VIVA MEDICARE IMPORTANT 2014 FORMULARY UPDATES
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- Hilary Small
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1 Drug Label Name Tier Note/ Explanation Requirements/Limits ZINACEF INJ 750MG 4 Added to the 2014 Formulary 3/1/2014 FORTAZ INJ 1GM 4 Added to the 2014 Formulary 3/1/2014 TETRACYCLINE CAP 250MG 2 Added to the 2014 Formulary 3/1/2014 TETRACYCLINE CAP 500MG 2 Added to the 2014 Formulary 3/1/2014 CIPRO I.V. INJ 200MG 4 Added to the 2014 Formulary 3/1/2014 TOBRAMYCIN NEB 300/5ML 5 Added to the 2014 Formulary B vs D Prior Auth 3/1/2014 NOXAFIL TAB 100MG 5 Added to the 2014 Formulary 3/1/2014 LAMIVUDINE TAB 100MG 2 Added to the 2014 Formulary 3/1/2014 ABACAV/LAMIV TAB 5 Added to the 2014 Formulary 3/1/2014 /ZIDOVUD MODIBA TAB 200MG 2 Added to the 2014 Formulary Prior Auth 3/1/2014 MODIBA PAK 800/DAY 5 Added to the 2014 Formulary Prior Auth 3/1/2014 MODIBA PAK 1200/DAY 5 Added to the 2014 Formulary Prior Auth 3/1/2014 MODIBA PAK 600/DAY 5 Added to the 2014 Formulary Prior Auth 3/1/2014 MODIBA PAK 1000/DAY 5 Added to the 2014 Formulary Prior Auth 3/1/2014 TENIVAC INJ 5 2LF 3 Added to the 2014 Formulary B vs D Prior Auth 3/1/2014 IFOSFAMIDE INJ 3GM 4 Added to the 2014 Formulary B vs D Prior Auth 3/1/2014 LOMUSTINE CAP 10MG 2 Added to the 2014 Formulary 3/1/2014 LOMUSTINE CAP 40MG 2 Added to the 2014 Formulary 3/1/2014 LOMUSTINE CAP 100MG 2 Added to the 2014 Formulary 3/1/2014 DOXORUBICIN INJ 2MG/ML 5 Added to the 2014 Formulary B vs D Prior Auth 3/1/2014 IMBRUVICA CAP 140MG 5 Added to the 2014 Formulary Prior Auth 3/1/2014 ICLUSIG TAB 15MG 5 Added to the 2014 Formulary Prior Auth 3/1/2014 ICLUSIG TAB 45MG 5 Added to the 2014 Formulary Prior Auth 3/1/2014 LYZA TAB 0.35MG 2 Added to the 2014 Formulary 3/1/2014 PIRMELLA TAB 1/35 2 Added to the 2014 Formulary 3/1/2014 ORTHO NOVUM TAB 1/35 4 Added to the 2014 Formulary 3/1/2014 LOMEDIA 24 TAB FE 2 Added to the 2014 Formulary 3/1/2014 TELMISARTAN TAB 20MG 1 Added to the 2014 Formulary 3/1/2014 TELMISARTAN TAB 40MG 1 Added to the 2014 Formulary 3/1/2014 TELMISARTAN TAB 80MG 1 Added to the 2014 Formulary 3/1/2014 TELMIS/AMLOD TAB 40 5MG 1 Added to the 2014 Formulary 3/1/2014 TELMIS/AMLOD TAB 40 1 Added to the 2014 Formulary 3/1/ MG TELMIS/AMLOD TAB 80 5MG 1 Added to the 2014 Formulary 3/1/2014 TELMIS/AMLOD TAB 80 1 Added to the 2014 Formulary 3/1/ MG ANTARA CAP 30MG 4 Added to the 2014 Formulary 3/1/2014 ANTARA CAP 90MG 4 Added to the 2014 Formulary 3/1/2014 LIPTRUZET TAB 10 10MG 4 Added to the 2014 Formulary 3/1/2014
