Changes to the Johns Hopkins Advantage MD (PPO) Formulary Please retain this with your formulary

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Christina Lindsey
6 years ago
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1 s to the Johns Hopkins Advantage MD (PPO) Formulary Please retain this with your mulary s may have occurred since the printing of the Johns Hopkins Advantage MD (PPO) mulary. Medics added or removed from the mulary are listed below. This is not a complete list of all mulary drugs covered by the plan. For a complete listing, or if you need additional inm about the Johns Hopkins Advantage MD (PPO) mulary, please view our website at or call Customer Service at (TTY: 711), 24 hours a day, seven days a week. If you are a current member already taking the below drug(s) bee the effective date of the change, we will continue to cover the drug the remainder of the plan year as long as the drug continues to be medically necessary treating your condition and prescribed you by your prescriber, and was not removed safety reasons. The table below outlines changes to our mulary that may impact you. Name of Affected Cost- ABACAVIR SULFATE- LAMIVUDINE TAB Amlodipine besylate/olmesartan medoxomil Added to Tier 1 Ampicillin Inj 10gm APTIOM TAB 800MG Increased QL from 30 tabs / 30 days to 60 tabs / 30 days BEVESPI Added to Tier 3 QL (1 inhaler / 30 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, Johns Hopkins Advantage MD is a PPO plan with a Medicare contract. Enrollment in Johns Hopkins Advantage MD depends on contract renewal. The mulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. H3890_FormularyErrata_1015 Approved 1015

2 BRILINTA Moved from Tier 4 to Tier 3 Cost- Caziant Pak Cholestyramine Pow 4gm Lite Clindacin-P Pad 1% Daptomycin Inj 500Mg Diltiazem Cap 120mg, 180mg,and 300mg Cd DILTIAZEM CAP 360MG CD ELIQUIS Added to Tier 4 PA ENTRESTO HEPARIN SOD INJ 2000/ML and 2500/ML INVOKAMET XR TAB MG INVOKAMET XR TAB MG, MG, AND MG Moved from Tier 4 to Tier 3 and removed PA Added to Tier 3 QL (120 tabs / 30 Added to Tier 3 QL (60 tabs / 30 Heparin Sod Inj 1000/ml Tier 2 1/1/2017 Larissia Tab LEVALBUTEROL TARTRATE HFA Levoleucovor Inj 50mg MEDROXYPR AC INJ 150MG/ML QL (2 inhalers / 30 NM PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 2

3 MESALAMINE TAB 800MG DR Morgidox Cap 1x50mg Naloxone Inj 0.4mg/ml Cost- NAMZARIC Added to Tier 4 Nitroglycerin Subl Olmesartan Medoxomil/ Amlodipine/ Hydrochlorothiazide Olmesartan Medoxomil/ Hydrochlorothiazide ORFADIN CAP 20MG ORKAMBI TAB Pot Citrate Tab 1620mg Quetiapine Tab 50mg Er Quetiapine Tab 150mg and 200mg Er Quetiapine Tab 300mg and 400mg Er Added to Tier 1 Added to Tier 1 QL (120 tabs every 30 QL (30 tabs every 30 QL (60 tabs every 30 RELPAX TAB Added to Tier 3 QL (12 tabs / 30 Roxicet Sol 5-325/5 Oxycodone w/ Acetaminophe n Soln Tier 2 1/1/2017 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 3

4 Roxicet Tab 5-325mg TAXOTERE INJ 80MG/4ML Valganciclovir Sol 50mg/ml Oxycodone w/ Acetaminophe n Tab mg Cost- Tier 2 1/1/2017 Yuvafem Tab 10mcg ZEPATIER TAB MG Adriamycin Inj /1/2017 A-hydrocort SOLU- CORTEF 250MG Tier 4 3/1/2017 Alyacen 1/ /1/2017 Aprepitant ARISTADA QL (1 syringe / 28 CERVARIX INJ Docetaxel Inj 80mg/4ml Ergotamine w/ Caffeine /1/ /1/2017 GARDASIL INJ Tier 3 3/1/ /1/ /1/2017 Ethynodiol Tab /1/2017 Ezetimibe /1/2017 Femynor 28 day /1/2017 Levetiracetam Inj /1/2017 Lopinavir-Ritonavir /1/2017 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 4

5 Lorcet Hd Tab mg QL (360 tabs / 30 Cost /1/2017 Nifedical XL /1/2017 Norethindrone Acet & Eth Estra /1/2017 Nyata /1/2017 Oseltamivir Phosphate PLASMA-LYTE INJ 56/D5W /1/2017 NORMOSOL -R INJ /D5W Tier 4 3/1/2017 Rasagiline Mesylate /1/2017 Stavudine Soln 1Mg/Ml ZERIT SOL 1MG/ML Tier 5 3/1/2017 TIGECYCLINE /1/2017 TILIA FE /1/2017 VASCEPA CAP 0.5GM RUBRACA SELZENTRY TAB 25MG SELZENTRY TAB 75MG Added to Tier /1/ /1/2017 Added to Tier /1/ /1/2017 BROMSITE Added to Tier /1/2017 Desvenlafaxine Succinate Tab Docetaxel Inj 140Mg/7Ml QL (30 tabs / /1/2017 Docetaxel Inj 80Mg/4Ml Tier 5 5/1/2017 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 5

