2015 FORMULARY CHANGE NOTICE

Size: px
Start display at page:

Download "2015 FORMULARY CHANGE NOTICE"

Transcription

1 Cigna-HealthSpring Primary (HMO),, Cigna-HealthSpring TotalCare AR (HMO SNP), Cigna-HealthSpring TotalCare SMS (HMO SNP), 2015 FORMULARY CHANGE NOTICE PLEASE NOTE THESE IMPORTANT CHANGES TO YOUR 2015 FORMULARY (LIST OF COVERED DRUGS) Formulary change Reason for Formulary change alternative Effective date of change: 08/01/2015 Tier alternative alosetron tab 0.5mg Enhancement Addition N/A N/A T1; PA; QL 60 EA per 30 days alosetron hcl tab 1 mg Enhancement Addition N/A N/A T1; PA; QL 60 EA per 30 days anaspaz Enhancement Addition N/A N/A T1 atropine 1% ophth sol Enhancement Addition N/A N/A T1 AURYXIA 210MG TABS Enhancement Addition N/A N/A T1 clozapine 150 mg disintegrating oral tablet Enhancement Addition N/A N/A T1 clozapine 200 mg disintegrating oral tablet Enhancement Addition N/A N/A T1 colchicine 0.6mg caps Enhancement Addition N/A N/A T1 colchicine 0.6mg tabs Enhancement Addition N/A N/A T1 ed spaz Enhancement Addition N/A N/A T1 glatopa 20mg/ml Enhancement Addition N/A N/A T1; QL 30 ML per 30 days hyoscyamine 0.125mg Enhancement Addition N/A N/A T1 hyoscyamine 0.125mg tabs Enhancement Addition N/A N/A T1 hyoscyamine 0.125mg tabs odt Enhancement Addition N/A N/A T1 hyoscyamine 0.125mg tabs subl Enhancement Addition N/A N/A T1 hyoscyamine 0.125mg/5ml elixir Enhancement Addition N/A N/A T1 hyosyne elixir Enhancement Addition N/A N/A T1 JADENU 180MG TABS Enhancement Addition N/A N/A T1 JADENU 360MG TABS Enhancement Addition N/A N/A T1 JADENU 90MG TABS Enhancement Addition N/A N/A T1 KINRIX Enhancement Addition N/A N/A T1 KUVAN POW 500MG Enhancement Addition N/A N/A T1; PA lopreeza 0.5mg; 0.1mg Enhancement Addition N/A N/A T1; PA lopreeza 1mg; 0.5mg Enhancement Addition N/A N/A T1; PA Notes 1

2 naftifine cre hcl 1% Enhancement Addition N/A N/A T1 nulev Enhancement Addition N/A N/A T1 oscimin Enhancement Addition N/A N/A T1 oscimin Enhancement Addition N/A N/A T1 oscimin Enhancement Addition N/A N/A T1 PAZEO Enhancement Addition N/A N/A T1 phenazopyridine 100mg tabs Enhancement Addition N/A N/A T1 phenazopyridine 200mg tabs Enhancement Addition N/A N/A T1 phospha neutral 250 Enhancement Addition N/A N/A T1 risedronate sodium tab 30 mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days risedronate sodium tab 35 mg Enhancement Addition N/A N/A T1; QL 4 EA per 28 days risedronate sodium tab 5 mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days salsalate 500mg tabs Enhancement Addition N/A N/A T1 salsalate 750mg tabs Enhancement Addition N/A N/A T1 SIMBRINZA 0.2%; 1% SUSP Enhancement Addition N/A N/A T1 symax fastabs Enhancement Addition N/A N/A T1 symax-sl Enhancement Addition N/A N/A T1 virt phos 250 neutral Enhancement Addition N/A N/A T1 Effective date of change: 07/01/2015 {21 (ethinyl estradiol 0.02 mg / levonorgestrel 0.1 mg Enhancement Addition N/A N/A T1 oral tablet) / 7 (inert ingredients 1 mg oral tablet) } pack aripiprazole tab 10mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 15mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 20mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 2mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 30mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) aripiprazole tab 5mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days; ST (new starts) bimatoprost 0.3 mg/ml ophthalmic solution Enhancement Addition N/A N/A T1; QL 5 ML per 30 days cefixime 20 mg/ml oral susp Enhancement Addition N/A N/A T1 cefixime 40 mg/ml oral susp Enhancement Addition N/A N/A T1 FOSRENOL PWDER 1000MG Enhancement Addition N/A N/A T1; ST FOSRENOL PWDER 750MG Enhancement Addition N/A N/A T1; ST 2