2 LIPTRUZET TAB 10 20MG 4 Added to the 2014 Formulary 3/1/2014 LIPTRUZET TAB 10 40MG 4 Added to the 2014 Formulary 3/1/2014 LIPTRUZET TAB 10 80MG 4 Added to the 2014 Formulary 3/1/2014 ZANTAC INJ 25MG/ML 4 Added to the 2014 Formulary 3/1/2014 ZANTAC INJ 25MG/ML 4 Added to the 2014 Formulary 3/1/2014 RABEPRAZOLE TAB 20MG 2 Added to the 2014 Formulary Quantity Limit (30 per 30 3/1/2014 ACIPHEX SPR CAP 5MG 4 Added to the 2014 Formulary 3/1/2014 ACIPHEX SPR CAP 10MG 4 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 TOLTODINE CAP 2MG 2 Added to the 2014 Formulary 3/1/2014 TOLTODINE CAP 4MG 2 Added to the 2014 Formulary 3/1/2014 DULOXETINE CAP 20MG 2 Added to the 2014 Formulary 3/1/2014 DULOXETINE CAP 30MG 2 Added to the 2014 Formulary 3/1/2014 DULOXETINE CAP 60MG 2 Added to the 2014 Formulary 3/1/2014 FETZIMA CAP 20MG 4 Added to the 2014 Formulary Quantity Limit (180 per 30 3/1/2014 FETZIMA CAP 40MG 4 Added to the 2014 Formulary Quantity Limit (90 per 30 3/1/2014 FETZIMA CAP 80MG 4 Added to the 2014 Formulary Quantity Limit (30 per 30 3/1/2014 FETZIMA CAP 120MG 4 Added to the 2014 Formulary Quantity Limit (30 per 30 3/1/2014 METHYLPHENID TAB 18MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 HORIZANT TAB 300MG 4 Added to the 2014 Formulary 3/1/2014 SUBSYS SPR 1200MCG 5 Added to the 2014 Formulary Quantity Limit (120 per 30 3/1/2014 MORPHINE SUL CAP 10MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 MORPHINE SUL CAP 20MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 MORPHINE SUL CAP 30MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 MORPHINE SUL CAP 50MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 MORPHINE SUL CAP 60MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 MORPHINE SUL CAP 80MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 MORPHINE SUL CAP 100MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 3/1/2014 ROXICODONE TAB 5MG 4 Added to the 2014 Formulary Quantity Limit (180 per 30 3/1/2014 OXYCODONE SOL 5MG/5ML 2 Added to the 2014 Formulary 3/1/2014 LORTAB ELX MG 4 Added to the 2014 Formulary Quantity Limit (6000 per 30 3/1/2014 ZORVOLEX CAP 18MG 4 Added to the 2014 Formulary 3/1/2014 ZORVOLEX CAP 35MG 4 Added to the 2014 Formulary 3/1/2014 Page 2 of 7
3 SIMPONI ARIA SOL 5 Added to the 2014 Formulary Prior Auth 3/1/ MG/4ML ZOMIG SPR 2.5MG 4 Added to the 2014 Formulary Quantity Limit (12 per 30 3/1/2014 DIASTAT PED GEL 2.5M GEL 4 Added to the 2014 Formulary None 3/1/2014 DIASTAT ACDL GEL 5 10MG 4 Added to the 2014 Formulary None 3/1/2014 DIASTAT ACDL GEL Added to the 2014 Formulary None 3/1/2014 OXTELLAR XR TAB 150MG 4 Added to the 2014 Formulary 3/1/2014 OXTELLAR XR TAB 300MG 4 Added to the 2014 Formulary 3/1/2014 OXTELLAR XR TAB 600MG 4 Added to the 2014 Formulary 3/1/2014 TROKENDI XR CAP 25MG 4 Added to the 2014 Formulary 3/1/2014 TROKENDI XR CAP 50MG 4 Added to the 2014 Formulary 3/1/2014 TROKENDI XR CAP 100MG 4 Added to the 2014 Formulary 3/1/2014 TROKENDI XR CAP 200MG 4 Added to the 2014 Formulary 3/1/2014 GARAMYCIN SOL 0.3% OP 4 Added to the 2014 Formulary 3/1/2014 BROMFENAC SOL 0.09% 2 Added to the 2014 Formulary 3/1/2014 BENZACLIN GEL 1 5% 4 Added to the 2014 Formulary 3/1/2014 DICLOFENAC GEL 3% 2 Added to the 2014 