2014 Medicare Part D Formulary Change
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- Phillip McBride
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1 2014 Medicare Part D Formulary Change 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 let you know of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug 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 let you know. The product changes noted below will be implemented on the Medicare Part D Plan formulary. To see if your drug is on this list, please refer to the tables below: New Added Products: Effective 04/01/2014 Drug Cost Restrictions* sharing NIACIN ER 1000MG TBCR Tier 2 NIACIN ER 500MG TBCR Tier 2 NIACIN ER 750MG TBCR Tier 2 ERWINAZE 10000UNIT SOLR Tier 5 PA ZYCLARA PUMP 2.5% CREA Tier 3 HORIZANT 300MG TB24 Tier 4 METRONIDAZOLE 375MG CAPS Tier 2 TELMISARTAN 40MG TABS Tier 2 TELMISARTAN 80MG TABS Tier 2 LAMIVUDINE 100MG TABS Tier 2 ONCASPAR 750UNIT/ML SOLN Tier 5 PA TELMISARTAN 20MG TABS Tier 2 MYCOPHENOLIC ACID DR 180MG TBEC Tier 2 PA B/D MYCOPHENOLIC ACID DR 360MG TBEC Tier 2 PA B/D FLUOCINONIDE 0.1% CREA Tier 2 ESOMEPRAZOLE SODIUM 20MG SOLR Tier 2 PA B/D ESOMEPRAZOLE SODIUM 40MG SOLR Tier 2 PA B/D ZENCHENT 35MCG; 0.4MG TABS Tier 2 TOLTERODINE TARTRATE ER 2MG CP24 Tier 2 TOLTERODINE TARTRATE ER 4MG CP24 Tier 2 Updated: 04/2014 H6864_MGM14_35 Formulary Change Web Posting_Approved
2 SIROLIMUS 0.5MG TABS Tier 2 PA B/D LIDOCAINE 5% PTCH Tier 2 CLONIDINE HCL ER 0.1MG TB12 Tier 2 HYDROCORTISONE BUTYRATE (LIPOPHILIC) 0.1% CREA Tier 2 EGRIFTA 2MG SOLR Tier 5 OXYCODONE HCL 5MG/5ML SOLN Tier 2 METHYLPHENIDATE HCL ER 18MG TBCR Tier 2 DONEPEZIL HCL 23MG TABS Tier 2 QL HORIZANT 600MG TB24 Tier 4 VESTURA 3MG; 0.02MG TABS Tier 2 REVLIMID 2.5MG CAPS Tier 5 PA INTELENCE 25MG TABS Tier 3 MYRBETRIQ 25MG TB24 Tier 3 MYRBETRIQ 50MG TB24 Tier 3 AFINITOR DISPERZ 2MG TBSO Tier 5 PA AFINITOR DISPERZ 3MG TBSO Tier 5 PA AFINITOR DISPERZ 5MG TBSO Tier 5 PA FYCOMPA 2MG TABS Tier 4 FYCOMPA 4MG TABS Tier 4 FYCOMPA 6MG TABS Tier 4 FYCOMPA 8MG TABS Tier 4 OXTELLAR XR 150MG TB24 Tier 4 OXTELLAR XR 300MG TB24 Tier 4 OXTELLAR XR 600MG TB24 Tier 4 ONFI 2.5MG/ML SUSP Tier 5 PA VERSACLOZ 50MG/ML SUSP Tier 5 INVOKANA 100MG TABS Tier 3 INVOKANA 300MG TABS Tier 3 TECFIDERA 120MG CPDR Tier 5 TECFIDERA 240MG CPDR Tier 5 TECFIDERA STARTER PACK 0 MISC Tier 5 PIRMELLA 1/35 35MCG; 1MG TABS Tier 2 REVLIMID 20MG CAPS Tier 5 PA BRISDELLE 7.5MG CAPS Tier 4 LYZA 0.35MG TABS Tier 2 GILOTRIF 20MG TABS Tier 5 PA GILOTRIF 30MG TABS Tier 5 PA GILOTRIF 40MG TABS Tier 5 PA LATUDA 60MG TABS Tier 4 ASTAGRAF XL 0.5MG CP24 Tier 4 PA B/D 2
