhancement N/A SPIRIVA SPR RESPIMAT NF 3 Formulary Enhancement N/A SYMBICORT AER 80-4.5 6.9GM 3 NF CMS Required Deletion N/A SYMBICORT AER 80-4.5 10.2GM NF 3 Formulary Enhancement N/A TOPIRAMATE CAP ER 100MG TOPIRAMATE CAP ER 150MG TOPIRAMATE CAP ER 200MG TOPIRAMATE CAP ER 25MG Page 4 of 13
, TOPIRAMATE CAP ER 50MG TREANDA INJ 45/0.5ML NF 5 Formulary Enhancement N/A TRIUMEQ TAB NF 5 Formulary Enhancement N/A TRUMENBA INJ NF 4 Formulary Enhancement N/A VALCHLOR GEL 0.016% NF 5 Formulary Enhancement N/A XARELTO STAR TAB 15/20MG NF 4 Formulary Enhancement N/A Effective 04/01/2015 CEREBYX INJ 500/10ML NF 4 Formulary Enhancement N/A COLCHICINE CAP 0.6MG COLCHICINE TAB 0.6MG EMBEDA CAP 100-4MG NF 5 + QL 60 Formulary Enhancement N/A EMBEDA CAP 20-0.8MG NF 4 + QL 60 Formulary Enhancement N/A EMBEDA CAP 30-1.2MG NF 4 + QL 60 Formulary Enhancement N/A EMBEDA CAP 50-2MG NF 4 + QL 60 Formulary Enhancement N/A EMBEDA CAP 60-2.4MG NF 4 + QL 60 Formulary Enhancement N/A EMBEDA CAP 80-3.2MG NF 4 + QL 60 Formulary Enhancement N/A ESBRIET CAP 267MG NF 5 + PA Formulary Enhancement N/A KAPVAY TAB 0.1 MG NF 3 Formulary Enhancement N/A LAMIVUDINE SOL 10MG/ML LYNPARZA CAP 50MG NF 5 + PA Formulary Enhancement N/A MACRODANTIN CAP 50MG NF 2 + PA Formulary Enhancement N/A OFLOXACIN TAB 200MG 1 NF CMS Required Deletion N/A OPDIVO INJ 40MG/4ML NF 5 + PA Formulary Enhancement N/A ORAPRED ODT TAB 10MG NF 4 Formulary Enhancement N/A PALGIC SOL 4MG/5ML 1 + PA NF CMS Required Deletion N/A PARICALCITOL INJ 2MCG/ML NF 2 + PA Formulary Enhancement N/A QVAR AER 80MCG (6.9GM) 3 NF CMS Required Deletion N/A REYATAZ POW 50MG NF 5 Formulary Enhancement N/A ZERBAXA INJ 1-0.5 GM NF 4 Formulary Enhancement N/A EFFECTIVE 05/01/2015 ABILIFY MAIN INJ 300, 400 MG NF 5 Formulary Enhancement N/A Page 5 of 13
, AMMONIUM LAC CRE 12% NF 1 Formulary Enhancement N/A BARACLUDE TAB 0.5, 1 MG 5 NF Formulary Update entecavir tab, 5 BUTISOL SOD TAB 50MG 4 + PA NF CMS Required Deletion N/A CELEBREX CAP 50, 100, 200, 400 MG 3 NF Formulary Update celecoxib cap, 2 CELLCEPT SUS 200MG/ML 3 + PA NF Formulary Update mycophenolat sus, 2 DELESTROGEN INJ 10MG/ML NF 4 + PA Formulary Enhancement N/A EVOTAZ TAB 300-150 NF 5 Formulary Enhancement N/A EXFORGE TAB 5-160, 5-320, 10- amlod/ valsar tab, 4 NF Formulary Update 160, 10-320 MG 2 EXFORGEH TAB 10-160-12.5, 10- amlod/ valsar / 4 NF Formulary Update 160-25, 10-320-25 HCTZ tab, 2 EXFORGEH TAB 5-160-12.5, 5-160-25 4 NF Formulary Update amlod/ valsar / HCTZ tab, 2 FAZACLO ODT TAB 12.5, 25, 100 4 NF Formulary Update clozapine tab, 2 GATIFLOXACIN SOL 0.5% GLEOSTINE CAP 10, 40, 100 MG NF 4 Formulary