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- Sherilyn Bridges
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50 Addendums to Preferred Care Partners 2013 Formulary Effective 1/2013 Drug Name Drug Tier Description of Change abacavir 300mg 2 Added, generic for Ziagen atorvastatin 1 Moved from Tier 2 to Tier 1 candesartan cilexetil hydrochlotothiazide 16mg/12.5mg, 32/12.5mg, 32/25mg 2 Added, generic for Atacand HCT diclofenac sodium misoprostol 50mg/0.2mg, 75mg/0.2mg 2 Added, generic for Arthrotec entacapone tab 200mg 1 Added, generic for Comtan fenofibrate 145mg, 48mg 2 Added, generic for Tricor griseofulvin 125mg, 250mg 1 Added, generic for Gris-Peg hydrochlorothiazide valsartan 12.5mg/160mg, 25mg/160mg, 12.5mg/320mg, 25mg/320mg 1 Added, generic for Diovan 12.5mg/80mg levalbuterol 0.21mg/ml, 0.103mg/ml 2 Added, generic for Xopenex metformin hydrochloride pioglitazone 500mg/15mg, 850mg/15mg 2 Added, generic for ActosPlusMet modafinil 100mg, 200mg 2 Added, generic for Provigil montelukast 1 Added, generic for Singulair nevirapine oral suspension 10mg/ml 2 Added, generic for Viramune pantoprazole 1 Moved from Tier 2 to Tier 1 pioglitazone 15mg, 30mg, 45mg 2 Added, generic for Actos quinine sulfate 324mg 2 Added, generic for Qualaquin tiagabine 2mg, 4mg 2 Added, generic for Gabitril tolterodine tartrate 1mg, 2mg 2 Added, generic Detrol Effective 2/2013 Drug Name Drug Tier Description of Change ACTOPLUS MET 3 Removing Brand from Formulary Effective 5/1, generic for metformin hydrochloride pioglitazone covered on Tier 2. ACTHAR 80UNT/ML 4 Added, with Prior Authorization ACTOS 3 Removing Brand from Formulary Effective 5/1, generic pioglitazone covered on Tier 2. anastrozole 1 Moved from Tier 2 to Tier 1 ANDROID 3 Added, with Prior Authorization ARTHROTEC 3 Removing Brand from Formulary Effective 5/1, generic diclofenac sodium misoprostol covered on Tier 2 ATACAND 3 Removing Brand from Formulary Effective 5/1, generic candesartan cilexetil hydrochlorothiazide covered on Tier 2. AUBAGIO 7MG/14MG 4 Added, with Prior Authorization bicalutamide 1 Moved from Tier 2 to Tier 1 brimonidine tartrate ophthalmic solution 1.5mg/ml 1 Added CHANTIX STARTING MONTH PAK 3 Removed Quantity Limit Added, with Prior Authorization to determine Part 2 CIALIS 2.5MG 5MG D clopidogrel 1 Moved from Tier 2 to Tier 1 clozapine 200mg 1 Added COMTAN 2 Removing Brand from Formulary Effective 5/1, generic entacapone covered on Tier 1 DETROL 3 Removing Brand from Formulary Effective 5/1, generic tolterodine tartrate covered on DIAZEPAM INTENSOL 5MG/ML 1 Moved from Tier 3 to Tier 1 DIAZEPAM SOLN 1MG/ML 1 Moved from Tier 3 to Tier 1 DIOVAN 2 Removing Brand from Formulary Effective 5/1, generic hydrochlorothiazide valsartan covered on Tier 1 donepezil hcl 10mg/ 5mg, 75mg 1 Moved from Tier 2 to Tier 1 ESTRADIOL INJECTABLE 10MG/ ML, 20 Added MG/ML, 40MG/ML 3 fenofribrate 145mg/ 48mg 2 Added GABITRIL 3 Removing Brand from Formulary Effective 5/1, generic tiagabine covered on Tier 2 GRIS-PEG 2 Removing Brand from Formulary Effective 5/1, generic griseofulvin covered on Tier 1
