FORMULARY ADDITIONS & DELETIONS UPDATE 2016: The following summary describes changes to Part D formularies from January to September 2016 Affected Drug Reference Name of Reason for Alternative Drugs (alternative Cephalexin Oral Tab 250 mg, 500 mg KEFLEX, 01/01/2016 Cefixime Susp. 100/5ml, 200/5ml SUPRAX, 01/01/2016 Minocycline Oral Tab 50 mg, 75 mg, 100 mg MINOCIN, 01/01/2016 Moxifloxacin Oral Tab 400 mg AVELOX,, QL 01/01/2016 Thiotepa Inj. 15 mg TES,, B vs D 01/01/2016 Bexarotene Oral Cap 75 mg TARGRETIN,, 01/01/2016 Budesonide Oral Cap 3 mg/24 HR ENTOCORT EC, 01/01/2016 Hydrocortisone Oral Tab 10mg CORTEF, 01/01/2016
Reference Name of Reason for Alternative Drugs (alternative Methylprednisolone Pak 4 mg MEDROL DOSEK, 01/01/2016 Estropipate Oral Tab 0.75 mg, 1.5 mg ORTHO-EST,, 01/01/2016 Megestrol susp. 625mg/5ml MEGACE ES,, 01/01/2016 Progesterone Oral Cap 100 mg PROMETRIUM, 01/01/2016 Progesterone Oral Cap 200 mg PROMETRIUM, 01/01/2016 Tolazomide Oral Tab 250mg, 500 mg TOLINASE,, QL 01/01/2016 Tolbutamide Oral Tab 500 mg ORINASE,, QL 01/01/2016 Metformin ER Tab 1000 mg GLUCOPHAGE/FORTAMET,, QL 01/01/2016 Pioglitazone/Glimepiride Oral Tab 30-2 mg 30-4 mg DUETACT,, QL 01/01/2016 Pioglitazone/Metformin Oral Tab 15-500mg, 15-850mg ACTOPLUS MET,, QL 01/01/2016
Reference Name of Reason for Alternative Drugs (alternative Editronate Disodium Tab 200 mg, 400 mg, 01/01/2016 Risedronate Oral Tab 150 mg ACTONEL,, QL 01/01/2016 Risedronate Sodium Tab 35 mg DR ATELVIA,, QL 01/01/2016 Betaxolol Oral Tab 10 mg, 20 mg KERLONE, 01/01/2016 Matzim LA Tab 180 mg/ 24HR, 240 mg/ 24 HR, 300 mg/ 24 HR, 360 mg/ 24HR 420 mg / 24 HR, 01/01/2016 Candesartan Oral Tab 4 mg, 8 mg, 16 mg, 32 mg ATACAND,, QL 01/01/2016 Guanfacine Oral Tab 1 mg, 2 mg TENEX,, 01/01/2016 Candesartan/HCTZ Oral Tab 16-12.5 mg, 32-12.5 mg, 32-25 mg ATACAND HCT,, QL 01/01/2016 Triamterene/HCTZ Oral Cap 50-25 mg DYAZIDE, 01/01/2016
Reference Name of Reason for Alternative Drugs (alternative Fenofibrate Oral Cap 43 mg, 130 mg, 01/01/2016 Fluvastatin Oral Cap 20 mg, 40 mg LESCOL,, QL 01/01/2016 Cyproheptadine Oral Tab 4 mg,, 01/01/2016 Cyproheptadine Syrup 2 mg/ 5 ml,, 01/01/2016 Desloratadin Oral Tab 5 mg CLARINEX,, QL 01/01/2016 Cimetidine Oral Tab 200 mg, 300 mg, 400 mg, 800 mg TAGAMET, 01/01/2016 Cimetidine Oral Sol 300/5 ml TAGAMET, 01/01/2016 Ranitidine Oral Cap 150mg, 200 mg ZANTAC, 01/01/2016 Nizatidine Oral Cap 150 mg, 300 mg AXID PULVULES, 01/01/2016 Nizatidine Oral Sol 15mg/ml AXID, 01/01/2016