Enhancement N/A IBRANCE CAP 75, 100, 125 MG NF 5 + PA Formulary Enhancement N/A INTUNIV TAB 1, 2, 3, 4 MG 4 + PA NF Formulary Update guanfacine tab, 2 + PA LAMOTRIGINE TAB ODT 25, 50, 100, 200 MG LEVOCETIRIZI TAB 5MG NF 1 Formulary Enhancement N/A LIDOCAINE SOL 2% VISC NF 1 Formulary Enhancement N/A MOMETASONE SOL 0.1% NF 1 Formulary Enhancement N/A MUPIROCIN CRE 2% PANTOPRAZOLE TAB 20, 40 MG NF 1 Formulary Enhancement N/A PREDNISOLONE SUS 1% OP PREZCOBIX TAB 800-150 NF 5 Formulary Enhancement N/A Page 6 of 13
, PROCTOSOL HC CRE 2.5% NF 1 Formulary Enhancement N/A RAPAMUNE TAB 1, 2 MG 5 + PA NF Formulary Update sirolimus tab, 2 + PA SIGNIFOR LAR INJ 20, 40, 60 MG NF 5 Formulary Enhancement N/A STROMECTOL TAB 3MG 3 NF Formulary Update ivermectin tab, 2 TERBINAFINE TAB 250MG NF 1 Formulary Enhancement N/A TESTOST CYP INJ 100, 200 MG/ML 2 NF CMS Required Deletion N/A TRIAMT/HCTZ CAP 37.5-25 NF 1 Formulary Enhancement N/A VALCYTE TAB 450MG 5 NF Formulary Update valganciclov tab, 5 VITEKTA TAB 85, 150 MG NF 5 Formulary Enhancement N/A ZEMPLAR INJ 5MCG/ML 3 + PA NF Formulary Update paricalcitol inj, 2 ZUBSOLV SUB 8.6-2.1 NF 4 Formulary Enhancement N/A EFFECTIVE 06/01/2015 ADRUCIL INJ 500/10ML NF 4 + PA Formulary Enhancement N/A AMP-SULBACTA INJ 1.5GM AVANDARYL TAB 4-4MG 4 NF CMS Required Deletion N/A AVANDARYL TAB 8-2MG 3 NF CMS Required Deletion N/A BEXSERO INJ NF 3 Formulary Enhancement N/A BUTISOL SOD ELX 30MG/5ML 4 + PA NF CMS Required Deletion N/A CHANTIX PAK 1MG NF 4 + QL 56/28 Formulary Enhancement N/A COLCRYS TAB 0.6MG 4 NF Formulary Update colchicine tab, 2 CORMAX SCALP SOL 0.05% DAUNOXOME INJ 2MG/ML NF 5 + PA Formulary Enhancement N/A DESMOPRESSIN SOL 0.01% EPIVIR SOL 10MG/ML 4 NF Formulary Update lamivudine sol, 2 FARYDAK CAP 10MG NF 5 + PA Formulary Enhancement N/A FARYDAK CAP 15MG NF 5 + PA Formulary Enhancement N/A FARYDAK CAP 20MG NF 5 + PA Formulary Enhancement N/A Page 7 of 13
, FENTANYL DIS 37.5MCG NF 2 + QL 10 + ST Formulary Enhancement N/A FENTANYL DIS 62.5MCG NF 2 + QL 10 + ST Formulary Enhancement N/A FENTANYL DIS 87.5MCG NF 2 + QL 10 + ST Formulary Enhancement N/A FLEBOGAMMA INJ DIF 10% NF 4 + PA Formulary Enhancement N/A GAMMAKED INJ 1GM/10ML NF 4 + PA Formulary Enhancement N/A ICLUSIG TAB 45MG NF 5 + PA Formulary Enhancement N/A LENVIMA CAP 10MG NF 5 Formulary Enhancement N/A LENVIMA CAP 14MG NF 5 Formulary Enhancement N/A LENVIMA CAP 20MG NF 5 Formulary Enhancement N/A LENVIMA CAP 24MG NF 5 Formulary Enhancement N/A LEVETIRACETA INJ 10MG/ML NF 4 Formulary Enhancement N/A LEVETIRACETA INJ 15MG/ML NF 4 Formulary Enhancement N/A LEVETIRACETA INJ 5MG/ML NF 4 Formulary