51 Addendums to Preferred Care Partners 2013 Formulary Cont'd Effective 2/2013 Drug Name Drug Tier Description of Change KLOR-CON 15 MEQ 1 Added 3 Added, with Quantity Limit of 240 tablets for 30 days LATUDA letrozle 1 Moved from Tier 2 to Tier 1 leucovorin 10MG/15MG 1 Added levalbuterol 2 Removed Quantity Limit LORAZEPAM INTENSOL 2MG/ML 1 Moved from Tier 3 to Tier 1 LYRICA ORAL SOLUTION 3 Added, with Quantity Limit of 960ML for 30 days meperidine hydrochloride 100mg/ml 3 Added 24hr nisoldipine extended release tablet 17mg/ 1 Added 25.5mg/ 34mg/ 8.5mg omeprazole 40mg 1 Added PACERONE 1 Added phenytoin sodium 200mg /300mg 1 Added PICATO GEL 3 Added, with Prior Authorization potassium chloride injectable solution 3 Added PROVIGIL 3 Removing Brand from Formulary Effective 5/1, generic modafinil covered on Tier 2 QUALAQUIN 3 Removing Brand from Formulary Effective 5/1, generic quinine sulfate covered on Tier 2 SINGULAIR 3 Removing Brand from Formulary Effective 5/1, generic montelukast covered on Tier 1 TRICOR 3 Removing Brand from Formulary Effective 5/1, generic fenofibrate covered on Tier 2 VIMPAT 3 Removed Quantity Limit VIRAMUNE 3 Removing Brand from Formulary Effective 5/1, generic nevirapine covered on Tier 2 voriconazole 200mg/50mg 2 Added XELJANZ 4 Added, with Prior Authorization XOPENEX 3 Removing Brand from Formulary Effective 5/1, generic levalbuterol covered on Tier 2 ZIAGEN 3 Removing Brand from Formulary Effective 5/1, generic abacavir covered on Tier 2 Effective 03/2013 Drug Name Drug Tier Description of Change COMETRIQ KIT/20MG 4 Added, with Prior Authorization ELELYSO 200 UNITS SOLR 4 Added, with Prior Authorization guanidine hcl 125mg tabs 1 Added ICLUSIG 15MG, 45MG TABS 4 Added, with Prior Authorization JUVISYNC 50MG/10MG, 50MG/20MG, Added, with Quantity Limit of 30 tablets for 30 days 50MG/40MG, 100MG/10MG, 100MG/20MG, 100MG/40MG TABS 2 JUXTAPID 5MG, 10MG, 20MG CAPS 4 Added, with Prior Authorization LATUDA 120MG TABS 3 Added, with Step Therapy and Quantity Limit of 30 tablets for 30 days pantoprazolam sodium 40mg solr 3 Added PERJETA 420MG/14ML SOLN 4 Added, with Prior Authorization phenytoin 50mg chew 1 Added PREZISTA 800MG TABS 4 Added PROMACTA 25MG TABS 4 Added, with Prior Authorization and Quantity Limit 90 tablets for 30 days. quinine sulfate 324mg caps 2 Added, with Quantity Limit of 126 tablets for 180 days stavudine 1mg/ml solr 2 Added SYNRIBO 3.5MG SOLR 4 Added, with Prior Authorization valsartan/hctz 12.5mg/80mg, 12.5mg/160mg, 1 Added, with Step Therapy, and with a Quantity Limit of 60 tablets for 30 days 25mg/160mg, 12.5mg/320mg, 25mg/320mg ZALTRAP 100MG/4ML SOLN 4 Added, with Prior Authorization