Reference Name of Reason for Alternative Drugs (alternative Lansoprazole Oral Cap DR 15 mg, 30 mg PREVACID, 01/01/2016 Potassium Citrate Oral Tab ER 1620 mg KLOR-CON M15, 01/01/2016 Fluoxetine Oral Cap 90 mg PROZAC,, QL 01/01/2016 Fluvoxamine Oral Cap ER 100 mg, 150 mg LUVOX, 01/01/2016 Paroxetine Oral Tab ER 12.5 mg, 37.5 mg, 25 mg XIL CR, 01/01/2016 Desvenlafaxine Oral Tab ER 500 mg, 100 mg KHEDEZLA, 01/01/2016 Venlafaxine Oral Tab ER 37.5 mg, 75 mg, 150 mg EFFEXOR, 01/01/2016 Aripiprazole Oral Tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg ABILIFY, 01/01/2016 Estazolam Oral Tab 1mg, 2 mg PROSOM,, QL 01/01/2016 Zaleplon Oral Cap 5 mg, 10 mg SONATA,, QL, 01/01/2016
Reference Name of Reason for Alternative Drugs (alternative Zolpidem Oral Tab ER 6.25 mg, 12.5 mg AMBIEN CR,, QL, 01/01/2016 Modafinil Oral Tab 100mg, 200 mg PROVIGIL,, QL, 01/01/2016 Memantine HCL Oral Tab 5 mg, 10 mg NAMENDA,, 01/01/2016 Tetrabenazine Oral Tab 12.5 mg, 25 mg XENAZINE,, QL, 01/01/2016 Oxaprozin Oral Tab 600 mg DAYPRO, 01/01/2016 Colchicine Oral Cap 0.6 mg MITIGARE, 01/01/2016 Colchicine Oral Tap 0.6 mg COLCRYS, 01/01/2016 Pramipexole Oral Tab 0.375mg, 3 mg, 4.5 mg MIRAPEX, 01/01/2016 Pramipexole Oral Tab ER 0.75 mg, 1.5 mg, 2.25 mg MIRAPEX ER, 01/01/2016 Ropinirole Oral Tab ER 2 mg, 4 mg, 6 mg, 8 mg, 12 mg REQUIP XL, 01/01/2016
Reference Name of Reason for (alternati ve Pyridostigmine Oral Tab 180 mg MESTINON, 01/01/2016 ASA/Dypiridamole Oral Cap 25-200 mg AGGRENOX, 01/01/2016 Bimatoprost Ophthalmic Sol. 0.03% LUMIGAN,, QL 01/01/2016 Travoprost Ophthalmic Sol. 0.004% TRAVATAN, 01/01/2016 Atropine Ophthalmic Sol. 1% OP ATROPEN, 01/01/2016 Acetic Acid/Hydrocortisone Otic Sol. VOSOL, 01/01/2016 Acetasol HC Otic Sol. VOSOL HC, 01/01/2016 Adapalene Gel 0.3 % DIFFERIN,, 01/01/2016 Clindamax Topical Gel 1 % CLINDAGEL, 01/01/2016 Metronidazole Topical Gel 1 % METROGEL, 01/01/2016
Reference Name of Reason for (alternati ve Mupirocin Cream 2% BACTROBAN, 01/01/2016 Nystatin/Triamcinolone Acetonide Topical Cream MYCOLOG II, 01/01/2016 Nystatin/Triamcinolone Acetonide Topical Ointment MYCOLOG II, 01/01/2016 Fluorouracil Topical Cream 0.5% EFUDEX, 01/01/2016 Fluocinonide Topical Cream 0.1% VANOS, 01/01/2016 Fluticasone Topical Lotion 0.05% CUTIVATE, 01/01/2016 Hydrocortisone Butyrate Topical Cream 0.1%, 01/01/2016 Mometasone Sol. 0.1% ELOCON, 01/01/2016 Lidocaine Topical Ointment 5%, 01/01/2016 Lindane Lotion 1%, 01/01/2016
