Changes to Open 2 Plus (4 Tier) Formulary

Transcription

1 Changes to Open 2 Plus (4 Tier) Formulary The table below outlines the changes to our 2018 formulary since the formulary list was last posted to our website on Name of Drug Affected Description of Change Nucynta ER 100MG Nucynta ER 150MG Nucynta ER 200MG Nucynta ER 250MG Nucynta ER 50MG NUCYNTA ER 100MG TABS will be ER 100MG TABS will NUCYNTA ER 150MG TABS will be ER 150MG TABS will NUCYNTA ER 200MG TABS will be ER 200MG TABS will NUCYNTA ER 250MG TABS will be ER 250MG TABS will NUCYNTA ER 50MG TABS will be ER 50MG TABS will Reason for Change Alternative Drug Alternative Drug Cost- Sharing Tier Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 1 of 9

2 Ozempic 2MG/1.5ML Injection Picato 0.015% Gel Picato 0.05% Gel Soliqua Injection Trelegy Ellipta Inhaler Trulicity 0.75MG/0.5ML Pen Trulicity 1.5MG/0.5ML Pen OZEMPIC 2MG/1.5ML to Tier 2. OZEMPIC 2MG/1.5ML moved on PICATO 0.015% GEL Tier 4 to Tier 2. PICATO 0.015% GEL will PICATO 0.05% GEL Tier 4 to Tier 2. PICATO 0.05% GEL will SOLIQUA to Tier 2. SOLIQUA moved on TRELEGY ELLIPAT INHALER will be to Tier 2. TRELEGY ELLIPAT INHALER will TRULICITY 0.75MG/0.5ML PEN Tier 3 to Tier 2. TRULICITY 0.75MG/0.5ML PEN will TRULICITY 1.5MG/0.5ML PEN Tier 3 to Tier 2. TRULICITY Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 2 of 9

3 1.5MG/0.5ML PEN PEN will Xultophy Injection XULTOPHY to Tier 2. XULTOPHY moved on Centany Ointment 2% Effective 6/1/2018, Centany Ointment 2% limit of 30 grams per Centany Ointment 2%. Mupirocin Ointment 2% Effective 6/1/2018, Mupirocin Ointment 2% will have a quantity limit of 30 Mupirocin Ointment 2%. Calcipotriene Cream 0.005% Effective 6/1/2018, Calcipotriene Cream 0.005% will have a quantity limit of 120 Calcipotriene Cream 0.005%. Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 3 of 9

4 Dovonex Cream 0.005% Effective 6/1/2018, Dovonex Cream 0.005% will have a quantity limit of 120 Dovonex Cream 0.005%. Diclofenac Gel 3% Effective 6/1/2018, Diclofenac Gel 3% limit of 100 grams per Diclofenac Gel 3%. Solaraze Gel 3% Effective 6/1/2018, Solaraze Gel 3% will have a quantity limit of 100 grams per 30 days. The quantity limit will only apply to members who are beginning therapy (new starts only) with Solaraze Gel 3%. Fluocinonide Cream 0.1% Effective 6/1/2018, Fluocinonide Cream 0.1% will have a quantity limit of 120 Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 4 of 9

5 Fluocinonide Cream 0.1%. Vanos Cream 0.1% Effective 6/1/2018, Vanos Cream 0.1% limit of 120 grams per Vanos Cream 0.1%. Doxepin HCl Cream 5% Effective 6/1/2018, Doxepin HCl Cream 5% will have a quantity limit of 45 Doxepin Cream 5%. Prudoxin Cream 5% Effective 6/1/2018, Prudoxin Cream 5% limit of 45 grams per Prudoxin Cream 5%. Zonalon Cream 5% Effective 6/1/2018, Zonalon Cream 5% limit of 45 grams per Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 5 of 9