3 LEVOLEUCOVORIN 10 MG/ML INJECT SLTN Enhancement Addition N/A N/A T1 levoleucovorin 175mg/17.5ml Enhancement Addition N/A N/A T1 potassium chloride 1.33 meq/ml oral solution Enhancement Addition N/A N/A T1 potassium chloride 2.67 meq/ml oral solution Enhancement Addition N/A N/A T1 QUADRACEL Enhancement Addition N/A N/A T1 SAPHRIS SUB 2.5MG Enhancement Addition N/A N/A T1; QL 60 EA per 30 days; ST (new starts) tolcapone tab 100mg Enhancement Addition N/A N/A T1 LYRICA 25MG Enhancement Update N/A N/A QL increased to 90 EA per 30 days Effective date of change: 06/01/2015 BEXSERO Enhancement Addition N/A N/A T1 cefixime 100/5ml Enhancement Addition N/A N/A T1 cefixime 200/5ml Enhancement Addition N/A N/A T1 FARYDAK CAP 10MG Enhancement Addition N/A N/A T1; PA (new starts); QL 9 EA per 28 days FARYDAK CAP 15MG Enhancement Addition N/A N/A T1; PA (new starts); QL 9 EA per 28 days FARYDAK CAP 20MG Enhancement Addition N/A N/A T1; PA (new starts); QL 9 EA per 28 days fluoxetine 10mg cap Enhancement Addition N/A N/A T1 k-sol 10% Enhancement Addition N/A N/A T1 k-sol 20% Enhancement Addition N/A N/A T1 LENVIMA CAP 10MG Enhancement Addition N/A N/A T1; PA (new starts) LENVIMA CAP 14MG Enhancement Addition N/A N/A T1; PA (new starts) LENVIMA CAP 20MG Enhancement Addition N/A N/A T1; PA (new starts) LENVIMA CAP 24MG Enhancement Addition N/A N/A T1; PA (new starts) LEVEMIR FLEXPEN Enhancement Addition N/A N/A T1 levetiracetam 10 mg/ml sltn Enhancement Addition N/A N/A T1 levetiracetam 15 mg/ml sltn Enhancement Addition N/A N/A T1 levetiracetam 5 mg/ml sltn Enhancement Addition N/A N/A T1 omega-3 acid 900 mg cap Enhancement Addition N/A N/A T1; QL 120 EA per 30 days ondansetron 2 mg/ml prefilled syr Enhancement Addition N/A N/A T1 pramipexole mg er tab Enhancement Addition N/A N/A T1; QL 90 EA per 30 days pramipexole 0.75 mg er tab Enhancement Addition N/A N/A T1; QL 90 EA per 30 days pramipexole 1.5 mg er tab Enhancement Addition N/A N/A T1; QL 90 EA per 30 days PRISTIQ 25MG Enhancement Addition N/A N/A T1; QL 30 EA per 30 days ST (new starts) PROAIR RESPICLICK Enhancement Addition N/A N/A T1; QL 2 EA per 30 days 3

4 RELISTOR 0.4ML Enhancement Addition N/A N/A T1; PA; QL 12 ML per 30 days RELISTOR 0.6ML Enhancement Addition N/A N/A T1; PA; QL 28 ML per 28 days STRIVERDI RESPIMAT Enhancement Addition N/A N/A T1; QL 4 GM per 30 days tazicef 200 mg/ml (6gm) Enhancement Addition N/A N/A T1 testosterone cyp 200 mg/ml sltn Enhancement Addition N/A N/A T1; PA TOUJEO SOLO INJ 300IU/ML Enhancement Addition N/A N/A T1 tramadol er 100mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days tramadol er 200mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days tramadol er 300mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days zenatane 30mg Enhancement Addition N/A N/A T1 Effective date of change: 05/01/2015 ABILIFY MAINTENA 300MG SUSR Enhancement Addition N/A N/A T1; QL 1.5 EA per 30 days ARANESP INJ 10MCG Enhancement Addition N/A N/A T1; PA docetaxel 200mg/20ml vial Enhancement Addition N/A N/A T1; PA (Part B) famotidine 10mg/ml Enhancement Addition N/A N/A T1 fentanyl td patch 72hr 37.5 mcg/hr Enhancement Addition N/A N/A T1; QL 15 EA per 30 days fentanyl td patch 72hr 62.5 mcg/hr Enhancement Addition N/A N/A T1; QL 15 EA per 30 days fentanyl td patch 72hr 87.5 mcg/hr Enhancement Addition N/A N/A T1; QL 15 EA per 30 days GLEOSTINE 100MG CAP Enhancement Addition N/A N/A T1 GLEOSTINE 10MG CAP Enhancement Addition N/A N/A T1 GLEOSTINE 40MG CAP Enhancement Addition N/A N/A T1 IBRANCE 100MG CAP Enhancement Addition N/A N/A T1; PA (new starts); QL 21 EA per 28 days IBRANCE 125MG CAP Enhancement Addition N/A N/A T1; PA (new starts); QL 21 EA per 28 days IBRANCE 75MG CAP Enhancement Addition N/A N/A T1; PA (new starts); QL 21 EA per 28 days klor-con 8 tab Enhancement Addition N/A N/A T1 lamotrigine 100mg odt Enhancement Addition N/A N/A T1 lamotrigine 200mg odt Enhancement Addition N/A N/A T1 lamotrigine 25mg odt Enhancement Addition N/A N/A T1 lamotrigine 50mg odt Enhancement Addition N/A N/A T1 morphine sulf 4mg/ml Enhancement Addition N/A N/A T1 NORMOSOL-R Enhancement Addition N/A N/A T1; PA (Part B) potassium chloride er tab 20 meq Enhancement Addition N/A N/A T1 PREZCOBIX 150/800MG TAB Enhancement Addition N/A N/A T1 4

5 trezix 320.5mg; 30mg; 16mg cap Enhancement Addition N/A N/A T1; QL 360 EA per 30 days VITEKTA 150MG TAB Enhancement Addition N/A N/A T1 VITEKTA 85MG TAB Enhancement Addition N/A N/A T1 celecoxib 50mg tab Enhancement Update N/A N/A Step Therapy removed celecoxib 100mg tab Enhancement Update N/A N/A Step Therapy removed celecoxib 200mg tab Enhancement Update N/A N/A Step Therapy removed celecoxib 400mg tab Enhancement Update N/A N/A Step Therapy removed Effective date of change: 04/01/2015 BEXSERO VACCINE Enhancement Addition N/A N/A T1 esomeprazole 20mg dr cap Enhancement Addition N/A N/A T1; QL 60 EA per 30 days esomeprazole 40mg dr cap Enhancement Addition N/A N/A T1; QL 60 EA per 30 days EVOTAZ TAB Enhancement Addition N/A N/A T1 fenoprofen 400mg capsule Enhancement Addition N/A N/A T1 HARVONI 90MG; 400MG TAB Enhancement Addition N/A N/A T1; PA; QL 28 EA per 28 days ILEVRO 0.3% OPHTHALMIC SUSP Enhancement Addition N/A N/A T1 INTRALIPID Enhancement Addition N/A N/A T1; PA (Part B) KABIVEN EMULSION Enhancement Addition N/A N/A T1; PA (Part B) LIPOSYN II Enhancement Addition N/A N/A T1; PA (Part B) LIPOSYN III Enhancement Addition N/A N/A T1; PA (Part B) LYNPARZA 50 MG CAPSULE Enhancement Addition N/A N/A T1; PA (new starts); QL 480 EA per 30 days LYNPARZA 50MG CAPS Enhancement Addition N/A N/A T1; PA (new starts); QL 480 EA per 30 days OPDIVO INJ 100MG/10 SOLN Enhancement Addition N/A N/A T1; PA (new starts) OPDIVO INJ 40MG/4ML SOLN Enhancement Addition N/A N/A T1; PA (new starts) OPDIVO 40 MG/4 ML VIAL Enhancement Addition N/A N/A T1; PA (new starts) PERIKABIVEN EMULSION Enhancement Addition N/A N/A T1; PA (Part B) REYATAZ 100MG CAP Enhancement Addition N/A N/A T1 REYATAZ 50 MG POWDER PACKET Enhancement Addition N/A N/A T1 REYATAZ 50MG POWDER PACK Enhancement Addition N/A N/A T1 SANDIMMUNE ORAL SOLN 100MG/ML Enhancement Addition N/A N/A T1; PA (Part B) LUFYLLIN-400 TABLET Deletion No longer available theophylline T1 No longer available on market on market klor-con 8 tab Enhancement Addition N/A N/A T1 Effective date of change: 03/01/2015 5