Reference Name of Reason for (alternative Lindane Shampoo 1%, 01/01/2016 Topiramate Oral Cap ER 25 mg, 50 mg, 100 mg, 150 mg, 200 mg QUDEXY, 01/01/2016 Prednisolone Ophtalmic Suspension 1% PRED FORTE, 01/01/2016 Budesonide Susp 32 mcg RHINOCORT AQUA, 01/01/2016 Abilify Disintegrating Oral Tab 10 mg Neumega Inj Sol. 5mg/ml Viibryd Titration Pack Pack Foscarnet Sodium Inj Sol. 24mg/ml Phenytoin Sodium ER Oral Cap 200 mg, 300 mg PHENYTEK Alecensa Oral Cap 150 mg,, QL,
Reference Name of Reason for (alternative Avastin Inj 25 mg/ml Bicillin C-R Inj 900/300 Units/2ml, 1200000 units/2 ml Brilinta Oral Tab. 60 mg Chantix Continuing Month Pack 1 mg Cotellic Oral Tab 20 mg Cyramza Inj Sol. 100 mg/10ml ; 500 mg/50 ml Darzalex Inj Sol. 100 mg/ 5 ml; 400 mg/20 ml Empliciti Inj. Sol. 300 mg Ferriprox Oral Sol. 100 mg/ml,,, BvsD,,,,, QL,,, QL,,,,,,,,,
Reference Name of FML Ophthalmic Oint. 1%, Gavilite-H and Bisacodyl Pack, Genvoya Oral Tab, Humalog Pen Inj. 100 units/ml Humalog Mix Prefilled Syr. 75-25 units/ml; 50-50 units/ml Humulin NPH Prefilled Syr. 70-30 Humulin N Prefilled Syr 100 units/ml Iressa Oral Tab 250 mg,, QL,, QL,, QL,, QL,, QL, Kenalog Inj. Susp. 40 mg/ml,
Reference Name of Keytruda Inj. 25mg/ml Klor-Con ER Oral Cap 10 Meq; 8 Meq,,, Lantus Prefilled Syr. 10 units/ml Lonsurf Oral Tab. 20-8.19 mg; 15-6.14 mg Lupron Prefilled Syr. 7.5 mg/ml,, QL,,,, Mestinon ER Oral Tab. 180 mg, Myorisan Oral Cap 30 mg, Nevanac Ophthalmic Susp. 1 mg/ml, Odomzo Oral Cap. 200 mg Orkambi Oral Tab. 125-200 mg,, QL,,, QL,
Reference Name of Pazeo ophthalmic Sol. 7mg/ml, Pradaxa Oral Cap. 110 mg, Rexulti Oral Tab 0.25 mg; 0.5 mg; 1 mg; 2 mg; 3 mg; 4 mg,, QL, Savella 4 week Titration Pack Spiriva Metered Dose Inhaler Stiolto Metered Dose Inhaler Tagrisso Oral Tab. 40 mg; 80 mg,,,, QL,, QL,, QL, Tenivac Prefiled Syr., Adapalene Gel 0.3 % DIFFERIN
Reference Name of Modafinil Oral Tab. 100 mg, 200 mg PROVIGIL Zaleplon 10 mg, 5 mg Oral Cap SONATA Zolpidem ER 12.5mg, 6.25 mg AMBIEN CR Guanfacine Oral Tab 1mg, 2 mg TENEX Cyproheptadine Oral Tab 4 mg Cyproheptadine Syrup 2 mg/ 5 ml Polyethylene Glycol/Potassium Chloride/Sodium Bicarbonate/Sodium Cloride Oral Sol., Verapamil Oral Tab ER 120 mg, Nevirapine Oral Cap ER 100 mg,
Reference Name of Erythromycin DR Oral Cap 250 mg, Levofloxacin Inj 5 mg/ml, Budesonide Inhalant Sol. 0.5 mg/ml Azithromycin Pack 250 mg Risedronate Sod. Oral Tab. 35 mg Bexarotene Oral Cap. 75 mg Megestrol Acetate Oral Susp. 125mg/ml,, B vsd,, QL,, QL,,,, Pyridostigmine Bromide ER Oral Tab. 180 mg, Sumatriptan Auto Injector 12 mg/ml,, QL
