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 been added or removed from the Formulary are listed below. Please retain this with your copy of the Formulary. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please call Customer Service at 844-860-6750 for HMO or 844-782-7672 for PPO (TTY users call 711), 24 hours a day, seven (7) days a week or visit healthplan.memorialhermann.org/medicare. The Formulary may change at any time. You will receive notice when necessary. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year. Memorial Hermann Advantage HMO and PPO are provided by Memorial Hermann Health Insurance Company and Memorial Hermann Health Plan, Inc., Medicare Advantage organizations with Medicare contracts. Enrollment in these plans depends on contract renewal. BvD May be covered under Medicare Part B or D depending upon the circumstances; NF Non-Formulary; PA Name, EFFECTIVE 01/01/2018 Amnesteem CAPSULE 10 MG NF 3 Formulary Enhancement N/A Amnesteem CAPSULE 20 MG NF 3 Formulary Enhancement N/A Amnesteem CAPSULE 40 MG NF 3 Formulary Enhancement N/A Austedo TABLET 12 MG NF 5 + PA1 + LA Formulary Enhancement N/A Austedo TABLET 6 MG NF 5 + PA1 + LA Formulary Enhancement N/A Austedo TABLET 9 MG NF 5 + PA1 + LA Formulary Enhancement N/A Page 1 of 13
Name, Balsalazide Disodium CAPSULE 750 MG Benlysta Solution Auto-injector 200 MG/ML Subcutaneous Benlysta Solution Prefilled Syringe 200 MG/ML Subcutaneous Caspofungin Acetate SOLUTION RECONSTITUTED 50 MG Caspofungin Acetate SOLUTION RECONSTITUTED 70 MG Desogestrel-Ethinyl Estradiol TABLET 0.15-30 MG-MCG Diastat AcuDial GEL 20 MG Rectal NF 4 Formulary Enhancement N/A DiazePAM GEL 10 MG RCT NF 4 Formulary Enhancement N/A DiazePAM GEL 2.5 MG RCT NF 4 Formulary Enhancement N/A Digox TAB 125 MCG NF 1 + QL 30 Formulary Enhancement N/A Digox TAB 250 MCG Eletriptan Hydrobromide TABLET 20 MG NF 2 + QL 9 Formulary Enhancement N/A Eletriptan Hydrobromide TABLET 40 MG NF 2 + QL 9 Formulary Enhancement N/A Estradiol TABLET 10 MCG Vaginal IDHIFA TABLET 100 MG NF 5 + PA2 + LA Formulary Enhancement N/A IDHIFA TABLET 50 MG NF 5 + PA2 + LA Formulary Enhancement N/A Isentress HD TAB 600 MG NF 5 Formulary Enhancement N/A Isibloom TABLET 0.15-30 MG-MCG Lidocaine HCl (PF) SOL 2 % INJ Lidocaine HCl SOL 1 % INJ Lynparza TABLET 100 MG NF 5 + PA2 + LA Formulary Enhancement N/A Lynparza TABLET 150 MG NF 5 + PA2 + LA Formulary Enhancement N/A Meropenem SOLUTION RECONSTITUTED 1 GM NF 4 + BvD Formulary Enhancement N/A Page 2 of 13