Enhancement N/A OMEGA-3-ACID CAP 1GM ONDANSETRON INJ 4MG/2ML NF 2 + PA Formulary Enhancement N/A RELISTOR INJ 12/0.6ML NF 4 + PA Formulary Enhancement N/A RELISTOR INJ 8/0.4ML NF 4 + PA Formulary Enhancement N/A SAIZEN INJ 8.8MG NF 5 + PA Formulary Enhancement N/A SUPRAX TAB 400MG 4 NF CMS Required Deletion N/A TARGRETIN GEL 1% 4 NF CMS Required Deletion N/A TENIVAC INJ 5-2LF NF 3 Formulary Enhancement N/A TESTOST CYP INJ 200MG/ML NF 1 Formulary Enhancement N/A TRANDO/VERAP TAB 1-240 CR TRANDO/VERAP TAB 2-180 CR TRANDO/VERAP TAB 2-240 CR TRANDO/VERAP TAB 4-240 CR TYPHIM VI INJ NF 4 Formulary Enhancement N/A ZEMPLAR CAP 4MCG 5 + PA NF CMS Required Deletion N/A ZEMPLAR INJ 2MCG/ML 3 + PA NF Formulary Update paricalcitol, 2 + PA Page 8 of 13
, ZYPREXA RELP INJ 210MG NF 4 Formulary Enhancement N/A EFFECTIVE 07/01/2015 ABILIFY SOL 1MG/ML 4 NF CMS Required Deletion N/A AMTURNIDE 150 TAB -5-12.5 4 NF CMS Required Deletion N/A AMTURNIDE 300 TAB -10-12.5 4 NF CMS Required Deletion N/A AMTURNIDE 300 TAB -10-25MG 4 NF CMS Required Deletion N/A AMTURNIDE 300 TAB -5-12.5 4 NF CMS Required Deletion N/A AMTURNIDE 300 TAB -5-25MG 4 NF CMS Required Deletion N/A ANDROXY TAB 10MG 4 NF CMS Required Deletion N/A AVANDAMET TAB 4-1000MG 4 NF CMS Required Deletion N/A BIMATOPROST SOL 0.03% KALYDECO PAK 50MG NF 5 + PA Formulary Enhancement N/A KALYDECO PAK 75MG NF 5 + PA Formulary Enhancement N/A LEVOLEUCOVOR INJ 50MG NF 2 + PA Formulary Enhancement N/A PANTOPRAZOLE INJ 40MG 2 NF CMS Required Deletion N/A PEDI-DRI POW 100000 2 NF CMS Required Deletion N/A POT CHLORIDE LIQ 10% PRIFTIN TAB 150MG NF 4 +PA Formulary Enhancement N/A PRISTIQ TAB 25MG NF 4 Formulary Enhancement N/A QUADRACEL INJ NF 3 Formulary Enhancement N/A EFFECTIVE 08/01/2015 ABILIFY INJ 9.75MG 4 NF CMS Required Deletion N/A ARIPIPRAZOLE TAB 10MG ARIPIPRAZOLE TAB 15MG ARIPIPRAZOLE TAB 20MG ARIPIPRAZOLE TAB 2MG ARIPIPRAZOLE TAB 30MG ARIPIPRAZOLE TAB 5MG CLINDAMAX GEL 1% CLOZAPINE TAB 150/ODT CLOZAPINE TAB 200/ODT NF 5 Formulary Enhancement N/A DOXYCYC MONO CAP 100MG NF 1 Formulary Enhancement N/A DOXYCYC MONO CAP 50MG NF 1 Formulary Enhancement N/A DOXYCYC MONO TAB 100MG NF 1 Formulary Enhancement N/A FOSRENOL POW 1000MG NF 4 Formulary Enhancement N/A Page 9 of 13
