Notice of Mid-Year Changes to 2018 Paramount Enhanced Formulary. Reason for
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1 Notice of Mid-Year s to 2018 Paramount Enhanced Formulary Paramount Elite (HMO) 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 to a higher costsharing tier, we will notify you of the change at least 60 days before the date 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, we may immediately remove the drug from our formulary and notify you as soon as possible. The table below outlines upcoming changes to our formulary that may impact you. Name of Affected AFREZZA POWDER 4 (60) & 8 (30) UNIT AMINOSYN II INJ 7% BROMFENAC OPHTH SOLN 0.09% BUDESONIDE SUSP 32MCG BUPHENYL TAB 500MG CEFTIBUTEN CAP 400MG AFREZZA POWDER 4 (30) & 8 (60) UNIT Tier 4 5/1/2018 AMINOSYN-HBC INJ 7% Tier 4 3/1/2018 BROMFENAC SODIUM OPHTH SOLN 0.09% (ONCE-DAILY) Tier 2 3/1/2018 FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT Tier 2 3/1/2018 SODIUM PHENYLBUTYRATE TAB 500 MG Tier 5 6/1/2018 CEFDINIR CAP 300MG Tier 2 3/1/2018
2 CEFTIBUTEN SUSP 180/5ML CLINDAMAX GEL 1% COPAXONE INJ 40MG/ML COREG CR CAP DIDANOSINE CAP 125 MG DOCEFREZ INJ 20MG EFFIENT TAB ESTRACE VAGINAL CREAM 0.01% FORTAZ IN D5W INJ 1GM/50ML, 2GM/50ML FORTAZ INJ 500MG GAVILYTE-H KIT GENTAMICIN INJ 10MG/ML GRASTEK CEFDINIR SUS 250/5ML Tier 2 3/1/2018 CLINDAMYCIN PHOSPHATE GEL 1% Tier 2 3/1/2018 GLATIRAMER INJ 40MG/ML Tier 5 6/1/2018 CARVEDILOL PHOSPHATE ER 24HR CAP Tier 2 6/1/2018 VIDEX EC CAP 125MG Tier 4 5/1/2018 DOCETAXEL INJ 80MG/4ML Tier 5 3/1/2018 PRASUGREL TAB Tier 2 6/1/2018 ESTRADIOL VAGINAL CREAM 0.01% Tier 2 6/1/2018 CEFTAZIDIME INJ Tier 2 3/1/2018 CEFTAZIDIME INJ Tier 2 3/1/2018 GAVILYTE-G SOL Tier 2 3/1/2018 GENTAMICIN INJ 40MG/ML Tier 2 5/1/2018 CONSULT YOUR MEDICARE WILL NO HEALTH CARE LONGER COVER PROFESSIONAL 4/1/2018
3 ISTALOL OPHTH SOLN 0.5% KETODAN AEROSOL 2% LAMOTRIGINE ODT KIT 25/50/100MG LAMOTRIGINE ODT KIT 25/50MG LAMOTRIGINE ODT KIT 50/100MG LIALDA TAB 1.2GM LOKARA LOTION 0.05% LORTAB TAB MG LORTAB TAB 5-325MG LORTAB TAB MENOMUNE INJ A/C/Y/W MORPHINE SULATE INJ 15MG/ML TIMOLOL MALEATE OPHTH SOLN 0.5% (ONCE-DAILY) Tier 2 6/1/2018 KETOCONAZOLE FOAM 2% Tier 2 3/1/2018 LAMOTRIGINE TAB Tier 1 3/1/2018 LAMOTRIGINE TAB Tier 1 3/1/2018 LAMOTRIGINE TAB Tier 1 3/1/2018 MESALAMINE TAB 1.2GM Tier 2 6/1/2018 DESONIDE LOTION 0.05% Tier 2 3/1/2018 ACETAMINOPHEN TAB MG Tier 2 3/1/2018 ACETAMINOPHEN TAB MG Tier 2 3/1/2018 ACETAMINOPHEN TAB MG Tier 2 3/1/2018 MENACTRA INJ Tier 3 3/1/2018 MORPHINE SULFATE IV SOLN PF 10 MG/ML Tier 4 3/1/2018
4 NECON TAB 10/11-28 NUVESSA GEL 1.3% NYATA PRIMSOL SOLN 50MG/5ML RAGWITEK RELPAX TAB RENVELA PAK RENVELA TAB 800MG REYATAZ CAP SABRIL PACK 500MG SUMAVEL DOSE INJ 4MG/0.5ML SUSTIVA CAP 200MG SUSTIVA CAP 50MG NECON TAB 7/7/7 Tier 2 3/1/2018 MEDICARE WILL NO METRONIDAZOLE LONGER COVER VAGINAL GEL 0.75% Tier 2 3/1/2018 NYSTATIN POW Tier 2 4/1/2018 MEDICARE WILL NO TRIMETHOPRIM TAB LONGER COVER 100MG Tier 1 3/1/2018 CONSULT YOUR MEDICARE WILL NO HEALTH CARE LONGER COVER PROFESSIONAL 4/1/2018 ELETRIPTAN TAB Tier 2 6/1/2018 SEVELAMER CARBONATE PACKET Tier 2 6/1/2018 SEVELAMER CARBONATE TAB 800 MG Tier 2 6/1/2018 ATAZANAVIR CAP Tier 5 6/1/2018 VIGABATRIN POWDER PACK 500MG Tier 5 6/1/2018 SUMATRIPTAN INJ 4MG/0.5ML Tier 2 5/1/2018 EFAVIRENZ CAP 200 MG Tier 5 6/1/2018 EFAVIRENZ CAP 50 MG Tier 2 6/1/2018
5 SYNALGOS-DC CAP TAMIFLU SUSP 6MG/ML TRANSDERM-SC PATCH 1.5MG TRETIN-X CRE 0.075% TRIKLO CAP 1GM TRISENOX SOL 10MG/10ML VIGAMOX DROPS 0.5% XYLON TAB MG ZINACEF INJ 750MG ACETAMINOPHEN- CAFFEINE- DIHYDROCODEINE CAP MG Tier 2 5/1/2018 OSELTAMIVIR PHOSPHATE SUSP 6 MG/ML Tier 2 6/1/2018 SCOPOLAMINE PATCH Tier 4 6/1/2018 TRETINOIN CREAM 0.05% Tier 2 3/1/2018 OMEGA-3-ACID ETHYL ESTERS CAP 1 GM Tier 2 3/1/2018 TRISENOX INJ 12MG/6ML Tier 5 5/1/2018 MOXIFLOXACIN HCL OPHTH SOLN 0.5% Tier 2 6/1/2018 IBUPROFEN TAB MG Tier 2 3/1/2018 ZAMICET SOLN MG ZAZOLE CREAM 0.8% ZIAGEN SOLN 20MG/ML ACETAMINOPHEN SOLN MG/15ML Tier 2 3/1/2018 TERCONAZOLE VAGINAL CREAM 0.8% Tier 2 3/1/2018 ABACAVIR SOLN 20MG/ML Tier 2 6/1/2018 CEFUROXIME INJ 750MG Tier 2 3/1/2018
6 ZOLEDRONIC INJ 4MG ZOLEDRONIC INJ 4MG/5ML Tier 2 3/1/2018
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