Name, MetroNIDAZOLE CREAM 0.75 % EXTERNAL Moxifloxacin HCl SOLUTION 0.5 % Ophthalmic Nerlynx TABLET 40 MG NF 5 + PA2 + LA Formulary Enhancement N/A Nucala SOLUTION RECONSTITUTED 100 MG Subcutaneous Olopatadine HCl SOLUTION 0.1 % Ophthalmic Olopatadine HCl SOLUTION 0.2 % Ophthalmic NF 3 Formulary Enhancement N/A Orfadin CAP 20 MG NF 5 + LA Formulary Enhancement N/A Phenadoz SUPP 25 MG Rec Promethazine HCl SUPPOSITORY 25 MG Rectal Promethegan SUPP 12.5 MG Rec Promethegan SUPPOSITORY 25 MG Rectal Radicava SOLUTION 30 MG/100ML NF 5 + PA1 + LA Formulary Enhancement N/A SUMAtriptan Succinate Refill Solution Cartridge 6 MG/0.5ML Subcutaneous SUMAtriptan Succinate SOLUTION 6 MG/0.5ML Subcutaneous Testosterone SOLUTION 30 MG/ACT Transdermal NF 3 + PA2 Formulary Enhancement N/A Vigabatrin PACKET 500 MG NF 5 + PA2 + LA Formulary Enhancement N/A Vyxeos SUSPENSION RECONSTITUTED 100-44 MG NF 5 + PA2 + LA Formulary Enhancement N/A Xatmep SOLUTION 2.5 MG/ML Zytiga TAB 500 MG NF 5 + PA2 Formulary Enhancement N/A EFFECTIVE 03/01/2018 Acetasol HC SOL 2-1 % OTIC 4 NF CMS Required Deletion N/A Page 3 of 13
Name, Adacel SUSPENSION 5-2-15.5 LF- MCG/0.5 Intramuscular (prefilled NF 3 Formulary Enhancement N/A syringe) Aliqopa SOLUTION RECONSTITUTED 60 MG NF 5 + PA2 + LA Formulary Enhancement N/A Aminosyn II SOL 7 % IV 4 + BvD NF CMS Required Deletion N/A Ampicillin CAP 250 MG 1 NF CMS Required Deletion N/A Ampicillin SUS 125 MG/5ML 1 NF CMS Required Deletion N/A Ampicillin SUS 250 MG/5ML 2 NF CMS Required Deletion N/A ARIPiprazole SOLUTION 1 MG/ML NF 4 Formulary Enhancement N/A Avonex KIT 30 MCG Intramuscular Avonex Pen Auto-injector Kit 30 MCG/0.5ML Intramuscular Avonex Prefilled Prefilled Syringe Kit 30 MCG/0.5ML Intramuscular Bortezomib SOLUTION RECONSTITUTED 3.5 MG NF 5 + PA2 Formulary Enhancement N/A Bosulif TABLET 400 MG NF 5 + PA2 Formulary Enhancement N/A Calquence CAPSULE 100 MG NF 5 + PA2 + LA Formulary Enhancement N/A DACTINomycin SOLUTION RECONSTITUTED 0.5 MG Efavirenz CAPSULE 50 MG NF 4 Formulary Enhancement N/A Engerix-B SUS 10 MCG/0.5ML INJ 3 + BvD NF CMS Required Deletion N/A Ethynodiol Diac-Eth Estradiol TABLET 1-35 MG-MCG Fosamprenavir Calcium TABLET 700 MG NF 5 Formulary Enhancement N/A GaviLyte-H KIT 5-210 MG-GM 3 NF CMS Required Deletion N/A Glatiramer Acetate Solution Prefilled Syringe 20 MG/ML Subcutaneous Page 4 of 13
Name, Glatiramer Acetate Solution Prefilled Syringe 40 MG/ML Subcutaneous Gocovri CAPSULE EXTENDED RELEASE 24 HOUR 137 MG NF 5 + PA1 + LA Formulary Enhancement N/A Gocovri CAPSULE EXTENDED RELEASE 24 HOUR 68.5 MG NF 5 + PA1 + LA Formulary Enhancement N/A Haloperidol Decanoate SOLUTION 100 MG/ML Intramuscular 1 ML Havrix SUSPENSION 1440 EL U/ML Intramuscular (prefilled syringe) NF 3 Formulary Enhancement N/A Havrix SUSPENSION 720 EL U/0.5ML Intramuscular (prefilled NF 3 Formulary Enhancement N/A syringe) Juluca TABLET 50-25 MG NF 5 Formulary Enhancement N/A Kadcyla SOLUTION RECONSTITUTED 160 MG NF 5 + PA2 + LA Formulary Enhancement N/A Klor-Con PACKET 20 MEQ Lartruvo SOLUTION 190 MG/19ML NF 5 + PA2 + LA Formulary Enhancement N/A Levo-T TABLET 100 MCG Levo-T TABLET 112 MCG Levo-T TABLET 125 MCG Levo-T TABLET 137 MCG Levo-T TABLET 150 MCG Levo-T TABLET 175 MCG Levo-T TABLET 200 MCG Levo-T TABLET 25 MCG Levo-T TABLET 300 MCG Levo-T TABLET 50 MCG Levo-T TABLET 75 MCG Levo-T TABLET 88 MCG Lomedia 24 FE TAB 1-20 MG- MCG(24) 4 NF CMS Required Deletion N/A Lortab TAB 10-325 MG 3 NF CMS Required Deletion N/A Page 5 of 13