52 Addendums to Preferred Care Partners 2013 Formulary Effective 4/2013 Drug Name Drug Tier Description of Change augmented betamethasone dipropionate gel 1 Added bupropion hcl xl 150mg, 300mg 2 Added, with Quantity Limit of 60 tablets for 30 clindamycin hcl 75mg caps 1 Added cyclosporine modified 25mg 2 Added, with Prior Authorization Added, with Quantity Limit of 180 tablets for 30 days 3 DELZICOL 400MG enoxaparin sodium 300mg/3ml 1 Added, with Prior Authorization KORLYM 300MG 4 Added, with Prior Authorization mafenide acetate 5% pack 2 Added metformin hcl er 1000mg 1 Added, with Step Therapy misoprostol 100mcg 1 Added montelukast sodium 4mg, pack 1 Added, with Quantity Limit 30 tablets for 30 days Added, with a Quantity Limit of 30 tablets for 30 days 1 montelukast sodium 4mg, 5mg, 10mg Moved from Tier 2 to Tier 1 NEXIUM 2.5MG, 5MG, 10MG 3 Added, with Step Therapy, and Quantity Limit of 30 tablets for 30 days POMALYST 1MG, 2MG, 3MG, 4MG CAPS 4 Added, with Prior Authorization PRUDOXIN 2 Added, with Quantity Limit 45 GM for 30 days UCERIS 9MG 4 Added, with Prior Authorization Effective 5/2013 Drug Name Drug Tier Description of Change ABILIFY 1MG/ML, 9.75MG/ML 3 Removed Quantity AFINITOR 5MG 4 Quantity Limit Increased 90 tablets for 30 days AFINITOR 10MG, 7.5MG tabs 4 Quantity Limit Increased 60 tablets for 30 days ALINIA 500MG TABS 3 Removed Quantity Limit ALINIA 100MG/5ML SUSR 3 Removed Quantity Limit amphetamine/dextroamphetamine 5mg, 1 Removed Quantity Limit 7.5mg, anastrozole 1 Removed Quantity Limit ASACOL 3 Removed Quantity Limit ATACAND 16MG TABS 3 Quantity Limit Increased 60 tablets for 30 days AVANDARYL 2 Removed Quantity Limit AZILECT 3 Removed Quantity Limit BANZEL 200MG, 400MG TABS 3 Removed Quantity Limit BENICAR 5MG TABS 2 Quantity Limit Increased 60 tablets for 30 days bicalutamide 50mg tabs 1 Removed Quantity Limit bupropion hcl xl 300mg tb 24 2 Removed Quantity Limit bupropion hcl xl 150mg tb 25 2 Quantity Limit Increased 90 tablets for 30 days clopidogrel 1 Removed Quantity Limit COREG CR 10MG, 20MG, 40MG,80MG CP 24 3 Removed Quantity Limit DELZICOL 400MG 3 Removed Quantity Limit DENAVIR 1% CREA 2 Removed Quantity Limit DIOVAN 320 MG TABS 2 Removed Quantity Limit ERIVEDGE 150mg 4 Removed Quantity Limit escitalopram oxalate 5mg/5ml soln 2 Quantity Limit Increased 72ml for 30 days etodolac 300mg caps 1 Added FANAPT TITRATION PACK 3 Removed Quantity Limit fluticasone propianate 50mcg/act susp 1 Removed Quantity Limit GLEEVEC 100MG, 400MG TABS 4 Removed Quantity Limit INLYTA 1MG, 5MG TABS 4 Removed Quantity Limit JANUMET XR 500MG;50MG, 1000MG;50MG 2 Quantity Limit Increased 60 tablets for 30 days KADCYLA 100MG SOLR 4 Added, with Prior Authorization ketorolac tromethamine tabs 1 Removed Quantity Limit KYNAMRO 200MG/ML SOLN 4 Added, with Prior Authorization leflunomide 20mg tabs 2 Quantity Limit Increased 42 tablets for 30 days letrozole tabs 1 Removed Quantity Limit
