Healthfirst Medicare Plan. Medicare Part D Formulary Change

Transcription

1 Healthfirst Medicare Plan Medicare Part D Formulary We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, [or] add prior authorizations, quantity limits and/or step therapy restrictions on a drug [or move a drug to 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, we will immediately remove the drug from our formulary and notify you. This document was last updated on 03/21/2016. Effective ADRIAMYC INJ 50MG APEXICON OINT 0.05% ARALAST NP INJ 800MG 05/01/2016 AUVI-Q INJ AVODART CAP 0.5MG Reason for Alternative Alternative DOXORUBICIN INJ 50MG Tier 1 DIFLORASONE OINT 0.05% Tier 1 ARALAST NP INJ 400MG, 500MG, OR 1000 MG Tier 4 EPIPEN Tier 2 DUTASTERIDE CAP 0.5 MG Tier 1 QLL

2 DILTZAC CAP FOSCARNET INJ 24MG/ML GLEEVEC TAB GLEEVEC TAB JALYN CAP LACLOTION LOTION 12% LEVOBUNOLOL SOL 0.25% OPTH LOMUSTINE CAP Reason for Alternative Alternative TAZTIA XT OR DILTIAZEM HCL ER BEADS CAP SR 24HR Tier 1 VALGANCICLOVIR TAB 450MG Tier 4 IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT) Tier 4 IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT) Tier 4 DUTASTERIDE- TAMSULOSIN HCL CAP MG Tier 1 AMMONIUM LACTATE LOTION 12% Tier 1 LEVOBUNOLOL SOLN 0.5% OPHTH Tier 1 GLEOSTINE CAP Tier 3 QLL

3 MEGACE ES SUS 625/5ML MY WAY TAB 1.5MG NAMENDA SOL NAMENDA TAB NAMENDA TAB NEXT CHOICE TAB 1.5MG ORAP TAB ORAP TAB Reason for Alternative Alternative MEDICARE WILL NO LONGER COVER MEDICARE WILL NO LONGER COVER MEGESTROL ACETATE SUSP 625 MG/5ML Tier 4 LEVONORGESTREL TAB 1.5MG Tier 1 MEMANTINE HC SOL 2MG/ML Tier 1 MEMANTINE HCL TAB 10 MG Tier 1 MEMANTINE HCL TAB 5 MG Tier 1 LEVONORGESTREL TAB 1.5MG Tier 1 PIMOZIDE TAB 1 MG Tier 1 PIMOZIDE TAB 2 MG Tier 1

4 SOLIA TAB TARGRETIN CAP 75MG TOBRAMYCIN/NACL INJ MG/ML IN SALINE XENAZINE TAB XENAZINE TAB ZYVOX SUS 100MG/5M Reason for Alternative Alternative CYRED TAB, APRI TAB, EMOQUETTE TAB, OR RECLIPSEN TAB Tier 1 BEXAROTENE CAP 75 MG Tier 4 TOBRAMYCIN INJ 80MG/2ML Tier 1 TETRABENAZINE TAB 12.5 MG Tier 4 TETRABENAZINE TAB 25 MG Tier 4 LINEZOLID FOR SUSP 100 MG/5ML Tier 4, QLL, QLL For more information about how these changes may affect your cost-sharing, such as copayments or co-insurance, or for more information about requesting an updated coverage determination or an exception to coverage determination, please see your plan Evidence of Coverage (EOC). If you have additional questions, please call Healthfirst Medicare Plan at , TTY , 7 days a week, 8am to 8pm.

5 *Indicates a restriction of Step Therapy, Prior Authorization or Quantity Level Limits may exist. [LA] = Limited Access, [] = Prior Authorization, [QLL] = Quantity Level Limit, [ST] = Step Therapy Healthfirst Health Plan, Inc., dba Healthfirst Medicare Plan, offers HMO plans that contract with the Federal Government. Healthfirst Medicare Plan has a contract with New York State Medicaid for Healthfirst CompleteCare (HMO SNP) and a Coordination of Benefits Agreement with the New York State Department of Health for the Healthfirst Life Improvement Plan (HMO SNP). Enrollment in Healthfirst Medicare Plan depends on contract renewal. This information is available for free in other languages. Please call our Member Services number at , TTY number , 7 days a week from 8:00am to 8:00pm. Esta información está disponible en forma gratuita en otros idiomas. Por favor, comuníquese con nuestro número de Servicios a los Miembros al , o al para los usuarios de TTY, los 7 días de la semana, de 8:00 a.m. a 8:00 p.m.