Name, Lortab TAB 5-325 MG 3 NF CMS Required Deletion N/A Lortab TAB 7.5-325 MG 3 NF CMS Required Deletion N/A Lupron Depot-Ped (3-Month) KIT 30 MG (Ped) Intramuscular NF 5 + PA2 Formulary Enhancement N/A Mavyret TABLET 100-40 MG Menomune INJECTABLE SUBQ 3 NF CMS Required Deletion N/A Methotrexate Sodium (PF) SOLUTION 250 MG/10ML INJECTION NF 1 + BvD Formulary Enhancement N/A Morphine Sulfate SOLUTION 5 MG/ML INJECTION Mylotarg SOLUTION RECONSTITUTED 4.5 MG NF 5 + PA2 + LA Formulary Enhancement N/A Necon 10/11 (28) TAB 35 MCG 3 NF CMS Required Deletion N/A Novarel SOLUTION RECONSTITUTED 5000 UNIT NF 3 + PA1 Formulary Enhancement N/A Intramuscular Olopatadine HCl SOLUTION 0.2 % Ophthalmic 3 2 Formulary Enhancement N/A Opdivo SOLUTION 100 MG/10ML NF 5 + PA2 Formulary Enhancement N/A Oseltamivir Phosphate SUSPENSION RECONSTITUTED 6 MG/ML Oxaliplatin SOLUTION RECONSTITUTED 100 MG NF 4 + BvD Formulary Enhancement N/A PEG 3350/Electrolytes SOLUTION RECONSTITUTED 240 GM Piperacillin Sod-Tazobactam So SOLUTION RECONSTITUTED 2.25 NF 4 + BvD Formulary Enhancement N/A (2-0.25) GM Plegridy Solution Pen-injector 125 MCG/0.5ML Subcutaneous Plegridy Solution Prefilled Syringe 125 MCG/0.5ML Subcutaneous NF 5+ PA1 Formulary Enhancement N/A Page 6 of 13
Name, Plegridy Starter Pack Solution Peninjector 63 & 94 MCG/0.5ML Subcutaneous Rexulti TABLET 0.25 MG 5 + PA2 5 Formulary Enhancement N/A Rexulti TABLET 0.5 MG 5 + PA2 5 Formulary Enhancement N/A Rexulti TABLET 1 MG 5 + PA2 5 Formulary Enhancement N/A Rexulti TABLET 2 MG 5 + PA2 5 Formulary Enhancement N/A Rexulti TABLET 3 MG 5 + PA2 5 Formulary Enhancement N/A Rexulti TABLET 4 MG 5 + PA2 5 Formulary Enhancement N/A Rituxan SOLUTION 100 MG/10ML Scopolamine Patch 72 Hour 1 MG/3DAYS Transdermal Sevelamer Carbonate TABLET 800 MG NF 4 Formulary Enhancement N/A Stelara SOLUTION 45 MG/0.5ML Subcutaneous Tecfidera 120 & 240 MG Tecfidera CAPSULE DELAYED RELEASE 120 MG Tecfidera CAPSULE DELAYED RELEASE 240 MG Timolol Maleate SOLUTION 0.5 % (DAILY) Ophthalmic Tracleer TABLET SOLUBLE 32 MG NF 5 + PA1 + LA Formulary Enhancement N/A Treanda SOLUTION RECONSTITUTED 25 MG Trisenox SOLUTION 12 MG/6ML Uloric TABLET 40 MG 4 + ST1 3 + ST1 Formulary Enhancement N/A Uloric TABLET 80 MG 4 + ST1 3 + ST1 Formulary Enhancement N/A Ursodiol CAPSULE 300 MG Page 7 of 13