53 Addendums to Preferred Care Partners 2013 Formulary Cont'd Effective 5/2013 Drug Name Drug Tier Description of Change levalbuterol hcl 0.31mg/3ml, 0.63mg/3ml 2 Added, with Prior Authorization LYRICA 300MG, 225MG CAPS 3 Removed Quantity Limit MICARDIS 80MG 2 Quantity Limit Increased 60 tablets for 30 days MINITRAN 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR PT24 2 Removed Quantity Limit MULTAQ 400MG TABS 3 Removed Quantity Limit NAMENDA 10MG/5ML SOLN 2 Removed Quantity Limit NAMENDA 5MG TABS 2 Quantity Limit Increased 90 tablets for 30 days NASONEX 50MCG/ACT SUSP 3 Removed Quantity Limit NIASPAN 500MG, 750MG, 1000MG TBCR 3 Removed Quantity Limit olanzapine 10mg solr 2 Removed Quantity Limit oxadrolone 2.5mg tb24 2 Removed Quantity Limit oxybutynin chloride er 10mg tbs 1 Removed Quantity Limit oxycodone/ibuprofen 400mg, 5mg 1 Removed Quantity Limit paroxetine hcl 30mg, 40mg, 10mg, 20mg tabs 1 Removed Quantity Limit paroxetine hcl er 12.5mg, 25mg tb24 2 Removed Quantity Limit PREMARIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, MG TABS Removed Quantity Limit PREMPHASE TABS 2 Removed Quantity Limit PREMPRO TABS 2 Removed Quantity Limit PREZISTA 100MG/ML SUSP 3 Added PROMACTA 25MG TABS 4 Removed Quantity Limit quetiapine fumarate 25mg, 50mg, 200mg tabs 2 Removed Quantity Limit RANEXA 500MG, 1000MG TB12 3 Removed Quantity Limit REGRANEX 0.01% GEL 4 Removed Quantity Limit RESTASIS 0.05% EMUL 2 Removed Quantity Limit REVLIMID 25MG CAPS 4 Removed Quantity Limit RHINOCORT AQUA 32MCG/ACT SUSP 3 Removed Quantity Limit RISPERDAL CONSTA 25MG, 37.5MG, 50MG, 3 Removed Quantity Limit RISPERIDONE 4MG TABS 2 Removed Quantity Limit SENSIPAR 30MG TABS 2 Removed Quantity Limit SENSIPAR 60MG, 90MG TABS 4 Removed Quantity Limit SEROQUEL XR 50MG, 200MG TB 24 3 Quantity Limit Increased 90 tablets for 30 days SEROQUEL XR 150MG TB 24 3 Quantity Limit Increased 60 tablets for 30 days SIGNIFOR 0.3MG/ML, 0.6MG/ML, 0.9MG/ML SOLN 4 Added, with Prior Authorization SPRYCEL 50MG TABS 4 Removed Quantity Limit SPRYCEL 100MG TABS 4 Quantity Limit Increased 60 tablets for 30 days sumatriptan succinate 25mg, 50mg tabs 2 Quantity Limit Increased 18 tablets for 30 days sumatriptan succinate 6mg/0.5ml soln 2 Quantity Limit Increased 12ml for 30 days SUTENT 12.5MG CAPS 4 Quantity Limit Increased 90 capsules for 30 days TARCEVA 25MG TABS 4 Quantity Limit Increased 60 tablets for 30 days TARGRETIN 1% GEL 4 Removed Quantity Limit TARZORAC 0.1%, 0.05%, GEL 3 Removed Quantity Limit TARZORAC 0.1%, 0.05%, CREAM 3 Removed Quantity Limit THALOMID 50MG, 100MG, 150MG, 200MG 4 Removed Quantity Limit CAPS tolterodine tartrate 1mg tabs 2 Removed Quantity Limit TRAVATAN Z 0.004% SOLN 3 Removed Quantity Limit triamcinolone