Formulary Prior Auth 3/1/2014 APEXICON E CRE 0.05% 4 Added to the 2014 Formulary 3/1/2014 MYCOPHENOLIC TAB 180MG 2 Added to the 2014 Formulary B vs D Prior Auth 3/1/2014 DR MYCOPHENOLIC TAB 360MG 5 Added to the 2014 Formulary 3/1/2014 DR FETZIMA CAP TITRATIO 4 Added to the 2014 Formulary 3/1/2014 ACTEMRA INJ 162/0.9 5 Added to the 2014 Formulary Prior Auth 3/1/2014 GRANIX INJ 300/0.5 5 Added to the 2014 Formulary Prior Auth 3/1/2014 GRANIX INJ 480/0.8 5 Added to the 2014 Formulary Prior Auth 3/1/2014 MONODOX CAP 75MG Termed from the formulary 3/1/2014 MONODOX CAP 100MG Termed from the formulary 3/1/2014 SOLODYN TAB 45MG Termed from the formulary 3/1/2014 SOLODYN TAB 90MG Termed from the formulary 3/1/2014 SOLODYN TAB 135MG Termed from the formulary 3/1/2014 TOBRA/NACL INJ 60/0.9 Termed from the formulary 3/1/2014 PREZISTA TAB 400MG Termed from the formulary 3/1/2014 ELSPAR INJ 10000UNT Termed from the formulary 3/1/2014 CELESTONE SOL 0.6MG/5 Termed from the formulary 3/1/2014 NORDETTE 28 TAB Termed from the formulary 3/1/2014 NORINYL TAB 1/35 Termed from the formulary 3/1/2014 LEVOTHROID TAB 25MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 50MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 75MCG Termed from the formulary 3/1/2014 Page 3 of 7
4 LEVOTHROID TAB 88MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 100MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 112MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 125MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 137MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 150MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 175MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 200MCG Termed from the formulary 3/1/2014 LEVOTHROID TAB 300MCG Termed from the formulary 3/1/2014 LOTENSIN TAB 10MG Termed from the formulary 3/1/2014 LOPRESS HCT TAB MG Termed from the formulary 3/1/2014 CLARINEX RDT TAB 2.5MG Termed from the formulary 3/1/2014 CLARINEX RDT TAB 5MG Termed from the formulary 3/1/2014 TYZINE SOL 0.1% Termed from the formulary 3/1/2014 CIMETIDINE INJ 150MG/ML Termed from the formulary 3/1/2014 ASACOL TAB 400MG DR Termed from the formulary 3/1/2014 ONSOLIS MIS 200MCG Termed from the formulary 3/1/2014 ONSOLIS MIS 400MCG Termed from the formulary 3/1/2014 ONSOLIS MIS 600MCG Termed from the formulary 3/1/2014 ONSOLIS MIS 800MCG Termed from the formulary 3/1/2014 ONSOLIS MIS 1200MCG Termed from the formulary 3/1/2014 ASTRAMORPH INJ 1MG/2ML Termed from the formulary 3/1/2014 ASTRAMORPH INJ 10/10ML Termed from the formulary 3/1/2014 LEUKINE INJ 500 MCG Termed from the formulary 3/1/2014 FLUOROPLEX CRE 1% Termed from the formulary 3/1/2014 CORDRAN SP CRE 0.05% Termed from the formulary 3/1/2014 CORDRAN LOT 0.05% Termed from the formulary 3/1/2014 KAYEXALATE POW Termed from the formulary 3/1/2014 AMOXAPINE TAB 100MG 2 Tier change T 3 to T 2 3/1/2014 AMOXAPINE TAB 150MG 2 Tier change T 3 to T 2 3/1/2014 AMOXAPINE TAB 25MG 2 Tier change T 3 to T 2 3/1/2014 AMOXAPINE TAB 50MG 2 Tier change T 3 to T 2 3/1/2014 BYETTA INJ 10MCG 4 Prior Auth termed 3/1/2014 BYETTA INJ 5MCG 4 Prior Auth termed 3/1/2014 BYDUREON INJ 4 Prior Auth termed 3/1/2014 XANAX TAB 0.25MG 4 Increased Quantity Limit (480 per 30 3/1/2014 ALPRAZOLAM TAB 0.25MG 1 Increased Quantity Limit (480 per 30 3/1/2014 Page 4 of 7