Name, Vaqta SUSPENSION 25 UNIT/0.5ML Intramuscular (injection) NF 3 Formulary Enhancement N/A Vaqta SUSPENSION 50 UNIT/ML Intramuscular (injection) NF 3 Formulary Enhancement N/A Varubi TABLET 90 MG NF 4 + QL 8 + BvD Formulary Enhancement N/A Verzenio TABLET 100 MG NF 5 + PA2 + LA Formulary Enhancement N/A Verzenio TABLET 150 MG NF 5 + PA2 + LA Formulary Enhancement N/A Verzenio TABLET 200 MG NF 5 + PA2 + LA Formulary Enhancement N/A Verzenio TABLET 50 MG NF 5 + PA2 + LA Formulary Enhancement N/A Xultophy Solution Pen-injector 100-3.6 UNIT-MG/ML Subcutaneous NF 3 + ST1 Formulary Enhancement N/A Zenpep CAPSULE DELAYED RELEASE PARTICLES 20000-63000 NF 3 Formulary Enhancement N/A UNIT EFFECTIVE 04/01/2018 Acyclovir SUSPENSION 200 MG/5ML Altavera TABLET 0.15-30 MG-MCG Alunbrig TABLET 180 MG NF 5 + PA2 Formulary Enhancement N/A Alunbrig TABLET 90 MG NF 5 + PA2 Formulary Enhancement N/A Alunbrig Tablet Therapy Pack 90 & 180 MG NF 5 + PA2 Formulary Enhancement N/A Atazanavir Sulfate CAPSULE 150 MG NF 4 Formulary Enhancement N/A Atazanavir Sulfate CAPSULE 200 MG NF 4 Formulary Enhancement N/A Atazanavir Sulfate CAPSULE 300 MG NF 5 Formulary Enhancement N/A Atorvastatin Calcium TABLET 10 MG Atorvastatin Calcium TABLET 20 MG Atorvastatin Calcium TABLET 40 MG Page 8 of 13
Name, Atorvastatin Calcium TABLET 80 MG Azithromycin PACKET 1 GM Azithromycin SUSPENSION RECONSTITUTED 100 MG/5ML Ciprodex SUSPENSION 0.3-0.1 % OTIC Ciprofloxacin HCl TABLET 100 MG Doripenem SOLUTION RECONSTITUTED 500 MG NF 3 + BvD Formulary Enhancement N/A Eliquis Starter Pack TABLET 5 MG NF 3 Formulary Enhancement N/A Enskyce TABLET 0.15-30 MG-MCG Enulose SOLUTION 10 GM/15ML 3 2 Formulary Enhancement N/A Estradiol CREAM 0.1 MG/GM Vaginal NF 3 Formulary Enhancement N/A Famciclovir TABLET 250 MG Famciclovir TABLET 500 MG FLUoxetine HCl TABLET 60 MG Gammagard SOLUTION 10 GM/100ML INJECTION GaviLyte-C SOLUTION RECONSTITUTED 240 GM GaviLyte-G SOLUTION RECONSTITUTED 236 GM GaviLyte-N with Flavor Pack SOLUTION RECONSTITUTED 420 GM Generlac SOLUTION 10 GM/15ML 3 2 Formulary Enhancement N/A Gentak Ointment 0.3 % Ophthalmic 3 2 Formulary Enhancement N/A GlucaGen HypoKit SOLUTION RECONSTITUTED 1 MG INJECTION Page 9 of 13
Name, Herceptin SOLUTION RECONSTITUTED 150 MG NF 5 + PA2 Formulary Enhancement N/A Irbesartan TABLET 150 MG Irbesartan TABLET 300 MG Irbesartan TABLET 75 MG Jantoven TABLET 1 MG 3 1 Formulary Enhancement N/A Jantoven TABLET 10 MG 3 1 Formulary Enhancement N/A Jantoven TABLET 2 MG 3 1 Formulary Enhancement N/A Jantoven TABLET 2.5 MG 3 1 Formulary Enhancement N/A Jantoven TABLET 3 MG 3 1 Formulary Enhancement N/A Jantoven TABLET 4 MG 3 1 Formulary Enhancement N/A Jantoven TABLET 5 MG 3 1 Formulary Enhancement N/A Jantoven TABLET 6 MG 3 1 Formulary Enhancement N/A Jantoven TABLET 7.5 MG 3 1 Formulary Enhancement N/A Kurvelo TABLET 0.15-30 MG-MCG LamoTRIgine TABLET CHEWABLE 25 MG Leucovorin Calcium TABLET 25 MG LevETIRAcetam TABLET 1000 MG Levonorgestrel-Ethinyl Estrad TABLET 0.15-30 MG-MCG MedroxyPROGESTERone Acetate Suspension Prefilled Syringe 150 MG/ML Intramuscular Memantine HCl SOLUTION 2 MG/ML Morphine Sulfate ER Tablet Extended Release 100 MG Morphine Sulfate ER Tablet Extended Release 60 MG Page 10 of 13