6 ANDROGEL 1% GEL PUMP Enhancement Addition N/A N/A T1; PA ANDROGEL 1%(2.5G) GEL PACKET Enhancement Addition N/A N/A T1; PA ANDROGEL 1.62%(1.25G) GEL PCKT Enhancement Addition N/A N/A T1; PA ANDROGEL 1.62%(2.5G) GEL PCKT Enhancement Addition N/A N/A T1; PA AMINOSYN 7%-ELECTROLYTE SOL Enhancement Addition N/A N/A T1; PA (Part B) AMINOSYN-RF 5.2% IV SOLUTION Enhancement Addition N/A N/A T1; PA (Part B) CLINIMIX-E 4.25% Enhancement Addition N/A N/A T1; PA (Part B) CLINIMIX-E 5% Enhancement Addition N/A N/A T1; PA (Part B) deblitane 0.35 mg tablet Enhancement Addition N/A N/A T1 delyla-28 tablet Enhancement Addition N/A N/A T1 desogestr-eth estrad eth estra Enhancement Addition N/A N/A T1 diazepam 5 mg/ml Enhancement Addition N/A N/A QL 240 ML per 30 days docetaxel 20mg/ml Enhancement Addition N/A N/A T1; PA (Part B) docetaxel 80mg/4ml Enhancement Addition N/A N/A T1; PA (Part B) epinephrine 0.15 mg auto-injct Enhancement Addition N/A N/A QL 2 EA per 30 days estradiol dis 0.025mg Enhancement Addition N/A N/A T1; PA estradiol dis mg Enhancement Addition N/A N/A T1; PA estradiol dis 0.05mg Enhancement Addition N/A N/A T1; PA estradiol dis 0.1mg Enhancement Addition N/A N/A T1; PA falmina-28 tablet Enhancement Addition N/A N/A T1 FREAMINE HBC 6.9% IV SOLN Enhancement Addition N/A N/A T1; PA (Part B) furosemide 10 mg/ml syringe Enhancement Addition N/A N/A T1 GARDASIL 9 SYRINGE Enhancement Addition N/A N/A T1 GARDASIL 9 VIAL Enhancement Addition N/A N/A T1 GARDASIL SYRINGE Enhancement Addition N/A N/A T1 gildess 1.5mg Enhancement Addition N/A N/A T1 HUMIRA 10 MG/0.2 ML SYRINGE Enhancement Addition N/A N/A QL increased to 2 EA per 28 days INTRON A 18 MILLION UNITS VIAL Enhancement Addition N/A N/A T1 INTRON A 50 MILLION UNITS VIAL Enhancement Addition N/A N/A T1 ivermectin 3 mg tablet Enhancement Addition N/A N/A T1 KEYTRUDA 100MG/4ML Enhancement Addition N/A N/A T1; PA (new starts) lamivudine sol 10mg/ml Enhancement Addition N/A N/A T1 linezolid inj 2mg/ml Enhancement Addition N/A N/A T1; PA 6

7 MINIVELLE 0.025MG PATCH/24 HR Enhancement Addition N/A N/A T1; PA; QL 8 EA per 28 days NUTRILIPID 20% IV FAT EMULSION Enhancement Addition N/A N/A T1; PA (Part B) sharobel 0.35 mg tablet Enhancement Addition N/A N/A T1 TRUMENBA 120 MCG/0.5 ML VACCIN Enhancement Addition N/A N/A T1 DULERA 5MCG/100MCG Enhancement Update N/A N/A QL increased to 18 EA per 30 days DULERA 5MCG/200MCG Enhancement Update N/A N/A QL increased to 18 EA per 30 days SYMBICORT 160MCG/4.5MCG Enhancement Update N/A N/A QL increased to 12 EA per 30 days Effective date of change: 02/09/2015 clonazepam 0.5mg tabs Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam 1mg tabs Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam odt 0.125mg tbdp Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam odt 0.25mg tbdp Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam odt 0.5mg tbdp Enhancement Update N/A N/A QL increased to 300 EA per 30 days clonazepam odt 1mg tbdp Enhancement Update N/A N/A QL increased to 300 EA per 30 days escitalopram oxalate 10mg tabs Enhancement Update N/A N/A QL removed escitalopram oxalate 20mg tabs Enhancement Update N/A N/A QL removed escitalopram oxalate 5mg tabs Enhancement Update N/A N/A QL removed escitalopram oxalate 5mg/5ml soln Enhancement Update N/A N/A QL removed lansoprazole 15 mg cap Enhancement Update N/A N/A QL removed lansoprazole 30 mg cap Enhancement Update N/A N/A QL removed NEXIUM 10 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 2.5 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 20 MG CAP Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 20 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 40 MG CAP Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 40 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days NEXIUM 5 MG PACK Enhancement Update N/A N/A QL increased to 60 EA per 30 days omeprazole 10 mg cap Enhancement Update N/A N/A QL removed omeprazole 20 mg cap Enhancement Update N/A N/A QL removed omeprazole 40 mg cap Enhancement Update N/A N/A QL removed pantoprazole 20 mg tab Enhancement Update N/A N/A QL removed pantoprazole 40 mg tab Enhancement Update N/A N/A QL removed venlafaxine hcl 100mg tabs Enhancement Update N/A N/A QL removed 7