Nitrofurantoin Macrocrystals Oral Cap. 25 mg Nitrofurantoin Macrocrystals/ Nitrofurantoin Monohydrate Oral Cap. 25 mg 75mg Reference Name of,,,, Molindone Oral Tab. 10mg, 25 mg, 5 mg Aripiprazole Oral Tab. Desintegrating 10 mg, 15 mg,, Dutasteride Oral Cap 0.5 mg Dutasteride/Tamsolusin Oral Cap. 0.5-0.4 mg Metformin Hcl/Repaglinide Oral Tab 500-1 mg, 500-2mg,,,, QL Trimipramine Oral Cap 100 mg, 25 mg, 50 mg Linezolid 20 mg/ml Inj,,,,
Memantine Hcl Pack, Memantine Oral Sol. Paliperidone ER Oral Tab. 1.5mg, 3 mg, 6 mg, 9 mg Pimozide Oral Tab. 1 mg, 2 mg Aggrenox Oral Cap 25-200 mg Targretin Oral Cap 75mg Suprax Oral Susp 20 mg/ml, 40 mg/ml Colcrys Oral Tab 0.6 mg Reference Name of,,,, Aspirin/Dipyridamole 25-200mg Bexarotene Oral Cap 75 mg, Cefixime Oral Susp 20mg/ml, 40 mg/ml Colchicine Oral Tab 0.6 mg
Jalyn Oral Cap 0.5-0.4 mg Ery-Tab DR Oral Tab. 250 mg Megace Oral Susp. 125mg/ml Namenda Oral Tab 10 mg, 5 mg Namenda Oral Sol 2mg/ml Invega ER Oral Tab 1.5mg, 3 mg, 6 mg, 9 mg Orap Oral Tab. 1 mg, 2 mg Reference Name of Dutasteride/Tamsolusin Oral Cap 0.5-0.4 mg Erythromycin Dr Oral Tab. 250 mg Megestrol Oral Susp 125mg/ml, Memantine Oral Tab. 10mg, 5 mg, Memeantine Oral Sol. 2mg/ml, Paliperidone ER Oral Tab. 1.5mg, 3 mg, 6 mg, 9 mg Pimozide Oral Tab. 1 mg, 2 mg
Xenazine Oral Tab. 12. 5 mg Xenazine Oral Tab. 25 mg Surmontil Oral Cap 100 mg, 25 mg, 50 mg Reference Name of Tetrabenazine Oralt Tab 12.5 mg, QL, Tetrabenazine Oralt Tab 25 mg, QL, Trimipramine Oral Cap. 100 mg, 25 mg, 50 mg, Aripiprazole Oral Tab 30 mg Humulin Regular Inj.Sol 500 units / ml Botox Inj Sol 200 units/ml Ondansetron Oral Desintegrating Tab. 4 mg, 8 mg,, in QL Ondansetron Oral Tab. 4 mg, 8 mg in QL from: 12/5 to: 15/5 from: 12/5 to: 15/5 Ibandronic Acid Oral Tab 150 mg removal
Ninlaro Oral Cap. 2.3 mg, 3 mg, 4 mg Reference Name of,,, QL Naloxone 0.4 mg/ml Inj Auvi-Q Inj Pen 0.3 mg/ 0.3 ml, 0.15 mg/0.15ml 04/01/2016 Roxicet Oral Soln 5-325/5 ml 04/01/2016 Lomustine Oral Cap 10 mg, 40 mg, 100 mg 04/01/2016 Tobramycin Inj. Sol 0.8 mg/ml 04/01/2016 Emend IV Sol 150 mg Empliciti IV Sol. 400 mg Humira Pen Inj 40 mg/0.8 ml, B vs D, Level 2,,,, QL, 04/01/2016 04/01/2016 04/01/2016
Reference Name of Viibryd Starter Kit 10/7&20/23 Phenytoin Sodium EX Oral Cap 200 mg, 300 mg Phenytoin Sodium EX Oral Cap 200 mg, 300 mg Nitrofurantoin Macrocrystals Oral Cap. 25 mg Nitrofurantoin Macrocrystals / Nitrofurantoin Monohydrate Oral Cap. 25-75 mg, ST, QL,,, from 2 to 1 from 2 to 1 04/01/2016 04/01/2016 04/01/2016 04/01/2016 04/01/2016 Avastin Inj Sol. 25 mg/ml Requirements LA 04/01/2016 Arzerra Inj 20mg/ml 05/01/2016 Fluconazole Inj 2 mg/ml Diflucan 05/01/2016 Fyavolv Oral Tab 0.5mg/25 mcg 1 mg/5mcg,, 05/01/2016