Name, Mycophenolate Mofetil CAPSULE 250 MG 4 + BvD 3 + BvD Formulary Enhancement N/A Mycophenolate Mofetil TABLET 500 MG 4 + BvD 3 + BvD Formulary Enhancement N/A Nevirapine ER Tablet Extended Release 24 Hour 400 MG Nevirapine SUSPENSION 50 MG/5ML Nyata POWDER 100000 UNIT/GM External 3 NF CMS Required Deletion N/A OLANZapine TABLET 10 MG OLANZapine TABLET 15 MG OLANZapine TABLET 20 MG OLANZapine TABLET 5 MG Ondansetron HCl TABLET 4 MG 4 + QL 60 2 + QL 60 + + BvD BvD Formulary Enhancement N/A Ondansetron HCl TABLET 8 MG 4 + QL 60 2 + QL 60 + + BvD BvD Formulary Enhancement N/A Ondansetron TABLET DISPERSIBLE 4 + QL 60 2 + QL 60 + 8 MG + BvD BvD Formulary Enhancement N/A Oxandrolone TABLET 2.5 MG 4 + PA2 3 + PA2 Formulary Enhancement N/A OxyCODONE HCl TABLET 30 MG Pioglitazone HCl TABLET 15 MG Pioglitazone HCl TABLET 30 MG Pioglitazone HCl TABLET 45 MG Primaquine Phosphate TABLET 26.3 MG QUEtiapine Fumarate ER Tablet Extended Release 24 Hour 150 MG QUEtiapine Fumarate ER Tablet Extended Release 24 Hour 200 MG Page 11 of 13
Name, QUEtiapine Fumarate ER Tablet Extended Release 24 Hour 300 MG QUEtiapine Fumarate ER Tablet Extended Release 24 Hour 400 MG QUEtiapine Fumarate ER Tablet Extended Release 24 Hour 50 MG QUEtiapine Fumarate TABLET 300 MG QUEtiapine Fumarate TABLET 400 MG Ribavirin TABLET 200 MG Rosuvastatin Calcium TABLET 10 MG Rosuvastatin Calcium TABLET 20 MG Rosuvastatin Calcium TABLET 40 MG Rosuvastatin Calcium TABLET 5 MG Roweepra TABLET 1000 MG Roweepra TABLET 500 MG Roweepra TABLET 750 MG Roweepra XR Tablet Extended Release 24 Hour 500 MG NF 4 Formulary Enhancement N/A Roweepra XR Tablet Extended Release NF 4 Formulary Enhancement N/A 24 Hour 750 MG Selzentry SOLUTION 20 MG/ML NF 4 Formulary Enhancement N/A Sertraline HCl TABLET 100 MG Shingrix SUSPENSION RECONSTITUTED 50 MCG Intramuscular NF 3 Formulary Enhancement N/A Suprax CAPSULE 400 MG Tenofovir Disoproxil Fumarate TABLET 300 MG NF 5 Formulary Enhancement N/A Page 12 of 13
Name, TriLyte SOLUTION RECONSTITUTED 420 GM Typhim VI SOLUTION 25 MCG/0.5ML Intramuscular (0.5ML SYRINGE) Valsartan TABLET 160 MG Valsartan TABLET 320 MG Valsartan TABLET 40 MG Valsartan TABLET 80 MG Valsartan-Hydrochlorothiazide TABLET 160-12.5 MG Valsartan-Hydrochlorothiazide TABLET 160-25 MG Valsartan-Hydrochlorothiazide TABLET 320-12.5 MG Valsartan-Hydrochlorothiazide TABLET 320-25 MG Valsartan-Hydrochlorothiazide TABLET 80-12.5 MG Venlafaxine HCl ER Tablet Extended Release 24 Hour 225 MG Zenpep CAPSULE DELAYED RELEASE PARTICLES 20000 UNIT 3 NF CMS Required Deletion N/A Zenpep CAPSULE DELAYED RELEASE PARTICLES 40000-126000 NF 3 Formulary Enhancement N/A UNIT Ziprasidone HCl CAPSULE 60 MG Ziprasidone HCl CAPSULE 80 MG Page 13 of 13