8 venlafaxine hcl 25mg tabs Enhancement Update N/A N/A QL removed venlafaxine hcl 37.5mg tabs Enhancement Update N/A N/A QL removed venlafaxine hcl 50mg tabs Enhancement Update N/A N/A QL removed venlafaxine hcl 75mg tabs Enhancement Update N/A N/A QL removed venlafaxine hcl er 150mg cp24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 150mg tb24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 37.5mg cp24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 37.5mg tb24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 75mg cp24 Enhancement Update N/A N/A QL removed venlafaxine hcl er 75mg tb24 Enhancement Update N/A N/A QL removed Effective date of change: 01/01/2015 ace acd/alum sol 2% otic Enhancement Addition N/A N/A T1 adrucil inj 500/10ml Enhancement Addition N/A N/A T1; PA (Part B) adrucil inj 5gm/100m Enhancement Addition N/A N/A T1; PA (Part B) ALOPRIM 500MG Enhancement Addition N/A N/A T1 amikacin inj 1gm/4ml Enhancement Addition N/A N/A T1 amiodarone inj 50mg/ml Enhancement Addition N/A N/A T1 amiodarone inj 50mg/ml Enhancement Addition N/A N/A T1 amlod/valsar tab mg Enhancement Addition N/A N/A T1 amlod/valsar tab 5-160mg Enhancement Addition N/A N/A T1 amlod/valsar tab 5-320mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 10mg; 12.5mg; 160mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 10mg; 25mg; 160mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 10mg; 25mg; 320mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 5mg; 12.5mg; 160mg Enhancement Addition N/A N/A T1 amlod/valsartan/hctz 5mg; 25mg; 160mg Enhancement Addition N/A N/A T1 amlod-valsar tab mg Enhancement Addition N/A N/A T1 ampicillin inj 2gm Enhancement Addition N/A N/A T1 amp-sulbacta inj 1.5gm Enhancement Addition N/A N/A T1 BELEODAQ Enhancement Addition N/A N/A T1; PA (new starts) bromfenac 0.09% 1.7ml bottle Enhancement Addition N/A N/A T1 butalbital/apap/caffeine 500/50/40 Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days 8

9 butalbital/apap/caffeine; butalbital compound products Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days butalbital/aspirin/caffeine 325/50/40 Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days BYDUREON INJ PEN Enhancement Addition N/A N/A T1; QL 4 EA per 28 days cefaclor 125mg/5ml susr Enhancement Addition N/A N/A T1 cefaclor 250mg/5ml susr Enhancement Addition N/A N/A T1 cefaclor 375mg/5ml susr Enhancement Addition N/A N/A T1 ceftriaxone inj 2gm Enhancement Addition N/A N/A T1 cefuroxime inj 7.5gm Enhancement Addition N/A N/A T1 celecoxib 100mg cap Enhancement Addition N/A N/A T1; ST; QL 60 EA per 30 days celecoxib 200mg cap Enhancement Addition N/A N/A T1; ST; QL 60 EA per 30 days celecoxib 400mg cap Enhancement Addition N/A N/A T1; ST; QL 60 EA per 30 days celecoxib 50mg cap Enhancement Addition N/A N/A T1; ST; QL 60 EA per 30 days ciclodan cre 0.77% Enhancement Addition N/A N/A T1 ciclodan sol 8% Enhancement Addition N/A N/A T1 ciprofloxacin 50 mg/ml Enhancement Addition N/A N/A T1 cisplatin inj 200mg Enhancement Addition N/A N/A T1; PA (Part B) cisplatin inj 50/50ml Enhancement Addition N/A N/A T1; PA (Part B) clobetasol aer 0.05% Enhancement Addition N/A N/A T1 clobetasol propionate Enhancement Addition N/A N/A T1 clobetasol propionate 0.05% foam Enhancement Addition N/A N/A T1 clobetasol shampoo 0.05% Enhancement Addition N/A N/A T1 clodan shampoo Enhancement Addition N/A N/A T1 CYRAMZA 100MG/10ML INJ Enhancement Addition N/A N/A T1; PA (new starts) CYRAMZA 500MG/50ML INJ Enhancement Addition N/A N/A T1; PA (new starts) DELESTROGEN 10MG/ML OIL Enhancement Addition N/A N/A T1 DELESTROGEN 20MG/ML OIL Enhancement Addition N/A N/A T1 DELESTROGEN 40MG/ML OIL Enhancement Addition N/A N/A T1 dexamethason sol 0.5/5ml Enhancement Addition N/A N/A T1 dexamethasone sodium phosphate 10mg/ml Enhancement Addition N/A N/A T1 dexrazoxone 500mg Enhancement Addition N/A N/A T1; PA (Part B) dextrose 5%/lactated ringers Enhancement Addition N/A N/A T1 diclofenac sod 1.5% Enhancement Addition N/A N/A T1 9

