Upcoming Changes to Molina Dual Options Medicare-Medicaid Plan s Formulary
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- Aldous Morris
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1 Upcoming s to Molina Dual Options Medicare-Medicaid Plan s Formulary Molina Dual Options Medicare-Medicaid Plan may add or remove drugs from our formulary (preferred drug list) during the year. When changes are made, we will let you know about them at least 60 days before they occur. These changes include: Removing drugs from our formulary Adding prior authorization criteria Adding quantity limit restriction Adding step therapy restriction Moving a drug to a higher cost-sharing tier Sometimes we can t provide a 60 day notice. When certain changes are made, we act quickly to remove the drug from our preferred drug list. No notice is given when The FDA determines that a drug on our formulary is unsafe The drug s manufacturer removes the drug from the market The table below shows the changes that will be coming soon to our preferred drug list. These changes may impact you. Name of Affected COMBIVENT AEROSOL INHALER FLUOROPLEX 1% CREAM ASTRAMORPH LEVOTHROID Deletion of from Formulary Deletion of from Formulary Reason for Combivent INH has been discontinued and replaced with Combivent Respimat. As of 1/1/14, Combivent INH cannot be made, dispensed, or sold in the US. Medicare Will No Longer Cover COMBIVENT AER RESPIMAT Tier 2 01/01/2014 CARAC CREAM 0.5% Tier 2 01/01/2014 MORPHINE SUL INJ Tier 1 LEVOTHYROXINE Tier 1
2 Name of Affected ARICEPT TAB 23MG CAMPRAL TAB 333MG CYMBALTA DETROL LA DOXIL INJ 2MG/ML ELSPAR INJ 10000UNT EPIVIR HBV FREAMINE III INJ 8.5% HEPSERA TAB 10MG LEUKINE INJ 500 MCG Reason for DONEPEZIL 23 MG Tier 1 06/01/2014 ACAMPROSATE CALCIUM 333 MG Tier 1 06/01/2014 DULOXETINE HCL Tier 1 06/01/2014 TOLTERODINE TARTRATE SR Tier 1 06/01/2014 DOXORUBICIN HCL LIPOSOMAL INJ 2 MG/ML Tier 2 06/01/2014 CONSULT HEALTH CARE PROVIDER N/A LAMIVUDINE 100 MG Tier 1 06/01/2014 AMINOSYN II INJ 8.5% Tier 2 ADEFOVIR Tier 2 06/01/2014 LEUKINE INJ 250MCG Tier 2
3 Name of Affected LIDODERM MYFORTIC TAB 180MG MYFORTIC TAB 360MG NIASPAN ONTAK INJ 150/ML PREVPAC MIS PREZISTA TAB 400MG Reason for LIDOCAINE PATCH 5% Tier 1 06/01/2014 MYCOPHENOLATE SODIUM 180 MG Tier 1 06/01/2014 MYCOPHENOLATE SODIUM 360 MG Tier 2 06/01/2014 NIACIN ER Tier 1 06/01/2014 CONSULT HEALTH CARE PROVIDER N/A AMOXICILLIN CAP-CLARITHRO TAB-LANSOPRAZ CAP DR THERAPY PACK Tier 1 06/01/2014 PREZISTA TAB 800MG Tier 2 DICLOFENAC SODIUM 3% GEL Tier 1 06/01/2014 SOLARAZE GEL SORIATANE ACITRETIN Tier 2 06/01/2014 TOBI NEB 300/5ML TOBRAMYCIN Tier 2 06/01/2014
4 Name of Affected TOBRA/NACL INJ 60/0.9 TRIZIVIR VFEND SUSP VIDAZA INJ 100MG VIRAMUNE SUS 50MG/5ML ZEMPLAR CAP 1MCG, 2MCG ZEMPLAR CAP 4MCG ZYMAXID Reason for NEB 300/5ML TOBRA/NACL INJ 80/0.9 Tier 2 ABACAVIR SULFATE- LAMIVUDINE- ZIDOVUDINE Tier 2 06/01/2014 VORICONAZOLE SUSP 40 MG/ML Tier 2 06/01/2014 AZACITIDINE INJ Tier 2 06/01/2014 NEVIRAPINE SUSP 50 MG/5ML Tier 1 06/01/2014 PARICALCITOL 1 MCG, 2 MCG Tier 1 06/01/2014 PARICALCITOL 4 MCG Tier 2 06/01/2014 GATIFLOXACIN OPHTH SOLN 0.5% Tier 1 06/01/2014 Molina Dual Options Medicare-Medicaid Plan is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits
5 of both programs to enrollees. You can get this document in Spanish, or speak with someone about this information in other languages for free. Call (877) The call is free. Usted puede recibir esta información en otros idiomas gratuitamente. Llame al (877) Esta es una llamada gratuita. Limitations, copays, and restrictions may apply. For more information, call Molina Dual Options Member Services or read the Molina Dual Options Member Handbook. Benefits, List of Covered s, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.
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