, FOSRENOL POW 750MG NF 4 Formulary Enhancement N/A HYDROXYZ HCL INJ 25MG/ML 1 + PA NF CMS Required Deletion N/A HYDROXYZ HCL INJ 50MG/ML 1 +PA NF CMS Required Deletion N/A METOCLOPRAM TAB 5MG ODT NEUPOGEN INJ 300MCG NF 4 Formulary Enhancement N/A NITROFUR MAC CAP 100MG NF 2 + PA Formulary Enhancement N/A NORETH/ETHIN TAB 0.5-2.5 NORETH/ETHIN TAB 1MG-5MCG PROAIR RESPI AER NF 3 Formulary Enhancement N/A QUINIDINE SU TAB 300MG ER 2 NF CMS Required Deletion N/A REBIF REBIDO INJ 22/0.5 NF 5 Formulary Enhancement N/A REBIF REBIDO INJ 44/0.5 NF 5 Formulary Enhancement N/A REBIF REBIDO SOL TITRATN NF 5 Formulary Enhancement N/A RISEDRON SOD TAB 35MG DR SAPHRIS SUB 2.5MG NF 4 Formulary Enhancement N/A TARKA TAB 1-240 CR 4 NF Formulary Update trando/verap tab cr, 2 TARKA TAB 2-180 CR 4 NF Formulary Update trando/verap tab cr, 2 TARKA TAB 2-240 CR 4 NF Formulary Update trando/verap tab cr, 2 TARKA TAB 4-240 CR 4 NF Formulary Update trando/verap tab cr, 2 TOLCAPONE TAB 100MG NF 5 Formulary Enhancement N/A EFFECTIVE 08/01/2015 ABILIFY DISC TAB 10MG 4 NF CMS Required N/A ABILIFY DISC TAB 15MG 4 NF CMS Required N/A ALOSETRON TAB 0.5MG NF 5 Formulary Enhancement N/A ALOSETRON TAB 1MG NF 5 Formulary Enhancement N/A AVANDAMET TAB 2-500MG 4 NF CMS Required N/A AVANDAMET TAB 4-500MG 4 NF CMS Required N/A AVANDARYL TAB 4-1MG 4 NF CMS Required N/A AVANDARYL TAB 4-2MG 4 NF CMS Required N/A AVANDARYL TAB 8-4MG 3 NF CMS Required N/A BREO ELLIPTA INH 200-25 NF 3 Formulary Enhancement N/A DOXYCYC MONO TAB 50MG NF 1 Formulary Enhancement N/A DULOXETINE CAP 40MG ENBREL SRCLK INJ 50MG/ML NF 5 Formulary Enhancement N/A Page 10 of 13
, HYPERRAB S/D INJ 150/ML NF 3 Formulary Enhancement N/A HYPERRAB S/D INJ 150/ML NF 3 Formulary Enhancement N/A IRENKA CAP 40MG NF 4 + ST Formulary Enhancement N/A KUVAN POW 500MG NF 5 Formulary Enhancement N/A KUVAN TAB 100MG 5 + LA 5 Formulary Enhancement N/A LINEZOLID TAB 600MG NF 5 Formulary Enhancement N/A NOVOLOG INJ PENFILL NF 3 Formulary Enhancement N/A PAZEO DRO 0.7% NF 4 Formulary Enhancement N/A PEGASYS INJ PROCLICK NF 5 Formulary Enhancement N/A RISEDRONATE TAB 30MG RISEDRONATE TAB 35MG RISEDRONATE TAB 35MG RISEDRONATE TAB 5MG SILDENAFIL INJ VARIZIG INJ 125UNIT NF 4 Formulary Enhancement N/A VICTRELIS CAP 200MG 5 + PA NF CMS Required N/A EFFECTIVE 10/01/2015 ABILIFY TAB 10MG 4 NF Formulary Update aripiprazole tab, 2 ABILIFY TAB 15MG 4 NF Formulary Update aripiprazole tab, 2 ABILIFY TAB 20MG 4 NF Formulary Update aripiprazole tab, 2 ABILIFY TAB 2MG 4 NF Formulary Update aripiprazole tab, 2 ABILIFY TAB 30MG 4 NF Formulary Update aripiprazole tab, 2 ABILIFY TAB 5MG 4 NF Formulary Update aripiprazole tab, 2 ASA/DIPYRIDA CAP 25-200MG ATELVIA TAB 3 NF Formulary Update risedron sod tab dr, 2 AVASTIN INJ 400/16ML NF 4 Formulary Enhancement N/A BEXAROTENE CAP 75MG NF 5 + PA Formulary Enhancement N/A BUDESONIDE SUS 1MG/2ML NF 3 + PA Formulary Enhancement N/A CLINDAMYCIN GEL 1% 2 NF Formulary Update clindamax gel, 2 CYRAMZA INJ 100/10ML NF 5 + PA