10 digitek 0.125mg Enhancement Addition N/A N/A T1; QL 30 EA per 30 days digitek 0.250mg Enhancement Addition N/A N/A T1; PA diltiazem cd 360mg Enhancement Addition N/A N/A T1 diltiazem hcl er 180mg tb24 Enhancement Addition N/A N/A T1 diltiazem hcl er 240mg tb24 Enhancement Addition N/A N/A T1 diltiazem hcl er 300mg tb24 Enhancement Addition N/A N/A T1 diltiazem hcl er 360mg tb24 Enhancement Addition N/A N/A T1 diltiazem hcl er 420mg tb24 Enhancement Addition N/A N/A T1 docetaxel 20mg/ml Enhancement Addition N/A N/A T1; PA (Part B) doxy 100mg Enhancement Addition N/A N/A T1 entecavir 0.5mg Enhancement Addition N/A N/A T1 entecavir 1mg Enhancement Addition N/A N/A T1 esgic 325mg; 50mg; 40mg Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days famotidine inj 200/20ml Enhancement Addition N/A N/A T1 famotidine inj 40mg/4ml Enhancement Addition N/A N/A T1 fluocinolone acetonide body 0.1% Enhancement Addition N/A N/A T1 fluocinolone acetonide scalp 0.1% Enhancement Addition N/A N/A T1 FLUOROURACIL CREAM 0.5% Enhancement Addition N/A N/A T1 fluorouracil inj 1gm/20ml Enhancement Addition N/A N/A T1; PA (Part B) fluorouracil inj 500/10ml Enhancement Addition N/A N/A T1; PA (Part B) fluorouracil inj 5gm/100m Enhancement Addition N/A N/A T1; PA (Part B) fluoxetine 20mg Enhancement Addition N/A N/A T1 gamunex-c 40gm/400mls Enhancement Addition N/A N/A T1; PA (Part B) GARDASIL SUSP Enhancement Addition N/A N/A T1 gentam/nacl inj 100mg pb Enhancement Addition N/A N/A T1 glipizide xl 10 tb24 Enhancement Addition N/A N/A T1 glipizide xl 10mg Enhancement Addition N/A N/A T1 glipizide xl 2.5 tb24 Enhancement Addition N/A N/A T1 glipizide xl 2.5mg Enhancement Addition N/A N/A T1 glipizide xl 5 tb24 Enhancement Addition N/A N/A T1 glipizide xl 5mg Enhancement Addition N/A N/A T1 glycopyrrol inj 0.2mg/ml Enhancement Addition N/A N/A T1 glycopyrrol inj 0.2mg/ml Enhancement Addition N/A N/A T1 10

11 glycopyrrol inj 0.2mg/ml Enhancement Addition N/A N/A T1 heparin sodium/sodium chloride 0.9% premix Enhancement Addition N/A N/A T1 HUMIRA INJ 10MG/0.2 Enhancement Addition N/A N/A T1; PA; QL 0.4 EA per 28 days HUMIRA PEDIATRIC KIT CROHNS STARTER Enhancement Addition N/A N/A T1; PA; QL 6 EA per 28 days HUMIRA PSORIASIS STARTER KIT Enhancement Addition N/A N/A T1; PA; QL 4 EA per 28 days ifosfamide inj 1gm/20ml Enhancement Addition N/A N/A T1; PA (Part B) ifosfamide inj 3gm/60ml Enhancement Addition N/A N/A T1; PA (Part B) INTRON A INJ 10MU Enhancement Addition N/A N/A T1 INTRON A INJ 18MU Enhancement Addition N/A N/A T1 INTRON A INJ 50MU Enhancement Addition N/A N/A T1 INVOKAMET 150/1000MG TAB Enhancement Addition N/A N/A T1; QL 60 EA per 30 days INVOKAMET 150/500MG TAB Enhancement Addition N/A N/A T1; QL 60 EA per 30 days INVOKAMET 50/1000MG TAB Enhancement Addition N/A N/A T1; QL 60 EA per 30 days INVOKAMET 50/500MG TAB Enhancement Addition N/A N/A T1; QL 60 EA per 30 days INVOKANA 100MG Enhancement Addition N/A N/A T1; QL 30 EA per 30 days INVOKANA 300MG Enhancement Addition N/A N/A T1; QL 30 EA per 30 days irinotecan inj 40mg/2ml Enhancement Addition N/A N/A T1; PA (Part B) irinotecan inj 500mg/25 Enhancement Addition N/A N/A T1; PA (Part B) ISENTRESS 100MG POWDER PACK Enhancement Addition N/A N/A T1 ivermectin tab 3mg Enhancement Addition N/A N/A T1 KEYTRUDA 50MG SOLR Enhancement Addition N/A N/A T1; PA (new starts) LEVEMIR FLEXTOUCH Enhancement Addition N/A N/A T1 levonor/ethi tab estradio Enhancement Addition N/A N/A T1 lidocaine hcl jelly * gel 2% Enhancement Addition N/A N/A T1 lidocaine hcl jelly * gel 2% Enhancement Addition N/A N/A T1 lorazepam intensol Enhancement Addition N/A N/A T1; QL 120 ML per 30 days lorazepam intensol 2mg/ml conc Enhancement Addition N/A N/A T1; QL 120 ML per 30 days LUPRON DEPOT-PED Enhancement Addition N/A N/A T1; PA (new starts); QL 1 EA per 30 days magnesium sulfate soln Enhancement Addition N/A N/A T1; PA (Part B) methadone intensol Enhancement Addition N/A N/A T1; QL 500 ML per 30 days MINIVELLE PATCH MG/24 HR Enhancement Addition N/A N/A T1; PA; QL 8 EA per 28 days MINIVELLE PATCH 0.05MG/24 HR Enhancement Addition N/A N/A T1; PA; QL 8 EA per 28 days MINIVELLE PATCH 0.075MG/24 HR Enhancement Addition N/A N/A T1; PA; QL 8 EA per 28 days 11