Kanuma Inj 20 mg/ 10 ml Linzess Oral Cap 145 mcg 290 mcg Nucala Inj 100mg vial Ofev Oral Cap 100 mg, 150 mg Opdivo Inj 40 mg/4 ml Uptravi Oral Tab 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1000 mcg, 1400 mcg, 1200 mcg, 1600 mcg Uptravi Titration Pack 100/800 mcg Reference Name of,,, B vs D, Level 4,, QL,,, B vs D, QL,,, QL,, B vs D,,, QL,, 05/01/2016 05/01/2016 05/01/2016 05/01/2016 05/01/2016 05/01/2016 05/01/2016
Vraylar Oral Cap 1.5 mg, 3 mg, 4.5 mg, 6 mg Imatiniv Oral Tab 100 mg, 400 mg Gleevec Oral Tab 100 mg, 400mg Reference Name Gleevec of,,, QL,,, 05/01/2016 05/01/2016 09/01/2016 Imitaniv 100mg, 400mg, Level 5 Amnesteem Oral Cap. 10mg, 20 mg, 40 mg Comvax Inj Susp. Traenda Inj Sol. 90 mg/ml Cefazolin 330 mg/ml Inj. Sol Benlysta Inj. 400 mg,, B vs D, Level 2
Reference Name of Humulin R Pen Inj. 500 units / ml Invega Trinza Prefilled Syringe 273 mg, 410 mg, 546 mg, 819 mg Odefsey Oral Tab. 200mg/25mg/25mg Vraylar Pack Carbamazepine ER Oral Tab. 100 mg Cefazolin Inj 1000 mg Diclofenac Sodium Topical Gel 1 % Doxepin Hydrochloride Topical Cream 5 % Fluconazole Inj. 2mg/ml Tegretol XR Ancef Voltaren Gel Prudoxin,, QL,,, QL,,,,,,,,, B vs D,
Reference Name of Oxycodone Hydrochloride ER Oral Tab. 15 mg, 30 mg, 60 mg Losartan 50 mg/ HCTZ 12.5 mg Oral Tab Losartan Potassium Oral Tab 25 mg, 50 mg Voltaren Topical Gel 1 % Oxycontin ER Hyzaar Cozaar, QL, in QL in QL from 30/30 to 60/30 from 30/30 to 60/30, 09/01/2016 Diclofenac Sodium Topical Gel 1% Level 3 Prudoxin Topical Cream 5%, 09/01/2016 Doxepin Hydrochloride Topical Cream 5 % Level 4 Daunoxome 2 mg/ml Inj. Sol. 07/01/2016 Promacta Oral Tab 75 mg 07/01/2016 Zazole Vaginal Cream 07/01/2016 Cholbam Oral Cap 250 mg, 50 mg,, 07/01/2016
Reference Name of Descovy Oral Tab 200 mg/25 mg Kuvan Oral Sol. 100 mg Roweepra Oral Tab 500 mg Venclexta Oral Tab 100 mg Venclexta Oral Tab 10 mg, 50 mg Venclexta Starting Pack 10/100/50 Azathioprine Inj Sol 10 mg/ml Pantoprazole Inj. 40 mg Imuran Protonix,,,,,, QL,,,,,, B vs D, Level 1, B vs D, Level 1 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016 Brintellix Oral Tab 10mg, 20mg, 5mg
Reference Name of Myozime Inj. 5 mg/ml Lindane Topical Lotion 10mg/ml Briviact Inj. Sol. 10 mg/ml Briviact Oral Tab. 10 mg, 25 mg, 50 mg, 75 mg, 100 mg Cabometyx Oral Tab 20 mg, 40 mg, 60 mg Colcrys Oral Tab. 0.6 mg Lenvima Oral Cap.4 mg Lenvima 18 Pack 10mg-4mg Nuplazid Oral Tab. 17 mg,, B vs D, Level 2,, B vs D, Level 2,, QL,,,, QL,,, QL,,, QL,