6 LINZESS 72Mcg CAPS Piperacillin/ Tazobactam Methergine 0.2Mg Tabs Methylpr SS Inj 125Mg Added to Tier 3 QL (30 tabs / 30 Cost /1/ /1/ /1/ /1/2017 VEMLIDY /1/2017 VITEKTA TAB ASACOL HD TAB 800MG AZILECT TAB Busulfan Cafergot Tab 1-100Mg EPZICOM TAB GAMMAPLEX INJ 10/100ML, 20/200ML, 5G/50ML Ilotycin Oin Op TIVICAY TAB (25MG, 50MG) OR ISENTRESS TAB Mesalamine 800Mg Dr Tab Rasagiline Mesylate Tab Tier 5 5/1/ /1/2017 Ergotamine W/ Caffeine Tab Mg Abacavir Sulfate- Lamivudine Tab Mg Tier 5 6/1/ /1/2017 Erythromycin Ophth Oint Tier 1 6/1/2017 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 6

7 LEVOLEUCOVORI N CALCIUM SOLR 175MG Magnesium Sulfate in D5W NILANDRON TAB 150MG NITROSTAT SL TAB SEROQUEL XR TAB TAMIFLU CAP NM Cost /1/ /1/2017 Tazarotene Cream PA VAGIFEM TAB 10MCG XOPENEX HFA AER ZETIA TAB 10MG Docetaxel Conc 200Mg/10Ml ESBRIET TAB Ezetimibe- Simvastatin Tabs HERCEPTIN INJ 150MG Added to Tier 1 QL (30 tabs / 30 KISQALI ZEJULA Nilutamide Tab 150Mg Nitroglycerin Sl Tab Quetiapine Er Tab Oseltamivir Phosphate Cap Tier 5 6/1/ /1/2017 Yuvafem Tab 10Mcg Levalbuterol Aer 45/Act Ezetimibe Tab 10Mg PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 7

8 ZYTIGA 500MG ALUMBRIG AMINOSYN II INJ 7% Atomoxetine Hcl 10Mg, 18Mg, 25Mg Atomoxetine Hcl 40Mg Atomoxetine Hcl 60Mg, 80Mg, 100Mg, DOCETAXEL INJ 200MG/20 QL (120 caps / 30 QL (60 caps / 30 QL (30 caps / 30 KISQALI FEMARA Klor-Con Pow 20Meq Olopatadine Sol 0.2% POTASSIUM CHLORIDE PACK RUBRACA TAB 250MG Cost- AMINOSYN- PF INJ 7%, AMINOSYN- HBC INJ 7% Tier 4 8/1/2017 DOCETAXE L INJ 160/16ML Tier 5 8/1/2017 POTASSIUM CHLORIDE PACK Tier 2 8/1/2017 RYDAPT XATMEP Added to Tier 4 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 8

9 ARISTADA INJ 1064MG CLINDMYC/NAC INJ 300/50ML, 600/50ML, 900/50ML QL (1 syringe / 56 Cost /1/2017 Added to Tier /1/2017 DIASTAT ACUDIAL Added to Tier /1/2017 DIASTAT PEDIATRIC Added to Tier /1/2017 Doxorubicin Inj 10Mg ISENTRESS HD TAB 600MG LEVETIRACETAM IV LORTAB TAB MG LORTAB TAB 5-325MG LORTAB TAB Moxifloxacin Sol 0.5% /1/ /1/2017 Moved from Tier 4 to Tier /1/2017 HYDROCOD ONE- ACETAMIN OPHEN TAB MG HYDROCOD ONE- ACETAMIN OPHEN TAB MG HYDROCOD ONE- ACETAMIN OPHEN TAB MG Tier 2 9/1/2017 Tier 2 9/1/2017 Tier 2 9/1/ /1/2017 PICATO GEL Added to Tier /1/2017 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 9

10 RESTASIS MULTIDOSE Added to Tier 3 QL (1 bottle / 30 Cost /1/2017 SELZENTRY SOL /1/2017 TESTOSTERONE SOL 30MG/ACT ZAZOLE CREAM 0.8% QL PA (440 ml / 30 Amnesteem Cap PA CASPOFUNGIN ACETATE Clindmax Gel 1% Desogestrel & Ethinyl Estradiol /1/2017 TERCONAZ OLE CREAM 0.8% Tier 2 9/1/ /1/ /1/2017 Eletriptan Tabs QL (12 tabs / 30 HAEGARDA Clindamycin Gel 1% Tier 2 10/1/ /1/ /1/ /1/2017 Isibloom 28 Day /1/2017 MENHIBRIX INJ Molindone Tab Hcl 5mg MENVEO INJ Risperidone Tab Tier 3 10/1/2017 Tier 2 10/1/2017 Prasugrel Hcl /1/2017 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 10

11 RITUXAN HYCELA Scopolamine Patch Added to Tier 4 QL PA (10 patches / 30 PA if 65 years and older AUSTEDO 6MG QL (60 tabs / 30 AUSTEDO 9MG AND 12MG QL (120 tabs / 30 EPCLUSA Estradiol Vaginal Tab 10Mcg Gentamicin In Saline Inj 0.9 and 1.4 Mg/Ml Cost /1/ /1/2017 HARVONI HYSINGLA ER 20MG, 30MG, 40MG, AND 60MG HYSINGLA ER 80MG, 100MG, AND 120MG Added to Tier 3 QL (60 tabs/ 30 Added to Tier 3 QL (30 tabs/ 30 IDHIFA MAVYRET NERLYNX Tier 2 11/1/2017 PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 11

12 Sodium Phenylbutyrate Tabs Cost- Triklo Vigabatrin Powder Pack QL (180 packets / 30 VIRAMUNE SUSP Added to Tier 4 VOSEVI PA = Prior Authoriz, QL = Quantity Limits, ST = Step Therapy, LA = Limited Access, 12

Changes to the Johns Hopkins Advantage MD (PPO) Formulary Please retain this with your formulary

Changes to the Johns Hopkins Advantage MD (PPO) Please retain this with your formulary Changes may have occurred since the printing of the Johns Hopkins Advantage MD (PPO) formulary. Medications added