3 ASTAGRAF XL 1MG CP24 Tier 4 PA B/D ASTAGRAF XL 5MG CP24 Tier 4 PA B/D FETZIMA 120MG CP24 Tier 4 FETZIMA 20MG CP24 Tier 4 FETZIMA 40MG CP24 Tier 4 FETZIMA 80MG CP24 Tier 4 FETZIMA TITRATION PACK 0 C4PK Tier 4 TIVICAY 50MG TABS Tier 5 KHEDEZLA 100MG TB24 Tier 4 KHEDEZLA 50MG TB24 Tier 4 EPANED 1MG/ML SOLR Tier 5 TROKENDI XR 50MG CP24 Tier 4 TROKENDI XR 25MG CP24 Tier 4 TROKENDI XR 100MG CP24 Tier 4 TROKENDI XR 200MG CP24 Tier 5 BRINTELLIX 5MG TABS Tier 4 BRINTELLIX 20MG TABS Tier 4 BRINTELLIX 10MG TABS Tier 4 ANTARA 30MG CAPS Tier 3 ANTARA 90MG CAPS Tier 3 IMBRUVICA 140MG CAPS Tier 5 PA CANDESARTAN CILEXETIL 4MG TABS Tier 2 CANDESARTAN CILEXETIL 8MG TABS Tier 2 LOMUSTINE 10MG CAPS Tier 3 LOMUSTINE 100MG CAPS Tier 3 LOMUSTINE 40MG CAPS Tier 3 TRIAMTERENE/HYDROCHLOROTHIAZIDE 25MG; 50MG CAPS Tier 2 ACITRETIN 10MG CAPS Tier 2 ACITRETIN 25MG CAPS Tier 5 REPAGLINIDE 1MG TABS Tier 2 REPAGLINIDE 0.5MG TABS Tier 2 REPAGLINIDE 2MG TABS Tier 2 BCG VACCINE 0 INJ Tier 4 PA B/D REGRANEX 0.01% GEL Tier 5 QL ESTRADIOL 0.05MG/24HR PTWK Tier 2 ESTRADIOL 0.1MG/24HR PTWK Tier 2 ESTRADIOL 0.075MG/24HR PTWK Tier 2 ESTRADIOL 0.025MG/24HR PTWK Tier 2 ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 300MG; 150MG; 300MG TABS Tier 2 3
4 CEFOTAXIME SODIUM 1GM SOLR Tier 2 PA B/D CEFOTAXIME SODIUM 2GM SOLR Tier 2 PA B/D CEFOTAXIME SODIUM 500MG SOLR Tier 2 PA B/D GENTAMICIN SULFATE 0.3% OINT Tier 2 NORTRIPTYLINE HCL 10MG/5ML SOLN Tier 2 TOBRAMYCIN 300MG/5ML NEBU Tier 5 METAXALONE 800MG TABS Tier 2 PA ESTRADIOL 37.5MCG/24HR PTWK Tier 2 ESTRADIOL 0.06MG/24HR PTWK Tier 2 VORICONAZOLE 40MG/ML SUSR Tier 5 FENOFIBRATE 130MG CAPS Tier 2 FENOFIBRATE 43MG CAPS Tier 2 AZACITIDINE 100MG SUSR Tier 5 CLINDAMYCIN PALMITATE HCL 75MG/5ML SOLR Tier 2 METRONIDAZOLE 1% GEL Tier 2 PARICALCITOL 1MCG CAPS Tier 2 PA B/D PARICALCITOL 2MCG CAPS Tier 2 PA B/D PARICALCITOL 4MCG CAPS Tier 2 PA B/D CANDESARTAN CILEXETIL 16MG TABS Tier 2 DULOXETINE HCL 20MG CPEP Tier 2 DULOXETINE HCL 30MG CPEP Tier 2 DULOXETINE HCL 60MG CPEP Tier 2 DECITABINE 50MG SOLR Tier 5 PA B/D CANDESARTAN CILEXETIL 32MG TABS Tier 2 NORETHINDRONE 0.35MG TABS Tier 2 LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN 500MG; 500MG; 30MG MISC Tier 2 NUVIGIL 150MG TABS Tier 3 FENOFIBRIC ACID DR 135MG CPDR Tier 2 FENOFIBRIC ACID DR 45MG CPDR Tier 2 ACAMPROSATE CALCIUM DR 333MG TBEC Tier 2 RABEPRAZOLE SODIUM 20MG TBEC Tier 2 CLEMASTINE FUMARATE 0.67MG/5ML SYRP Tier 2 ADEFOVIR DIPIVOXIL 10MG TABS Tier 5 MORPHINE SULFATE ER 10MG CP24 Tier 2 QL ACITRETIN 17.5MG CAPS Tier 5 GATIFLOXACIN 0.5% SOLN Tier 2 4
5 Formulary Removals: Effective 04/01/2014 Drug ONTAK 150MCG/ML SOLN ENDOCET 500MG; 7.5MG TABS ENDOCET 650MG; 10MG TABS ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE 712.8MG; 60MG; 32MG TABS ICLUSIG 15MG TABS ICLUSIG 45MG TABS LEUKINE 500MCG/ML SOLN CIMETIDINE HCL 150MG/ML SOLN TOBRAMYCIN SULFATE/SODIUM CHLORIDE 0.9%; 1.2MG/ML SOLN CLARINEX REDITABS 2.5MG TBDP CLARINEX REDITABS 5MG TBDP FREAMINE III 72MEQ/L; 600MG/100ML; 810MG/100ML; 