Upcoming Changes to Molina Medicare Options HMO and Molina Medicare Options Plus HMO SNP s Formulary MEDICARE WILL NO LONGER COVER
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1 Upcoming s to Molina Medicare Options HMO and Molina Medicare Options Plus HMO SNP s Formulary Molina Medicare may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug and/or move a drug at a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, in which case we will immediately remove the drug from our formulary. The table below outlines upcoming changes to our formulary that may impact you. ADRIAMYCIN INJ 2MG/ML ALLOPURINOL INJ 500MG ARICEPT TAB 23MG ASTRAMORPH AVINZA. AZATHIOPRINE INJ 100MG CAMPRAL TAB 333MG Reason for DOXORUBICIN INJ 50MG Tier 1 07/01/2014 CONSULT YOUR Medicare Will No Longer HEALTH CARE Cover PROVIDER N/A 05/01/2014 DONEPEZIL 23 MG Tier 1 06/01/2014 MORPHINE SUL INJ Tier 1 Medicare Will No Longer Cover MORPHINE SULFATE BEADS CAP SR 24H Tier 1 09/01/2014 CONSULT YOUR HEALTH CARE PROVIDER N/A 05/01/2014 ACAMPROSATE CALCIUM 333 MG Tier 1 06/01/2014
2 COMBIVENT AEROSOL INHALER CYMBALTA DETROL LA DOXIL INJ 2MG/ML ELSPAR INJ 10000UNT EPIVIR HBV EVISTA TAB 60MG Reason for Combivent INH has been discontinued and replaced with Combivent Respimat. As of 1/1/14, Combivent INH cannot Deletion of be made, dispensed, or sold in COMBIVENT AER from Formulary the US. RESPIMAT Tier 3 01/01/2014 DULOXETINE HCL Tier 1 06/01/2014 TOLTERODINE TARTRATE SR Tier 1 06/01/2014 DOXORUBICIN HCL LIPOSOMAL INJ 2 MG/ML Tier 4 06/01/2014 CONSULT HEALTH CARE PROVIDER N/A LAMIVUDINE 100 MG Tier 1 06/01/2014 RALOXIFENE HCL TAB 60 MG Tier 1 09/01/2014 EXELON SOL 2MG/ML RIVASTIGMINE CAP Tier 1 07/01/2014 FLUOROPLEX 1% Deletion of Medicare Will No Longer CARAC CREAM 0.5% Tier 3 01/01/2014
3 CREAM from Formulary Cover FREAMINE III INJ 8.5% HEPSERA TAB 10MG ISOLYTE-M INJ /D5W JUVISYNC JUVISYNC LEUKINE INJ 500 MCG LEVOTHROID LIDODERM Reason for AMINOSYN II INJ 8.5% Tier 3 ADEFOVIR Tier 4 06/01/2014 NORMOSOL -M INJ /D5W Tier 1 06/01/2014 Simvastatin Tier 1 11/01/2014 Januvia/Tradjenta Tier 2 11/01/2014 LEUKINE INJ 250MCG Tier 4 LEVOTHYROXINE Tier 1 LIDOCAINE PATCH 5% Tier 1 06/01/2014 LODOSYN TAB 25MG CARBIDOPA TAB 25 MG Tier 1 09/01/2014 LUNESTA ESZOPICLONE Tier 1 09/01/2014
4 MEPRON SUS MYCOBUTIN CAP 150MG MYFORTIC TAB 180MG MYFORTIC TAB 360MG NEXIUM I.V. NIASPAN ONFI TAB 5MG ONTAK INJ 150/ML ORTHO EVRA Reason for ATOVAQUONE 750 MG/5ML SUSP Tier 4 09/01/2014 RIFABUTIN 150 MG CAP Tier 1 09/01/2014 MYCOPHENOLATE SODIUM 180 MG Tier 1 06/01/2014 MYCOPHENOLATE SODIUM 360 MG Tier 4 06/01/2014 ESOMEPRAZOLE INJ Tier 1 09/01/2014 NIACIN ER Tier 1 06/01/2014 ONFI TAB 10MG Tier 2 01/01/2015 CONSULT HEALTH CARE PROVIDER N/A XULANE Tier 1 09/01/2014
5 Reason for PENTOSTATIN INJ 10MG PILOPINE HS GEL 4% OP PREVPAC MIS PREZISTA TAB 400MG RAPAMUNE TAB 0.5MG REGONOL INJ 5MG/ML SOLARAZE GEL SORIATANE TOBI NEB 300/5ML NIPENT INJ 10MG Tier 4 07/01/2014 PILOCARPINE OPHTH SOLN Tier 1 07/01/2014 AMOXICILLIN CAP- CLARITHRO TAB- LANSOPRAZ CAP DR THERAPY PACK Tier 1 06/01/2014 PREZISTA TAB 800MG Tier 4 SIROLIMUS 0.5 MG TAB Tier 1 09/01/2014 CONSULT YOUR HEALTH CARE PROVIDER N/A 06/01/2014 DICLOFENAC SODIUM 3% GEL Tier 1 06/01/2014 ACITRETIN Tier 4 06/01/2014 TOBRAMYCIN NEB 300/5ML Tier 4 06/01/2014
6 TOBRA/NACL INJ 60/0.9 TRIZIVIR VFEND SUSP VIDAZA INJ 100MG VIRAMUNE XR TAB 400MG VIRAMUNE SUS 50MG/5ML ZEMPLAR CAP 1MCG, 2MCG ZEMPLAR CAP 4MCG ZYMAXID Reason for TOBRA/NACL INJ 80/0.9 Tier 2 ABACAVIR SULFATE- LAMIVUDINE- ZIDOVUDINE Tier 4 06/01/2014 VORICONAZOLE SUSP 40 MG/ML Tier 4 06/01/2014 AZACITIDINE INJ Tier 4 06/01/2014 NEVIRAPINE SR 24HR 400 MG Tier 1 09/01/2014 NEVIRAPINE SUSP 50 MG/5ML Tier 1 06/01/2014 PARICALCITOL 1 MCG, 2 MCG Tier 1 06/01/2014 PARICALCITOL 4 MCG Tier 4 06/01/2014 GATIFLOXACIN OPHTH SOLN 0.5% Tier 1 06/01/2014
7 Molina Medicare Options HMO is a Health Plan with a Medicare Contract. Enrollment in Molina Medicare Options depends on contract renewal. Molina Medicare Options Plus HMO SNP is a Health Plan with a Medicare Contract and a contract with the state Medicaid program. Enrollment in Molina Medicare Options Plus depends on contract renewal. This information is available for free in other languages. Please call our customer service number at (888) , TTY/TDD 711, 7 days a week, 8 a.m. - 8 p.m., local time. Esta información está disponible gratuitamente en otros idiomas. Por favor, comuníquese a nuestro número de teléfono para servicio al cliente al (888) , TTY/TDD 711, los 7 días de la semana, de 8:00 a.m. a 8:00 p.m., hora local. 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, provider network, premium and/or copayments/ co-insurance may change on January 1 of each year.
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