Changes to the Johns Hopkins Advantage MD (PPO) Formulary Please retain this with your formulary
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1 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 or removed from the formulary are listed below. This is not a complete list of all formulary drugs covered by the plan. For a complete listing, or if you need additional information about the Johns Hopkins Advantage MD (PPO) formulary, 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) before the effective date of the change, we will continue to cover the drug for the remainder of the plan year as long as the drug continues to be medically necessary for treating your condition and prescribed for you by your prescriber, and was not removed for safety reasons. The table below outlines changes to our formulary that may impact you. Name of Affected Drug Description of Change Reason for Change Alternative Drug Alternative Drug Cost- Share Tier Effective Date Abacavir Sol 20Mg/Ml Added to Tier 2 AUSTEDO 6MG TAB * QL NM LA PA (60 tabs / 30 AUSTEDO 9MG, 12 MG TAB * QL NM LA PA (120 tabs / 30 CASPOFUNGIN INJ PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, NM - Not available at mail order, B/D - Covered under Medicare B or D, LA - Limited Access, * - Not available as extended days supply Johns Hopkins Advantage MD is a Medicare Advantage plan with a Medicare contract offering HMO and PPO products. Enrollment in Johns Hopkins Advantage MD depends on contract renewal. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. Y0124 _Errata_1017 Approved 1017
2 Eletriptan Tab Added to Tier 2 QL (12 tabs / 30 Endocet Tab Added to Tier 2 QL (360 tabs / 30 EPCLUSA TAB PA Fosamprenavi Tab 700Mg Glatiramer Inj 40Mg/Ml HAEGARDA INJ 2000UNIT HAEGARDA INJ 3000UNIT * QL NM PA (12 syringes / 28 * QL NM LA PA (30 vials / 30 * QL NM LA PA (20 vials / 30 HARVONI TAB PA HYSINGLA ER 20MG, 30MG, 40MG, QL (60 tabs / 30 60MG TAB HYSINGLA ER 80MG, 100MG, 120MG TAB QL (30 tabs / 30 IDHIFA LA PA Levalbuterol Neb Added to Tier Mg B/D LYNPARZA LA PA MAVYRET PA MORPHINE SUL INJ Added to Tier 4 10MG/ML B/D NERLYNX LA PA Prasugrel Tab Added to Tier 2 RAYALDEE 2
3 RITUXAN INJ HYCELA LA PA Scopolamine Dis Added to Tier 4 1Mg/3Day QL PA (10 patches / 30 Sodium Pheny Tab 500Mg PA TRELEGY AER ELLIPTA QL (60 blisters / 30 Triklo Cap 1Gm Added to Tier 2 VERZENIO TAB LA PA Vigabatrin Pak 500Mg * QL NM LA PA (180 packets / 30 VIRAMUNE SUS Added to Tier 4 50MG/5ML VOSEVI PA XULTOPHY INJ 100/3.6 QL (5 pens / 30 ZEPATIER AMINOSYN II INJ 7% PA Amnesteem Cap Added to Tier 2 PA ANDROGEL 1.62% QL PA (150 grams / 30 Atazanavir Cap BENLYSTA INJ 200MG/ML PA BORTEZOMIB PA Bromfenac Ophth Soln 0.09% AMINOSYN -HBC INJ 7% Tier 4 3/1/2018 Bromfenac Sodium Ophth Soln 0.09% (Once-Daily) 3