12 mitoxantrone inj 2mg/ml Enhancement Addition N/A N/A T1; PA (Part B) mitoxantrone inj 2mg/ml Enhancement Addition N/A N/A T1; PA (Part B) morphine sulfate add-vantage Enhancement Addition N/A N/A T1 mycophenolate mofetil for oral susp 200 mg/ml Enhancement Addition N/A N/A T1; PA (Part B) nafcillin inj 1gm Enhancement Addition N/A N/A T1 NAMENDA 10MG Enhancement Addition N/A N/A T1; QL 60 EA per 30 days NAMENDA 5MG Enhancement Addition N/A N/A T1; QL 90 EA per 30 days NAMENDA TITRATION PACK Enhancement Addition N/A N/A T1; QL 49 EA per 28 days neo-polycin oin hc 1%op Enhancement Addition N/A N/A T1 NEUPOGEN 300MCG/ML VIAL Enhancement Addition N/A N/A T1; PA NEXIUM 10MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 2.5MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 20MG DR CAPSULE Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 20MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 40MG DR CAPSULE Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 40MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NEXIUM 5MG PACK Enhancement Addition N/A N/A T1; QL 30 EA per 30 days NIPENT Enhancement Addition N/A N/A T1; PA (Part B) norlyroc Enhancement Addition N/A N/A T1 ondansetron inj 40/20ml Enhancement Addition N/A N/A T1 oxacillin sodium 1g solr Enhancement Addition N/A N/A T1 oxaliplatin inj 100mg Enhancement Addition N/A N/A T1; PA (Part B) oxaliplatin inj 50mg Enhancement Addition N/A N/A T1; PA (Part B) oxycodone 2.5mg/325 mg tab Enhancement Addition N/A N/A T1; QL 360 EA per 30 days paclitaxel inj 100mg Enhancement Addition N/A N/A T1; PA (Part B) paclitaxel inj 150/25ml Enhancement Addition N/A N/A T1; PA (Part B) paclitaxel inj 30mg/5ml Enhancement Addition N/A N/A T1; PA (Part B) pamidronate inj 30mg Enhancement Addition N/A N/A T1; PA (Part B) pamidronate inj 90mg Enhancement Addition N/A N/A T1; PA (Part B) paroex soln Enhancement Addition N/A N/A T1 PEGINTRON KIT 120MCG Enhancement Addition N/A N/A T1; PA PEGINTRON KIT 150MCG Enhancement Addition N/A N/A T1; PA PEGINTRON KIT 50MCG Enhancement Addition N/A N/A T1; PA 12

13 PEGINTRON KIT 80MCG Enhancement Addition N/A N/A T1; PA pot chloride tab 8meq er Enhancement Addition N/A N/A T1 potassium chloride 0.15% d5w/ nacl 0.45% viaflex Enhancement Addition N/A N/A T1; PA (Part B) potassium chloride 0.15% d5w/ nacl 0.9% viaflex Enhancement Addition N/A N/A T1; PA (Part B) potassium citrate cr 15meq Enhancement Addition N/A N/A T1 prednisolone sol 15mg/5ml Enhancement Addition N/A N/A T1 prednisone pak 5mg Enhancement Addition N/A N/A T1 PURIXAN SUS 20MG/ML Enhancement Addition N/A N/A T1; PA (new starts) RECOMBIVA HB INJ 5MCG/0.5 Enhancement Addition N/A N/A T1; PA (Part B) rosadan cre 0.75% Enhancement Addition N/A N/A T1 SILVER SULFADIAZINE CREAM 1% Enhancement Addition N/A N/A T1 sirolimus 1mg tab Enhancement Addition N/A N/A T1; PA (Part B) sirolimus 2mg tab Enhancement Addition N/A N/A T1; PA (Part B) sod poly sul sus 30/120ml Enhancement Addition N/A N/A T1 sodium bicarbonate Enhancement Addition N/A N/A T1 SOMAVERT 25MG Enhancement Addition N/A N/A T1; PA; QL 30 EA per 30 days SOMAVERT 30MG Enhancement Addition N/A N/A T1; PA; QL 30 EA per 30 days SPIRIVA RESPIMAT Enhancement Addition N/A N/A T1; QL 4 EA per 30 days sulfasalazine Enhancement Addition N/A N/A T1 sulfasalazine 500mg tbec Enhancement Addition N/A N/A T1 sulfatrim pediatric Enhancement Addition N/A N/A T1 sulfatrim pediatric 200mg/5ml; 40mg/5ml susp Enhancement Addition N/A N/A T1 sumatriptan inj 6mg/0.5 Enhancement Addition N/A N/A T1; QL 8 EA per 30 days SUTENT 37.5MG Enhancement Addition N/A N/A T1; PA (new starts) tacrolimus ointment 0.1% Enhancement Addition N/A N/A T1 tacrolimus ointment 0.3% Enhancement Addition N/A N/A T1 tarina fe Enhancement Addition N/A N/A T1 theophylline tab 100mg er Enhancement Addition N/A N/A T1 tobramycin inj 1.2/30ml Enhancement Addition N/A N/A T1 tobramycin inj 40mg/ml Enhancement Addition N/A N/A T1 TREANDA INJECTION 180 MG/2 ML VIAL Enhancement Addition N/A N/A T1; PA (Part B) 13