6 Zonalon Cream 5%. Xarelto 10MG Xarelto 10mg will be to Tier 2. Also, Xarelto 10mg no longer has a quantity limit. Xarelto 10mg will be moved on 01/01/2018. Xarelto 15MG Xarelto 15mg will be to Tier 2. Also, Xarelto 15mg no longer has a quantity limit. Xarelto 15mg will be moved on 01/01/2018. Xarelto 20mg Xarelto 20mg will be to Tier 2. Also, Xarelto 20mg no longer has a quantity limit. Xarelto 20mg will be moved on 01/01/2018. Xarelto Starter Pack Xarelto Starter Pack Tier 3 to Tier 2. Also, Xarelto Starter Pack no longer has a quantity limit. Xarelto Starter Pack will 01/01/2018. Sensipar 30MG Effective 1/1/2018, Sensipar 30MG tablets will require prior authorization when the drug is being used as part of renal dialysis services for members with end-stage renal disease (ESRD). Prior Members: Formulary Addition. Members: Formulary Addition. Members: Formulary Addition. Members: Formulary Addition. This change is to comply with a new Medicare requirement issued 08/18/2017. Effective 1/1/2018 for members with ESRD, Aetna will cover Sensipar 30MG tablets as part of renal dialysis treatment. We None Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 6 of 9

7 authorization will not be required when the drug is being used by non-esrd members. will pay the renal dialysis provider for this drug. We will not pay the pharmacy directly. Sensipar 60MG Effective 1/1/2018, Sensipar 60MG tablets will require prior authorization when the drug is being used as part of renal dialysis services for members with end-stage renal disease (ESRD). Prior authorization will not be required when the drug is being used by non-esrd members. There is no change in coverage or payment for members who do not have ESRD. This change is to comply with a new Medicare requirement issued 08/18/2017. Effective 1/1/2018 for members with ESRD, Aetna will cover Sensipar 60MG tablets as part of renal dialysis treatment. We will pay the renal dialysis provider for this drug. We will not pay the pharmacy directly. None Sensipar 90MG Effective 1/1/2018, Sensipar 90MG tablets will require prior authorization when the drug is being used as part of renal dialysis services for members with end-stage renal disease (ESRD). Prior authorization will not be required when the drug is being used by non-esrd members. There is no change in coverage or payment for members who do not have ESRD. This change is to comply with a new Medicare requirement issued 08/18/2017. Effective 1/1/2018 for members with ESRD, Aetna will cover Sensipar 90MG tablets as part of renal dialysis treatment. We will pay the renal dialysis provider for this drug. We will not pay the pharmacy directly. None There is no change in coverage or payment for members who do not have ESRD. Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 7 of 9

8 The first column lists the drug name. The second column describes what change occurred to the coverage of the drug in the first column and includes the tier of the drug and any special requirements. The third column explains why we made the change. If we remove a drug from the formulary then we will provide you information on the name and cost share of the alternative drug covered on the formulary (see the fourth and fifth columns). The fourth and fifth columns include possible formulary alternatives that you could consider with your doctor. Alternative drugs are drugs in the same therapeutic category/class as the affected drug. Only your doctor can determine alternative drugs that are appropriate for you given the individualized nature of the drug therapy. Please talk to your doctor about any changes or recommendations to your medical care and prescription drug therapy. Alternative drugs and additional information about formulary changes can be found on the plan formulary. What if you disagree with these changes? A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. If you disagree with our decision to remove or change the tiering structure of a drug, you may file a grievance with us. If you disagree with any of the coverage decisions we have made, you can make an appeal. If a drug is not covered in the way you would like it to be covered, you can ask us to make an exception. An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. To make an exception, your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. Please refer to the Chapter titled What to do if you have a problem or complaint (coverage decisions, appeals, complaints), in your Evidence of Coverage for more information on how to request a coverage decision, grievance, or to appeal any of the changes we have made to the formulary. If you have any questions or would like assistance requesting a coverage decision, grievance, or appeal, please call us at the number on your Member ID card, 24 hours a day, 7 days a week. You may also send coverage decisions to: PO Box 7773 London, Kentucky, 40742, or grievances and appeals to: PO Box Lexington, KY For more information about how these changes may impact your cost-sharing, please see the plan s Evidence of Coverage. e: This is not a complete list of drugs covered by our plan. See the rest of the Formulary document for a complete listing. 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. Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 8 of 9

9 Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, and/or co-payments/co-insurance may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. See Evidence of Coverage for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location. Y0022_PDPCCP_2013_5035_1488 approved 1/2013 Formulary ID Page 9 of 9