Formulary Enhancement N/A CYRAMZA INJ 500/50ML NF 5 + PA Formulary Enhancement N/A ENTRESTO TAB 24-26MG NF 4 + PA + ST Formulary Enhancement N/A ENTRESTO TAB 49-51MG NF 4 + PA + ST Formulary Enhancement N/A ENTRESTO TAB 97-103MG NF 4 + PA + ST Formulary Enhancement N/A ERBITUX INJ 100MG 5 + PA NF CMS Required Deletion N/A FAZACLO TAB 150MG 4 NF Formulary Update clozapine tab odt, 2 FOSCARNET INJ 24MG/ML 2 NF CMS Required Deletion N/A Page 11 of 13
, GLATOPA INJ 20MG/ML NF 5 Formulary Enhancement N/A KADCYLA INJ 100MG 5 NF CMS Required Deletion N/A KETOCONAZOLE AER 2% KEYTRUDA INJ 100MG/4M NF 5 + PA Formulary Enhancement N/A KIMIDESS TAB NF 3 Formulary Enhancement N/A MEMANTINE HC TAB 10MG NF 1 Formulary Enhancement N/A MEMANTINE TAB HCL 5MG NF 1 Formulary Enhancement N/A MOXIFLOXACIN INJ OFLOXACIN TAB 300MG 1 NF CMS Required Deletion N/A ORKAMBI TAB 200-125 NF 5 + PA Formulary Enhancement N/A REXULTI TAB 0.25MG NF 5 + PA + ST Formulary Enhancement N/A REXULTI TAB 0.5MG NF 5 + PA + ST Formulary Enhancement N/A REXULTI TAB 1MG NF 5 + PA + ST Formulary Enhancement N/A REXULTI TAB 2MG NF 5 + PA + ST Formulary Enhancement N/A REXULTI TAB 3MG NF 5 + PA + ST Formulary Enhancement N/A REXULTI TAB 4MG NF 5 + PA + ST Formulary Enhancement N/A STIOLTO AER RESPIMAT NF 3 Formulary Enhancement N/A TEKAMLO TAB 150-10MG 4 NF CMS Required Deletion N/A TEKAMLO TAB 150-5MG 4 NF CMS Required Deletion N/A TEKAMLO TAB 300-10MG 4 NF CMS Required Deletion N/A TEKAMLO TAB 300-5MG 4 NF CMS Required Deletion N/A TETANUS TOX INJ 5LF ADS 4 NF CMS Required Deletion N/A TEVETEN HCT TAB 600-12.5 4 NF CMS Required Deletion N/A U-CORT CRE 1% 1 NF CMS Required Deletion N/A VECTIBIX INJ 100MG 4 + PA NF CMS Required Deletion N/A YERVOY INJ 50MG 5 NF CMS Required Deletion N/A EFFECTIVE 11/01/2015 AZITHROMYCIN TAB 250 MG MEGESTROL SUS 625 MG/5M NF 5 + PA Formulary Enhancement N/A ORAVIG TAB 50 MG NF 3 Formulary Enhancement N/A PRAMIPEXOLE TAB 3 MG TETRABENAZIN TAB 12.5 MG NF 5 Formulary Enhancement N/A TETRABENAZIN TAB 25 MG NF 5 Formulary Enhancement N/A TEVETEN HCT TAB 600-25MG 4 NF CMS Required Deletions N/A THIOTEPA INJ 15 MG NF 5 + PA Formulary Enhancement N/A Page 12 of 13
You must use network pharmacies to access prescription drug benefits, except under non-routine circumstances and quantity limitation and restrictions may apply. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, and/or co-payments/co-insurance may change on January 1 of each year. Memorial Hermann Advantage HMO is a health plan with a Medicare contract. Enrollment in Memorial Hermann Advantage HMO depends on contract renewal. Page 13 of 13