14 TREANDA INJECTION 45 MG/0.5 ML VIAL Enhancement Addition N/A N/A T1; PA (Part B) tretinoin microsphere pump Enhancement Addition N/A N/A T1; PA; QL 50 GM per 30 days TRIUMEQ 600/50/300MG Enhancement Addition N/A N/A T1; QL 30 EA per 30 days TYBOST 150MG TAB Enhancement Addition N/A N/A T1 valganciclovir hcl tab 450 mg Enhancement Addition N/A N/A T1 valsartan 160mg Enhancement Addition N/A N/A T1 valsartan 320mg Enhancement Addition N/A N/A T1 valsartan 40mg Enhancement Addition N/A N/A T1 valsartan 80mg Enhancement Addition N/A N/A T1 XARELTO STAR TAB 15/20MG Enhancement Addition N/A N/A T1; QL 102 EA per 365 days zebutal 325mg; 50mg; 40mg Enhancement Addition N/A N/A T1; PA; QL 180 EA per 30 days ZENPEP UNIT; 40000UNIT; UNIT Enhancement Addition N/A N/A T1 CPEP zinecard 500mg Enhancement Addition N/A N/A T1; PA (Part B) zoledronic inj 4mg Enhancement Addition N/A N/A T1; PA (Part B) ZYDELIG 100MG Enhancement Addition N/A N/A T1; PA (new starts); QL 60 EA per 30 days ZYDELIG 150MG Enhancement Addition N/A N/A T1; PA (new starts); QL 60 EA per 30 days SEROQUEL XR 150MG Enhancement Update N/A N/A Step Therapy removed SEROQUEL XR 200MG Enhancement Update N/A N/A Step Therapy removed SEROQUEL XR 300MG Enhancement Update N/A N/A Step Therapy removed SEROQUEL XR 400MG Enhancement Update N/A N/A Step Therapy removed SEROQUEL XR 50MG Enhancement Update N/A N/A Step Therapy removed buprenorphine 0.3mg/ml inj Enhancement Update N/A N/A PA removed BYDUREON INJ PEN Enhancement Update N/A N/A QL increased to 4 EA per 28 days ELIQUIS 2.5MG TAB Enhancement Update N/A N/A PA removed ELIQUIS 5MG TAB Enhancement Update N/A N/A PA removed ELIQUIS 5MG TAB Enhancement Update N/A N/A PA removed HUMIRA PEN-PSORIASIS STARTER Enhancement Update N/A N/A QL increased to 6 EA per 28 days PRADAXA 150MG TAB Enhancement Update N/A N/A PA removed PRADAXA 75MG TAB Enhancement Update N/A N/A PA removed SYMLIN PEN 120 Enhancement Update N/A N/A QL increased to 11 EA per 28 days XARELTO 10 MG TAB Enhancement Update N/A N/A PA removed XARELTO 15 MG TAB Enhancement Update N/A N/A PA removed 14

15 XARELTO 20 MG TAB Enhancement Update N/A N/A PA removed 15

16 Formulary change Reason for change Formulary alternative Tier alternative Notes Cost-sharing tier description key Utilization management requirements/limits key Tier 1: Preferred drugs. PA: Prior authorization is required QL: Quantity limits apply RA: Restricted access. This prescription may be available only at certain pharmacies. MO: Mail order ST: Step therapy is required B vs. D: Coverage determination for Part B or Part D required. Note: Inhalant solutions used in a nebulizer are only covered under Part D when the member is located in a long term care (LTC) setting. You have a right to ask us to make a coverage determination, including an exception to this change. You can ask us to make a coverage determination about the drug(s) or payment you need, including an exception. Look in your Evidence of Coverage for information about how to ask for a coverage decision, including an exception. If you have any questions, please contact Cigna-HealthSpring at , 8 am 8 pm, 7 days a week. TTY/TDD users should call 711. This information is available for free in other languages. Please call our customer service number at (TTY 711), 8 am 8 pm, 7 days a week. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al (TTY 711), 8 a.m. a 8 p.m., 7 días de la semana, Los usuarios de TTY deben llamar al TTY number. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. 16

2014 Medicare Part D Formulary Change

2014 Medicare Part D Formulary Change 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

More information

2015 Formulary Addendum Notice of Change

2015 Formulary Addendum Notice of Change 2015 Formulary Addendum Notice of Change Prescription Drug Plans WellCare Prescription Insurance, Inc. WellCare Extra (PDP) This is a listing of the changes that have occurred in our formulary. Please

More information

Drug Cost Estimates Generics

Drug Cost Estimates Generics Cost Estimates Generics Note: The retail pharmacy prices displayed below are estimates only. The actual price of your prescription W/ CODEINE TAB 300-30 MG ACYCLOVIR TAB 400 MG ALBUTEROL INHAL AEROSOL

More information

Extra Value Drug List. *

Extra Value Drug List. * List. * Brand Diabetes Levemir 100 units/ml Vial 10mL $122.29 Levemir FlexPen 100 units/ml 15mL $203.03 NovoLog 100 units/ml Vial 10mL $116.84 NovoLog FlexPen Syringe 15mL $222.41 NovoLog 100 units/ml

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Premier (HMO-POS) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Premier (HMO-POS). Next year, there will

More information

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative

More information

Preferred Drug List Updates Effective: Jan. 1, 2016

Preferred Drug List Updates Effective: Jan. 1, 2016 Molina Healthcare regularly reviews and updates the Preferred Drug List (PDL). Items may be added, removed or changed. Below is the list of updates made to the PDL this quarter. Some items require a prior

More information

2016 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary)

2016 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary) 2016 Cigna-HealthSpring Rx COMPREHENSIVE LIST (Formulary) Please read: This document contains information about all of the drugs we cover in this plan. Plan covered Cigna-HealthSpring Rx Secure (PDP) This

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Cigna-HealthSpring Rx Secure (PDP) offered by Cigna HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna Medicare Rx Secure (PDP). Next year, there will be some

More information

Magellan Rx Medicare Basic (PDP) 2016 Formulary. (List of Covered Drugs)

Magellan Rx Medicare Basic (PDP) 2016 Formulary. (List of Covered Drugs) Magellan Rx Medicare Basic (PDP) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN Formulary File 16144, Version 22 This formulary

More information

Emergency Medications Approved for Use at VAPAHCS

Emergency Medications Approved for Use at VAPAHCS Table 1: Medications (PAD GM&S) Emergency Medications Approved for Use at VAPAHCS PAD GM&S (See HCSM 11-12-35 Attachment A CPR Committee Atropine 1mg/10ml syringe X 3 Normal saline 1000ml bag X 2 Sodium

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring TotalCare (HMO SNP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring TotalCare (HMO SNP). Next year, there

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring Rx Secure (PDP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring Rx Secure (PDP). Next year, there will be