4 BYDUREON INJ BCISE QL (4 pens / 28 CALQUENCE LA PA Caspofungin Inj 50Mg Clindamax Gel 1% Clindamycin Phosphate Gel 1% Dasetta Tab 1/35 Added to Tier 2 Dasetta Tab 7/7/7 Added to Tier 2 Deso/Ethinyl Tab Added to Tier 2 Estradiol Diazepam Gel Added to Tier 2 Diltiazem Cap 180Mg/24 DOCEFREZ INJ 20MG Added to Tier 2 Docetaxel Inj 80Mg/4Ml Tier 5 3/1/2018 Efavirenz Cap 200Mg Efavirenz Cap 50Mg Added to Tier 2 Enskyce Tab Added to Tier 2 Estradiol Cream Added to Tier % Ethy Eth Est Tab 1-35 Added to Tier 2 FIASP FLEX INJ TOUCH and FIASP INJ 100/ML GAMMAPLEX INJ 5% Gavilyte-h Glatiramer Inj 20Mg/Ml PA * QL NM PA (30 syringes /30 Glydo Gel 2% Added to Tier 2 QL PA (30 ml / 30 Gavilyte-g 4
5 Isibloom Tab Added to Tier 2 Klor-Con Pak 20Meq Added to Tier 2 Levo-T Added to Tier 2 Lortab Tab 5-325Mg, Mg, Mg Hydrocodone/ acetaminophe n 5-325Mg, Mg, Mg Mafenide Ace Pak 5% Added to Tier 2 Magnesium Su Inj 20/500Ml, 40G/1000, 4G/100Ml, 80Mg/Ml MENOMUNE INJ A/C/Y/W Morphine Sulfate Inj 15Mg/Ml MYLOTARG INJ 4.5MG NECON TAB 10/11-28 OCTAGAM INJ 10/100ML, 20/200ML, 5GM/50ML Oseltamivir Sus 6Mg/Ml Triklo Cap 1 Gm LA PA PA Added to Tier 2 QL (1080 ml / year) Sevelamer Pow 0.8Gm Added to Tier 2 QL (540 packs / 30 Sevelamer Pow 2.4Gm Added to Tier 2 QL (180 packs / 30 Sevelamer Tab 800Mg Added to Tier 2 QL (540 tabs / 30 MENACTR A INJ Morphine Sulfate IV Soln PF 10M/Ml Tier 3 3/1/2018 Tier 4 3/1/2018 Necon Tab 7/7/7 Omega-3- Acid Ethyl Esters Cap 1 Gm 5
6 SHINGRIX INJ 50MCG QL (2 vials per lifetime) Tenofovir Tab 300Mg Tigecycline Inj 50Mg Timolol Maleate Ophth Soln 0.5% (Once-Daily) Added to Tier 2 VIDEX EC and VIDEX SOL 2GM XIGDUO XR TAB Zazole Cream 0.8% ZOLEDRONIC INJ 4MG Added to Tier 4 QL (60 tabs / 30 Terconazole Vaginal Cream 0.8% Zoledronic Inj 4Mg/5Ml ELIQUIS STARTER /1/2018 PACK JULUCA /1/2018 Kurvelo Added to Tier /1/2018 Levonor/Ethi Tab Estradiol MORPHINE SULFATE SOLN 2MG/ML, 4 MG/ML, 5 MG/ML, 8 MG/ML, 10 MG/ML Nyata Added to Tier /1/2018 Added to Tier 4 B/D /1/2018 Nystatin Pow Tier 2 4/1/2018 Roweepra XR Added to Tier /1/2018 SOLIQUA 100/33 QL (10 pens / 30 Trientine Hcl VIVITROL /1/ /1/ /1/2018 6
7 AMITIZA CAP 8MCG Increased QL to 120 caps / 30 days BIKTARVY TAB Caspofungin Inj 70Mg DALIRESP TAB Added to Tier 4 250MCG Didanosine 125 Mg VIDEX EC CAP 125MG Tier 4 5/1/2018 Efavirenz Tab 600Mg ENDARI POW 5GM LA PA ERLEADA TAB 60MG LA PA Flunisolide (nasal) Increased QL to 3 bottles / 30 days Gentamicin Inj 10Mg/Ml Glatopa Inj 40Mg/Ml * QL NM PA (12 syringes / 28 Haloperidol Inj 5Mg/Ml IMBRUVICA CAP 70MG, IMBRUVICA TAB 140MG, IMBRUVICA TAB 280MG, IMBRUVICA TAB 420MG, IMBRUVICA TAB 560MG Gentamicin Inj 40Mg/Ml Tier 2 5/1/2018 Added to Tier 2 LA PA 7
