FORMULARY CHANGE NOTICE 2014 MARCH
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1 FORMUARY CHANGE NOTICE 2014 MARCH Drug Name Change and Reason ABACAVIR SUFATE/AMIVUDINE/ZIDOVUDI NE TABS 300MG; 150MG; 300MG Addition ACAMPROSATE CACIUM DR TBEC 333MG Addition PA ACITRETIN CAPS 10MG Addition PA ACITRETIN CAPS 17.5MG Addition PA ACITRETIN CAPS 25MG Addition PA ADEFOVIR DIPIVOXI TABS 10MG Addition PA GIOTRIF TABS 20MG Addition T2 PA GIOTRIF TABS 30MG Addition T2 PA GIOTRIF TABS 40MG Addition T2 PA AZACITIDINE SUSR 100MG Addition PA BCG VACCINE INJ 0 Addition T2 REGRANEX GE 0.01% Addition PA/Q ZUBSOV SUB 1.4MG; 0.36MG Addition T2 ZUBSOV SUB 5.7MG; 1.4MG Addition T2 CEFOTAXIME SODIUM SOR 500MG Addition CEFOTAXIME SODIUM SOR 1GM Addition CEFOTAXIME SODIUM SOR 2GM Addition CEMASTINE FUMARATE SYRP 0.67MG/5M Addition CINDAMYCIN PAMITATE HC SOR 75MG/5M Addition ONFI SUSP 2.5MG/M Addition T2 PA/Q CONIDINE HC ER TB12 0.1MG Addition Q VERSACOZ SUSP 50MG/M Addition T2 Q
2 Change and Reason DECITABINE SOR 50MG Addition (BVS D) PIMTREA TABS 0; 0 Addition KHEDEZA TB24 100MG Addition T2 KHEDEZA TB24 50MG Addition T2 DEXMETHYPHENIDATE HC ER CP24 15MG Addition DEXMETHYPHENIDATE HC ER CP24 30MG Addition DEXMETHYPHENIDATE HC ER CP24 40MG Addition TIVICAY TABS 50MG Addition T2 DONEPEZI HC TABS 23MG Addition DUOXETINE HC CPEP 20MG Addition DUOXETINE HC CPEP 30MG Addition DUOXETINE HC CPEP 60MG Addition ESTRADIO PTWK 0.025MG/24HR Addition ESTRADIO PTWK 37.5MCG/24HR Addition ESTRADIO PTWK 0.05MG/24HR Addition ESTRADIO PTWK 0.06MG/24HR Addition ESTRADIO PTWK 0.075MG/24HR Addition ESTRADIO PTWK 0.1MG/24HR Addition PIRMEA 1/35 TABS 35MCG; 1MG Addition INTEENCE TABS 25MG Addition T2 AFINITOR DISPERZ TBSO 2MG Addition T2 PA AFINITOR DISPERZ TBSO 3MG Addition T2 PA AFINITOR DISPERZ TBSO 5MG Addition T2 PA
3 Change and Reason FENOFIBRIC ACID DR CPDR 135MG Addition FENOFIBRIC ACID DR CPDR 45MG Addition GENTAMICIN SUFATE OINT 0.3% Addition SIMPONI ARIA SON 50MG/4M Addition T2 PA TRIAMTERENE/HYDROCHOROT HIAZIDE CAPS 25MG; 50MG Addition HYDROCORTISONE BUTYRATE (IPOPHIIC) CREA 0.10% Addition ST IMBRUVICA CAPS 140MG Addition T2 PA REVIMID CAPS 2.5MG Addition T2 PA REVIMID CAPS 20MG Addition T2 PA FETZIMA CP24 120MG Addition T2 FETZIMA CP24 20MG Addition T2 FETZIMA TITRATION PACK C4PK 0 Addition T2 FETZIMA CP24 40MG Addition T2 FETZIMA CP24 80MG Addition T2 IDOCAINE PTCH 5% Addition PA/Q OMUSTINE CAPS 10MG Addition OMUSTINE CAPS 100MG Addition OMUSTINE CAPS 40MG Addition ATUDA TABS 60MG Addition T2 Q METHYPHENIDATE HC ER TBCR 18MG Addition METRONIDAZOE GE 1% Addition MORPHINE SUFATE ER CP24 10MG Addition Q NORETHINDRONE TABS 0.35MG Addition
4 Change and Reason YZA TABS 0.35MG Addition NORTRIPTYINE HC SON 10MG/5M Addition OXTEAR XR TB24 150MG Addition T2 OXTEAR XR TB24 300MG Addition T2 OXTEAR XR TB24 600MG Addition T2 OXYCODONE HYDROCHORIDE 5MG/5 M 5MG/5M Addition Q PARICACITO CAPS 1MCG Addition PARICACITO CAPS 2MCG Addition PARICACITO CAPS 4MCG Addition FYCOMPA TABS 2MG Addition T2 FYCOMPA TABS 4MG Addition T2 FYCOMPA TABS 6MG Addition T2 FYCOMPA TABS 8MG Addition T2 NOXAFI TBEC 100MG Addition T2 PHENADOZ SUPP 25MG Addition REPAGINIDE TABS 0.5MG Addition ST REPAGINIDE TABS 1MG Addition ST REPAGINIDE TABS 2MG Addition ST ASTAGRAF X CP24 0.5MG Addition T2 PA ASTAGRAF X CP24 1MG Addition T2 PA ASTAGRAF X CP24 5MG Addition T2 PA GRANIX SOSY 300MCG/0.5M Addition T2 PA GRANIX SOSY 480MCG/0.8M Addition T2 PA