5 XANAX TAB 0.5MG 4 Increased Quantity Limit (240 per 30 3/1/2014 ALPRAZOLAM TAB 0.5MG 1 Increased Quantity Limit (240 per 30 3/1/2014 ALPRAZOLAM TAB 1MG 1 Increased Quantity Limit (120 per 30 3/1/2014 XANAX TAB 1MG 4 Increased Quantity Limit (120 per 30 3/1/2014 CEPHALEXIN CAP 750MG 2 Added to the 2014 Formulary 4/1/2014 CEFUROXIME SUS 125/5ML 2 Added to the 2014 Formulary 4/1/2014 FORTAZ INJ 2GM 4 Added to the 2014 Formulary 4/1/2014 MODIBA PAK 1200/DAY 5 Added to the 2014 Formulary Prior Auth 4/1/2014 METRONIDAZOL CAP 375MG 2 Added to the 2014 Formulary 4/1/2014 MITOMYCIN INJ 5MG 2 Added to the 2014 Formulary B vs D Prior Auth 4/1/2014 MITOMYCIN INJ 40MG 2 Added to the 2014 Formulary B vs D Prior Auth 4/1/2014 ESTRA/NORETH TAB 1 2 Added to the 2014 Formulary 4/1/ MG VYFEMLA TAB Added to the 2014 Formulary 4/1/2014 PIMTREA TAB 2 Added to the 2014 Formulary 4/1/2014 FARXIGA TAB 5MG 4 Added to the 2014 Formulary Quantity Limit (60 per 30 4/1/2014 FARXIGA TAB 10MG 4 Added to the 2014 Formulary Quantity Limit (30 per 30 4/1/2014 DOXCALCIF INJ 2 Added to the 2014 Formulary B vs D Prior Auth 4/1/2014 PARICALCITOL CAP 4 MCG 2 Added to the 2014 Formulary B vs D Prior Auth 4/1/2014 LANOXIN TAB MG 3 Added to the 2014 Formulary Quantity Limit (60 per 30 4/1/2014 LANOXIN TAB MG 3 Added to the 2014 Formulary Prior Auth 65 years and older 4/1/2014 TRIAMT/HCTZ CAP 50 25MG 2 Added to the 2014 Formulary 4/1/2014 NIACIN TAB 500MG 2 Added to the 2014 Formulary 4/1/2014 NIACIN TAB 750MG 2 Added to the 2014 Formulary 4/1/2014 NIACIN TAB 1000MG 2 Added to the 2014 Formulary 4/1/2014 ADEMPAS TAB 0.5MG 5 Added to the 2014 Formulary Prior Auth 4/1/2014 ADEMPAS TAB 1MG 5 Added to the 2014 Formulary Prior Auth 4/1/2014 ADEMPAS TAB 1.5MG 5 Added to the 2014 Formulary Prior Auth 4/1/2014 ADEMPAS TAB 2MG 5 Added to the 2014 Formulary Prior Auth 4/1/2014 ADEMPAS TAB 2.5MG 5 Added to the 2014 Formulary Prior Auth 4/1/2014 OPSUMIT TAB 10MG 5 Added to the 2014 Formulary Prior Auth 4/1/2014 ESOMEPRAZOLE INJ 20MG 2 Added to the 2014 Formulary 4/1/2014 ESOMEPRAZOLE INJ 40MG 2 Added to the 2014 Formulary 4/1/2014 VSACLOZ SUS 50MG/ML 5 Added to the 2014 Formulary 4/1/2014 MORPHINE SUL CAP 30MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 4/1/2014 Page 5 of 7