Tecentriq Inj. 60 mg/ml Trintellix Oral Tab. 5 mg, 10 mg, 20 mg Truvada Oral Tab. 100-150mg, 133-200mg, 167 250mg Uceris Rectal Foam 2 mg/actuation Miglitol Oral Tab. 25 mg, 50 mg, 100 mg Naloxone Inj. 0.4mg/ml Rosuvastatin Oral Tab. 5 mg, 10 mg, 20 mg, 40 mg Aristada Prefilled Syringe 882 mg/3.2 ml, 662 mg/2.5ml, 441 mg / 1.6 ml Fycompa Susp. 0.5 mg/ml Reference Name Glyset Narcan Crestor of, B vs D, Level 2, ST, QL,,,, QL,,, QL,, QL,, 09/01/2016 09/01/2016
Reference Name of Hiberix Ijn 0.5 ml Jentadueto Oral Tab ER 2.5 mg / 1000 mg, 5mg / 1000 mg Lenvima 8 Pack Tivicay Oral Tab 5 mg, 10 mg Armodafinil Oral Tab 150 mg, 200 mg, 250 mg, 50 mg Doxorubicin HCL Inj 2mg/ml Meperidine Inj. Sol. 25 mg/ml, 50 mg/ml Rivastigmine Transdermal Patch 4.6 mg/24 hr, 9.5 mg/24 hr, 13.3 mg/24 hr Invokana Oral Tab 300 mg Nuvigil Demerol Exelon,,, QL,,, QL,,,, QL,, B vs D,,, QL,,, QL,,, QL, 09/01/2016 09/01/2016 09/01/2016 09/01/2016 09/01/2016 09/01/2016 09/01/2016 09/01/2016 09/01/2016
Invokamet Oral Tab 150 mg/ 1,000 mg, 150 mg/500 mg 50 mg/ 1000 mg, 50 mg/ 500 mg Reference Name of,, QL, 09/01/2016 Buproban HCL ER Oral Tab. 150 mg Bupropion Hydrochloride Gleevec Oral Tab 100 mg, 400mg Prudoxin Topical Cream 5% Voltaren Topical Gel 1 %,,, Imitaniv 100mg, 400mg, Doxepin Hydrochloride Topical Cream 5 % Diclofenac Sodium Topical Gel 1% Naphazoline HCL Ophthalmic Sol. 1 mg/ml Albalon Adrenaclick Auto-Injector 0.15 mg/0.15ml; 0.3 mg/0.3 ml Emend Oral Susp. 125mg, QL,, QL,, B vs D
Gengraf Oral Cap 50 mg Humira Pen Psoriasis Starter Pack 50 mg/ml Orencia Auto-Injector 125 mg/ml SPS Oral Susp. 250 mg/ml Ampicillin-Sulbactam Inj. 1000mg/500mg Reference Name of,, B vs D,, QL,,,,,, B vs D Bupropion HCl ER 150 mg Cholestyramine Resin Oral Susp. 4000mg Ciclopirox Topical Sol. 80 mg/ml Buproban Questran Loprox,,,
Reference Name of Fluocinonide Topical Cream 0.5 mg/ml Nilutamide Oral Tab 150 mg Pramipexole ER Oral Tab 150 mg Sumatriptan Auto-Injector 8 mg/ml Lidex Nilatron Mirapex ER Imitrex,,,,, QL Apply to: Diamante Choice Platino, Diamante Extra Platino, Diamante Excel Platino
To make a request, you should provide the evidence of a written medical need statement by the prescriber. For more information, please refer to the section: How can I request a formulary exception? From the Evidence of Coverage. For more information, contact our Customer Services Department at (787) 620-2397 (Metro Area), 1-866-333-5470 (toll free) o al 1-866-333-5469 TTY (hearing impaired), Monday to Sunday from 8:00 a.m. to 8:00 p.m.