acetonide 55mcg/act inha 2 Removed Quantity Limit TYZEKA 600MG TABS 4 Removed Quantity Limit valacyclovir hcl 500mg tabs 2 Quantity Limit Increased 67 tablets for 30 days valacyclovir hcl 1000mg tabs 2 Quantity Limit Increased 33 tablets for 30 days valsartan/hydrochlorothiazide 12.5mg;80mg, 12.5mg;160mg, 25mg;160mg, 12.5mg;320mg, 1 Removed Quantity Limit 25mg;320mg tabs venlafaxine hcl er 75mg cp 24 3 Quantity Limit Increased 90 capsules for 30 days venlafaxine hcl er 75mg tb 24 2 Quantity Limit Increased 90 tablets for 30 days VIMPAT 50MG, 100MG, 150MG, 200MG 3 Removed Quantity Limit zaleplon 10mg caps 1 Quantity Limit Increased 60 tablets for 30 days zoledronic acid 4mg/5ml conc 4 Added, with Prior Authorization, and Quantity Limit of 10ml for 30 days ZONALON 5% CREAM 3 Removed Quantity Limit
54 Addendums to Preferred Care Partners 2013 Formulary Effective 6/2013 Drug Name Drug Tier Description of Change ABILIFY MAINTENA 300MG SUSR 4 Added, with Step Therapy acebutolol hcl 200mg, 400mg caps 1 Removed Step Therapy ACTONEL 5MG, 35MG, 150MG TABS 2 Removed Step Therapy alendronate sodium 5mg, 10mg, 40mg, 35mg, 1 Removed Step Therapy 70mg tabs ATACAND 4MG, 8MG, 16MG, 32MG TABS 3 Removed Step Therapy atenolol 25mg, 50mg, 100mg, tabs 1 Removed Step Therapy atorvastatin calcium 10mg 20mg, 40mg, 1 Removed Step Therapy 80mg tabs BENICAR 5MG, 20MG, 40MG TABS 2 Removed Step Therapy BENICAR HCT 12.5MG;20MG, 12.5MG;40MG, 25MG;40MG TABS 2 Removed Step Therapy betaxolol hcl 10mg, 20mg tabs 1 Removed Step Therapy bisoprolol fumarate 5mg, 10mg tabs 1 Removed Step Therapy candesartan cilexetil/ hydrochlorothiazide 16mg;12.5mg, 32mg;12.5mg, 32mg;25mg 2 Removed Step Therapy carvedilol 3.125mg, 6.25mg, 12.5mg, 25mg tabs 1 Removed Step Therapy COREG CR 10MG, 20MG, 40MG, 5MG TABS 2 Removed Step Therapy CREON UNIT, UNIT, 3 Added UNIT CPEP CRESTOR 10MG, 20MG, 40MG, 5MG TABS 2 Removed Step Therapy CYSTARAN 0.44% SOLN 4 Added desvenlafaxine er 100mg, 50mg tb24 3 Added diltiazem er 100mg, 50mg tb24 3 Added DIOVAN 80MG, 160MG, 320MG, 40MG TABS 2 Removed Step Therapy entacapone 200mg tabs 1 Added EXFORGE 10MG;160MG, 10MG;320MG, 5MG;160MG, 5MG;320MG TABS 3 Added EXFORGE HCT 10MG; 12.5MG; 160MG TABS 3 Added EXFORGE HCT 10MG; 25MG; 160 MG 3 Added EXFORGE HCT 10MG; 25MG; 320MG 3 Added EXFORGE HCT 5MG; 12.5MG; 160MG TABS 3 Added EXFORGE HCT 5MG; 25MG; 160MG TABS 3 Added ibandronate sodium 150mg tabs 2 Removed Step Therapy irbesartan 75mg, 150mg, 300mg tabs 2 Removed Step Therapy irbesartan/hydrochlorothiazide 12.5;150mg, 2 Removed Step Therapy 12.5;300mg tabs labetalol hcl 100mg, 200mg, 300mg tabs 1 Removed Step Therapy losartan potassium 25mg, 50mg, 100mg tabs 1 Removed Step Therapy losartan potassium/ hydrocholorothiazide 12.5; 50mg, 1 Removed Step Therapy lovastatin 10mg, 20mg, 40mg tabs 1 Removed Step Therapy metoprolol succinate er 25mg, 