6 MORPHINE SUL CAP 45MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 4/1/2014 MORPHINE SUL CAP 60MG Added to the 2014 Formulary Quantity Limit (60 per 30 4/1/ MORPHINE SUL CAP 75MG Added to the 2014 Formulary Quantity Limit (60 per 30 4/1/ MORPHINE SUL CAP 90MG Added to the 2014 Formulary Quantity Limit (60 per 30 4/1/ MORPHINE SUL CAP 120MG Added to the 2014 Formulary Quantity Limit (60 per 30 4/1/ ENBREL SRCLK INJ 50MG/ML 5 Added to the 2014 Formulary Prior Auth 4/1/2014 FYCOMPA TAB 2MG 4 Added to the 2014 Formulary Prior Auth 4/1/2014 FYCOMPA TAB 4MG 4 Added to the 2014 Formulary Prior Auth 4/1/2014 FYCOMPA TAB 6MG 4 Added to the 2014 Formulary Prior Auth 4/1/2014 FYCOMPA TAB 8MG 4 Added to the 2014 Formulary Prior Auth 4/1/2014 FYCOMPA TAB 10MG 4 Added to the 2014 Formulary Prior Auth 4/1/2014 FYCOMPA TAB 12MG 4 Added to the 2014 Formulary Prior Auth 4/1/2014 GENTAMICIN OIN 0.3% OP 1 Added to the 2014 Formulary 4/1/2014 YGEL GEL 2% 4 Added to the 2014 Formulary 4/1/2014 TACZO CRE 2% 4 Added to the 2014 Formulary 4/1/2014 PENNSAID SOL 2% 4 Added to the 2014 Formulary 4/1/2014 FLUOCINONIDE CRE 0.1% 2 Added to the 2014 Formulary 4/1/2014 HC BUTYRATE CRE 0.1% 2 Added to the 2014 Formulary 4/1/2014 SIROLIMUS TAB 0.5MG 2 Added to the 2014 Formulary B vs D Prior Auth 4/1/2014 VDESO A 0.05% Termed from the formulary 4/1/2014 ONTAK INJ 150/ML Termed from the formulary 4/1/2014 MIGGOT SUP 2/100 Tier Change T 4 to T 2 4/1/2014 ANORO ELLIPT A Added to the 2014 Formulary Quantity Limit (60 per 30 5/1/2014 CLOCORTOLONE CRE PIV 2 Added to the 2014 Formulary 5/1/ % DOXCALCIF CAP 0.5MCG 2 Added to the 2014 Formulary B vs D Prior Auth 5/1/2014 DOXCALCIF CAP 1MCG 2 Added to the 2014 Formulary B vs D Prior Auth 5/1/2014 DOXCALCIF CAP 2.5MCG 2 Added to the 2014 Formulary B vs D Prior Auth 5/1/2014 MOXIFLOXACIN TAB 400MG 2 Added to the 2014 Formulary 5/1/2014 NUVIGIL TAB 200MG 4 Added to the 2014 Formulary Prior Auth 5/1/2014 RESTORIL CAP 15MG 4 Added to the 2014 Formulary Quantity Limit (60 per 30 5/1/2014 RESTORIL CAP 7.5MG 4 Added to the 2014 Formulary Quantity Limit (30 per 30 5/1/2014 TELMISA/HCTZ TAB Added to the 2014 Formulary 5/1/2014 TELMISA/HCTZ TAB Added to the 2014 Formulary 5/1/2014 Page 6 of 7
7 TELMISA/HCTZ TAB 80 25MG 1 Added to the 2014 Formulary 5/1/2014 TEMAZEPAM CAP 15MG 2 Added to the 2014 Formulary Quantity Limit (60 per 30 5/1/2014 TEMAZEPAM CAP 7.5MG 2 Added to the 2014 Formulary Quantity Limit (30 per 30 5/1/2014 BREO ELLIPTA INH Tier Change T 4 to T 3 5/1/2014 BUTRANS DIS 15MCG/HR 2 Tier Change T 4 to T 3 5/1/2014 BUTRANS DIS 10MCG/HR 2 Tier Change T 4 to T 3 5/1/2014 BUTRANS DIS 20MCG/HR 2 Tier Change T 4 to T 3 5/1/2014 BUTRANS DIS 5MCG/HR 2 Tier Change T 4 to T 3 5/1/2014 SILENOR TAB 3MG 2 Tier Change T 4 to T 3 5/1/2014 SILENOR TAB 6MG 2 Tier Change T 4 to T 3 5/1/2014 LOCOID OIN 0.1% Termed from Formulary 5/1/2014 ALLOPURINOL INJ 500MG Termed from Formulary 5/1/2014 HELIDAC MIS Termed from Formulary 5/1/2014 AZATHIOPRINE INJ 100MG Termed from Formulary 5/1/2014 Page 7 of 7
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