5 Change and Reason EGRIFTA SOR 2MG Addition T2 PA TOBRAMYCIN NEBU 300MG/5M Addition PA ACTEMRA SOSY 162MG/0.9M Addition T2 PA TROKENDI XR CP24 100MG Addition T2 TROKENDI XR CP24 200MG Addition T2 TROKENDI XR CP24 25MG Addition T2 TROKENDI XR CP24 50MG Addition T2 VORICONAZOE SUSR 40MG/M Addition BRINTEIX TABS 10MG Addition T2 BRINTEIX TABS 20MG Addition T2 BRINTEIX TABS 5MG Addition T2 HYDROCODONE- ACETA TABS MG HYDROCODONE/AC ETA Deletion of NDC This product is ENDOCET TABS MG Deletion of NDC This product is PERCOCET TABS MG Deletion of NDC This product is ENDOCET TABS 10MG-650MG Deletion of NDC This product is PERCOCET TABS 10MG-650MG Deletion of NDC This product is ACETAMINOPH-CAFF- DIHYDROCODEIN TABS Deletion of NDC This product is COMBIVENT AER W/ADA P MCG COMBIVENT RESPIMAT T2 Deletion of NDC This product is ESPAR VIA UNIT CERUBIDINE T2 PA Deletion of NDC This product will not be covered by Medicare Part D. Effective date of ORPHENADRINE COMPOUND TABS CARISOPRODO/AS PIRIN PA Deletion of NDC This product is CIMETIDINE VIA 150 MG/M RANITIDINE HC PREZISTA TABS 400 MG NORVIR T2 EVOTHROID TABS 25 MCG EVOTHYROXINE Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is
6 Change and Reason EVOTHROID TABS 50 MCG EVOTHYROXINE EVOTHROID TABS 75 MCG EVOTHYROXINE EVOTHROID TABS 88 MCG EVOTHYROXINE EVOTHROID TABS 100 MCG EVOTHYROXINE EVOTHROID TABS 112 MCG EVOTHYROXINE EVOTHROID TABS 125 MCG EVOTHYROXINE EVOTHROID TABS 137 MCG EVOTHYROXINE EVOTHROID TABS 150 MCG EVOTHYROXINE EVOTHROID TABS 175MCG EVOTHYROXINE EVOTHROID TABS 200 MCG EVOTHYROXINE EVOTHROID TABS 300 MCG EVOTHYROXINE ICUSIG TABS 15 MG GEEVEC T2 PA ICUSIG TABS 45 MG GEEVEC T2 PA EUKINE VIA 500 MCG/M NEUPOGEN T2 PA NUTROPIN AQ VIA 10 MG/2 M HUMATROPE T2 PA TYZINE DROPS 0.1 % NASONEX T2 Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is. Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is 3/1/14 Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product is Deletion of NDC This product will not be covered by Medicare Part D. Effective date of CACITRIO SON 1MCG/M Removal of Prior Authorization CACITRIO SON 0.25MCG Removal of Prior Authorization CACITRIO CAPS 0.5MCG Removal of Prior Authorization HECTORO CAPS 0.5MCG Removal of Prior Authorization T2 HECTORO CAPS 1MCG Removal of Prior Authorization T2 HECTORO CAPS 2.5MCG Removal of Prior Authorization T2 HECTORO SON 4MCG/2M Removal of Prior Authorization T2
7 Change and Reason CACITONIN SON 200 UNIT Removal of Prior Authorization FORTICA SON 200 UNIT Removal of Prior Authorization HEPARIN SON 1000/M inj Removal of Prior Authorization EVOCARNITINE TABS 330MG Removal of Prior Authorization EVOCARNITINE SON 1GM/10M Removal of Prior Authorization IDOCAINE OINT 5% Removal of Prior Authorization IDOCAINE-PRIOCAINE CREA 2.5%-2.5% Removal of Prior Authorization SYNERA PTCH 70MG/70MG Removal of Prior Authorization T2 PAMIDRONATE SON 30MG/10M Removal of Prior Authorization PAMIDRONATE SON 90MG/10M Removal of Prior Authorization PAMIDRONATE SON 6MG/M INJ Removal of Prior Authorization VICTOZA SON 18MG/3M Addition T2 NAMENDA XR TITRATION PACK CP24 0 Addition T2 NAMENDA XR CP24 7MG Addition T2 NAMENDA XR CP24 14MG Addition T2 NAMENDA XR CP24 28MG Addition T2 NAMENDA XR CP24 21MG Addition T2
8 Change and Reason TUDORZA PRESSAIR AEPB 400MCG/ACT Addition T2 INZESS CAPS 145MCG Addition T2 INZESS CAPS 290MCG Addition T2 FUNISOIDE SON 0.025% Addition Key = Tier One Cost Share T2 = Tier Two Cost Share PA = Prior Authorization Required ST = Step Therapy Required Q = Quantity imits Addition = Drug Was Added To Deletion= Drug Was Removed From Drug Name= Name of the affected Part D drug Medicine= Drugs in the same therapeutic category, class or cost-sharing tier = The expected cost-sharing for alternative medicine Change and Reason= Description of the formulary change and reason if the covered part D drug is being removed from the formulary * drugs listed here are only suggestions. Only your physician can determine if the alternative listed here is appropriate for you. Please consult to your physician as to whether this is an appropriate drug for you.
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