200mg, 50mg, 100mg tb24 1 Removed Step Therapy metoprolol tartrate 100mg, 50mg, 25mg tabs 1 Removed Step Therapy MICARDIS 20MG, 40MG, 80MG TABS 2 Removed Step Therapy MICARDIS HCT 25MG;80MG, 12.5;40MG 12.5MG;80MG TABS 2 Removed Step Therapy nadalol 40mg, 80mg, 20mg tabs 1 Removed Step Therapy NAMENDA XR 14MG, 21MG, 28MG, 7MG 2 Added NAMENDA XR TITRATION PACK CP 24 2 Added pindolol 5mg, 10mg tabs 1 Removed Step Therapy pravastatin sodium 10mg, 80mg, 20mg, 40mg tabs 1 Removed Step Therapy propranolol hcl 50ml/5ml, 40mg/5ml soln 1 Removed Step Therapy propranolol hcl 80mg, 10mg, 20mg, 40mg, 60mg tabs 1 Removed Step Therapy simvastatin 10mg, 5mg, 20mg, 40mg, 80mg 1 Removed Step Therapy SIRTURO 100MG TABS 4 Added SOLTAMOX 10MG/5ML SOLN 3 Added TECFIDERA 120MG, 240MG CPDR 4 Added, with Prior Authorization TECFIDERA STARTER PACK 4 Added, with Prior Authorization timolol maleate 5mg, 10mg, 20mg tabs 1 Removed Step Therapy TOBI PODHALER 28MG CAPS 4 Added
55 Addendums to Preferred Care Partners 2013 Formulary Cont'd Effective 6/2013 Drug Name Drug Tier Description of Change TOPROL XL 25MG, 50MG, 100MG, 200MG TB 24 3 Removed Step Therapy travoprost 0.004% Soln 3 Added TYVASO 0.6MG/ML SOLN 4 Added, with Prior Authorization valsartan/hydrochlorothiazide 12.5; 80mg, 12.5mg; 1 Removed Step Therapy 160mg, 25mg; 160mg, 25mg; 320mg tabs VENTAVIS 20MCG/ML SOLN 4 Added, with Prior Authorization VIRMUNE XR 100MG TB 24 3 Added XARELTO 10MG TABS 3 Added XARELTO 15MG, 20MG, TABS 3 Added, with Prior Authorization ZEMPLAR 1MCG, 2MCG, 4MCG CAPS 3 Added, with Prior Authorization ZEMPLAR 2MCG/ML, 5MCG/ML SOLN 3 Added, with Prior Authorization ZYVOX 600MG TABS 2 Removed Quantity Limit Effective 7/2013 Drug Name Drug Tier Description of Change amlodipine besylate/benazepril hydrochloride 1 5mg; Removing Quantity Limit amoxicillin/clavulanate potassium er 1000mg, mg tb12 Added ASMANEX 30 METERED DOSES 3 Added, with a Quantity Limit of 1 each 30 days DEXTROSE 5%; 0.225% SOLN 3 Added ENDOCET 325MG; 10MG, 350MG;10MG, 1 325MG;5MG, 500MG;7.5MG TABS Added EPINASTINE HCL 0.05% SOLN 3 Added ERY-TAB 250MG, 500MG TBEC 1 Added fluocinolone acetonide 0.01% oil 1 Added fluocinolone acetonide body 0.01% oil 1 Added KCL 0.075%/ D5W /NACL 0.45% 5%; 3 Added 10MEQ/L;0.45% SOLN KCL 0.3%/ D5W/ NACL 0.45% 5%; 3 Added 40MEQ/L; 0.45% SOLN levofloxacin 25mg/ml soln 2 Added lidocaine viscous 2% soln 1 Added minocycline hcl 100mg, 50mg, 75mg tabs 1 Added mometasone furoate 0.1% soln 1 Added PRUDOXIN 5% CREAM 2 Removing Quantity Limit RAPAMUNE 0.5MG TABS 3 Added, with Prior Authorization VANCOMYCIN HCL 500MG SOLR 3 Added, with Prior Authorization venlafaxine hcl er 150mg cp24 3 Removing Quantity Limit venlafaxine hcl er 150mg tb24 2 Removing Quantity Limit XOPENEX 1.25MG/3ML NEBU 3 Added, with Prior Authorization
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