3MEQ/L; 14MG/100ML; 1190MG/100ML; 240MG/100ML; 590MG/100ML; 770MG/100ML; 620MG/100ML; 450MG/100ML; 480MG/100ML; 10MMOLE/L; 115MG/100ML; 950MG/100ML; 500MG/100ML; 10MEQ/L; 340MG/100ML; 130MG/100ML; 560MG/100M PREZISTA 400MG TABS COMBIVENT 103MCG/ACT; 18MCG/ACT AERO HYDROCODONE/ACETAMINOPHEN 500MG; 2.5MG TABS ELSPAR 10000UNIT SOLR ASTRAMORPH 0.5MG/ML SOLN ASTRAMORPH 1MG/ML SOLN LEVOTHROID 25MCG TABS LEVOTHROID 50MCG TABS LEVOTHROID 75MCG TABS LEVOTHROID 88MCG TABS LEVOTHROID 100MCG TABS LEVOTHROID 112MCG TABS LEVOTHROID 137MCG TABS LEVOTHROID 150MCG TABS LEVOTHROID 175MCG TABS LEVOTHROID 200MCG TABS LEVOTHROID 300MCG TABS LEVOTHROID 125MCG TABS Reason Cost Sharing Tier Updates: There were no cost sharing tier updates this month. 5
6 For more information about how these changes may affect your cost-sharing, such as copayments or coinsurance, or for more information about asking for an updated coverage determination or a formulary exception, please see the plan Evidence of Coverage. Alternative drugs are drugs in the same therapeutic category/class as the affected drug. Only your doctor can determine alternative drugs that are appropriate for you given the individualized nature of drug therapy. Please talk to your doctor about any changes or recommendations to your medical care and prescription drug therapy. Alternative drugs and additional information about formulary changes can be found on the plan formulary, *Indicates a restriction of Step Therapy, Prior Authorization or Quantity Level Limits may exist. LA = Limited Access, PA = Prior Authorization, QL = Quantity Limit, ST = Step Therapy Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayment/coinsurance may change on January 1, This document includes GuildNet Gold and GuildNet Health Advantage partial formulary as of 04/01/2014. For a complete, updated formulary, please visit our Web site at or call the Member Service number below. This information is available for free in other languages. Please contact Member Services number at for additional information. (TTY users should call ). Hours are Monday through Friday, 8am -8pm. Member Services has free language interpreter services available for non- English speakers. Esta información esta disponible en otros idiomas a gratis. Por favor llame a Servicios a los Clientes, al por información adicional. (Los usuarios de TTY deben llamar al ). Se atiende de lunes a viernes, de 8 a. m. a 8 p. m. Servicios a los Clientes tienen los servicios gratuitos de intérprete de idioma disponibles para altavoces de no-inglés. GuildNet Gold and GuildNet Health Advantage are HMO-POS SNP plans with Medicare and New York State contracts. Enrollment in GuildNet Gold and GuildNet Health Advantage depends on contract renewal. 6
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