8 Isotretinoin Cap 10Mg, Isotretinoin Cap 20Mg, Isotretinoin Cap 30Mg, Isotretinoin Cap 40Mg, Memantine Hc Cap 14Mg ER, Memantine Hc Cap 21Mg ER, Memantine Hc Cap 28Mg ER, Memantine Hc Cap 7Mg ER OZEMPIC INJ 0.25 OR 0.5MG/DOSE OZEMPIC INJ 1MG/DOSE Added to Tier 2 PA Added to Tier 2 PA if < 30 years QL (1 pen / 28 QL (2 pens / 28 Ritonavir Tab 100Mg Added to Tier 2 Tiagabine Tab 12Mg, Tiagabine Tab 16Mg TRISENOX SOL 10MG/10ML Acetic Acid 2% in Aluminum Acetate Otic Soln AMITIZA CAP 8MCG BUPHENYL TAB 500MG COPAXONE INJ 40MG/ML ESTRACE VAGINAL CREAM 0.01% GANCICLOVIR INJ 500MG/10ML Added to Tier 2 Increased QL to 180 caps / 30 days Added to Tier 2 B/D TRISENOX INJ 12MG/6ML Acetic Acid Otic Soln 2% Tier 5 5/1/ /1/2018 Sodium Phenylbutyra te Tab 500Mg Glatiramer Acetate 40Mg/Ml Estradiol Vaginal Cream 0.01% Tier 5 6/1/2018 Tier 5 6/1/ /1/2018 8
9 Gengraf Cap 50Mg Ibu Tabs 600Mg and 800Mg ISTALOL OPHTH SOLN 0.5% Cyclosporine Modified Cap 50Mg Added to Tier /1/2018 Timolol Maleate Ophth Soln 0.5% (Once- Daily) Kelnor 1/50 Added to Tier /1/2018 Nevirapine Susp 50Mg/5Ml Oxycodone W/ Acetaminophen Soln 5-325Mg/Ml RELPAX TAB RENVELA PAK RENVELA TAB 800MG REYATAZ CAP SABRIL PACK 500MG SUSTIVA CAP 200MG SUSTIVA CAP 50MG SYMFI LO TAMIFLU SUSP 6MG/ML VIRAMUNE SUSP 50Mg/5Ml Oxycodone Hcl Soln 5Mg/5Ml Eletriptan Tab Sevelamer Carbonate Packet Sevelamer Carbonate Tab 800Mg Atazanavir Cap Vigabatrin Powd Pack 500Mg Efavirenz Cap 200Mg Efavirenz Cap 50Mg Tier 4 6/1/2018 Tier 5 6/1/2018 Tier 5 6/1/2018 Tier 5 6/1/ /1/2018 Oseltamivir Phosphate Susp 6Mg/Ml 9
10 TASIGNA CAP 50MG TRANSDERM-SC PATCH 1.5MG VIGAMOX DROPS 0.5% ZIAGEN SOLN 20MG/ML Acyclovir Sodium Inj 500Mg Colesevelam Tab 625Mg Cyclophosphamide Caps 25mg and 50mg DOCETAXEL SOLN 20MG/2ML, 80MG/8ML, 160MG/16ML PA /1/2018 Scopolomine Patch Moxifloxacin Hcl Ophth Soln 0.5% Abacavir Soln 20Mg/Ml Acyclovir Sodium Inj 50Mg/Ml Tier 4 6/1/2018 Tier 2 7/1/2018 Added to Tier 2 Added to Tier 2 B/D * B/D NM Glipizide Xl 10Mg Added to Tier 1 QL (60 tabs / 30 HUMIRA 10MG/0.1ML, 20MG/0.2ML * QL NM PA (2 syringes / 28 HUMIRA 40MG/0.4ML, * QL NM PA (6 syringes / 28 HUMIRA PEDIATRIC CROHNS DISEASE HUMIRA PEN INJ 40/0.4ML Methotrexate Inj 100/4Ml and 200/8Ml PA * QL NM PA (6 pens / 28 Methotrexate Inj 50Mg/2Ml Tier 2 7/1/2018 Miglustat Cap 100Mg PA NARCAN 10
11 Praziquantel Tabs Added to Tier 2 SYMDEKO TAB LA PA Topotecan Inj 4Mg/4Ml * B/D NM Tri-Vylibra Added to Tier 2 TROGARZO LA Vylibra Tab Added to Tier 2 ZENPEP CAP 15000UNT and 3000UNIT Added to Tier 4 11
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