Upcoming Changes to Molina Medicare Options HMO Molina Medicare Options Plus HMO SNP s Formulary
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- Malcolm Quinn
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1 Upcoming s to Molina Medicare Options HMO 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. Name of Affected COMBIVENT AEROSOL INHALER FLUOROPLEX 1% CREAM ASTRAMORPH LEVOTHROID ARICEPT TAB 23MG Reason for Deletion of from Formulary 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. COMBIVENT AER RESPIMAT Tier 3 01/01/2014 Deletion of Medicare Will No Longer CARAC CREAM from Formulary Cover 0.5% Tier 3 01/01/2014 MANUFACTURER MORPHINE SUL DISCONTINUATION INJ Tier 1 MANUFACTURER DISCONTINUATION LEVOTHYROXINE Tier 1 DONEPEZIL 23 MG Tier 1 06/01/2014 CAMPRAL TAB 333MG ACAMPROSATE CALCIUM 333 MG Tier 1 06/01/2014 CYMBALTA DULOXETINE HCL Tier 1 06/01/2014
2 DETROL LA DOXIL INJ 2MG/ML ELSPAR INJ 10000UNT EPIVIR HBV FREAMINE III INJ 8.5% HEPSERA TAB 10MG LEUKINE INJ 500 MCG LIDODERM Reason for TOLTERODINE TARTRATE SR Tier 1 06/01/2014 DOXORUBICIN HCL LIPOSOMAL INJ 2 MG/ML Tier 4 06/01/2014 MANUFACTURER CONSULT HEALTH DISCONTINUATION CARE PROVIDER N/A LAMIVUDINE 100 MG Tier 1 06/01/2014 MANUFACTURER AMINOSYN II INJ DISCONTINUATION 8.5% Tier 3 ADEFOVIR Tier 4 06/01/2014 MANUFACTURER LEUKINE INJ DISCONTINUATION 250MCG Tier 4 LIDOCAINE PATCH 5% Tier 1 06/01/2014 MYFORTIC TAB 180MG MYCOPHENOLATE SODIUM 180 MG Tier 1 06/01/2014 MYFORTIC TAB MYCOPHENOLATE Tier 4 06/01/2014
3 360MG NIASPAN PREVPAC MIS PREZISTA TAB 400MG SOLARAZE GEL SORIATANE TOBI NEB 300/5ML TOBRA/NACL INJ 60/0.9 Reason for SODIUM 360 MG NIACIN ER Tier 1 06/01/2014 AMOXICILLIN CAP-CLARITHRO TAB-LANSOPRAZ CAP DR THERAPY PACK Tier 1 06/01/2014 MANUFACTURER DISCONTINUATION PREZISTA TAB 800MG Tier 4 DICLOFENAC SODIUM 3% GEL Tier 1 06/01/2014 ACITRETIN Tier 4 06/01/2014 MANUFACTURER DISCONTINUATION TOBRAMYCIN NEB 300/5ML Tier 4 06/01/2014 TOBRA/NACL INJ 80/0.9 Tier 2 ABACAVIR SULFATE- LAMIVUDINE- ZIDOVUDINE Tier 4 06/01/2014 TRIZIVIR VFEND SUSP VORICONAZOLE Tier 4 06/01/2014
4 VIDAZA INJ 100MG VIRAMUNE SUS 50MG/5ML ZEMPLAR CAP 1MCG, 2MCG ZEMPLAR CAP 4MCG ZYMAXID Reason for SUSP 40 MG/ML AZACITIDINE INJ Tier 4 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 1 06/01/2014 GATIFLOXACIN OPHTH SOLN 0.5% Tier 1 06/01/2014 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.
5 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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