More information

CONTRACT UPDATE August 10, 2012

CONTRACT UPDATE August 10, 2012 CONTRACT UP August 10, 2012 ADDS SODIUM CHLORIDE INHAL SOL 10% 4MLX60 00487-9010-60 $16.05 NEPHRON PHARMACEUTICALS 08-06-2012 12--2012 ADDS SODIUM CHLORIDE INHAL SOL 7% 4MLX60 00487-9007-60 $16.05 NEPHRON

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring TotalCare SMS (HMO SNP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring TotalCare SMS (HMO SNP). Next year,

More information

FORMULARY. (List of Covered Drugs) Molina Dual Options Medicare-Medicaid Plan

FORMULARY. (List of Covered Drugs) Molina Dual Options Medicare-Medicaid Plan FORMULARY (List of Covered Drugs) 2015 Molina Dual Options Medicare-Medicaid Plan Version 14 UPDATED: 11/2015 Member Services (877) 901-8181, TTY/TDD 711 Monday - Friday, 8 a.m. - 8 p.m. local time H8046_15_16003_0002_MMPILRx

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring Rx Secure (PDP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring Rx Secure (PDP). Next year, there will be

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Cigna-HealthSpring Rx Secure-Xtra (PDP) offered by Cigna-HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna Medicare Rx Secure-Xtra (PDP). Next year, there will

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring TotalCare (HMO SNP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring TotalCare (HMO SNP). Next year, there

More information

Medicare Part D Transition Policy CY 2016 HCSC Medicare Part D

Medicare Part D Transition Policy CY 2016 HCSC Medicare Part D Blue Cross Medicare Advantage (HMO) SM / Blue Cross Medicare Advantage (HMO-POS) SM / Blue Cross Medicare Advantage (PPO) SM Medicare Part D Transition Policy CY 2016 HCSC Medicare Part D Medicare Part

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring Rx Secure (PDP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring Rx Secure (PDP). Next year, there will be

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring Rx Secure Extra (PDP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring Rx Secure Xtra (PDP). Next year, there

More information

AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan

AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan 2015 List of Covered Drugs/Formulary Aetna Better Health of Ohio, a MyCare Ohio plan (Medicare-Medicaid Plan) is a health plan that contracts with Medicare

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Cigna-HealthSpring Advantage (HMO) offered by Cigna-HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna-HealthSpring Advantage (HMO). Next year, there will be

More information

PROJECT LIST GENERIC PRODUCTS

PROJECT LIST GENERIC PRODUCTS PROJECT LIST GENERIC PRODUCTS Acetylcysteine, Effervescent tablets 200 mg, 600 mg Alendronate sodium, Tablets 10, 70 mg Alfuzosin,Tablets 2.5mg Alfuzosin, ER Tablets 10 mg Ambroxol, Effervescent tablets

More information

2015 List of Covered Drugs

2015 List of Covered Drugs +B/LVW2I'UXJV5B$SSURYHG 2015 List of Covered s (Formulary) FOR MORE INFORMATION, contact Member Services at 1-855-735-4398 from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. On weekends and

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Traditions (HMO SNP) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Traditions (HMO SNP). Next year, there

More information

2015 Comprehensive Formulary Aetna Medicare

2015 Comprehensive Formulary Aetna Medicare Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2015 Comprehensive Formulary Aetna Medicare (List of Covered s) Standard Formulary 2 PLEASE READ: This document

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 1 Cigna-HealthSpring Preferred Plus HMO offered by Cigna HealthCare of Arizona, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred Plus. Next

More information

Asthma, COPD and Diabetes Preferred Drug List Medications

Asthma, COPD and Diabetes Preferred Drug List Medications GPI Name Dexamethasone Tab 0.5 MG Dexamethasone Tab 0.75 MG Dexamethasone Tab 1 MG Dexamethasone Tab 1.5 MG Dexamethasone Tab 2 MG Dexamethasone Tab 4 MG Dexamethasone Tab 6 MG Dexamethasone Elixir 0.5

More information

Plan Year Allegian Advantage (HMO) Step Therapy Criteria (ST)

Plan Year Allegian Advantage (HMO) Step Therapy Criteria (ST) Plan Year 2015 Allegian Advantage (HMO) Step Therapy (ST) Step Therapy: In some cases, Allegian Advantage requires you to first try certain drugs to treat your medical condition before we will cover another

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Cigna-HealthSpring Advantage (HMO) offered by Cigna-HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna-HealthSpring Advantage (HMO). Next year, there will be

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring Rx Secure Extra (PDP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring Rx Secure Xtra (PDP). Next year, there

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be

More information

Retail Prescription Program Drug List

Retail Prescription Program Drug List Retail Prescription Program Drug List Price Matters New Men s Health Category Convenience Free Home Delivery Our 4 prescriptions have saved our customers over 3 billion The program is available to everyone,

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Tufts Medicare Preferred PDP Plus (Medicare Prescription Drug Plan) offered by Tufts Health Plan Medicare Preferred Annual Notice of Changes for 2015 You are currently enrolled as a member of Tufts Medicare

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 P.O. Box 52424, Phoenix, AZ 85072-2424 SilverScript Plus (PDP) offered by SilverScript Insurance Company Annual Notice of Changes for 2016 You are currently enrolled as a member of SilverScript Plus (PDP).

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Cigna-HealthSpring Rx Secure (PDP) offered by Cigna HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna Medicare Rx Secure (PDP). Next year, there will be some

More information

May 2015 P&T Updates. Prior Authorization. Traditional. Formulary. Yes No. Formulary. Non Formulary. Non Formulary. Non Formulary

May 2015 P&T Updates. Prior Authorization. Traditional. Formulary. Yes No. Formulary. Non Formulary. Non Formulary. Non Formulary Commercial Triple Tier 4th Tier Applicable Traditional s EVOTAZ 2 2 Alternatives Flovent Diskus/HFA, Pulmicort Flexhaler, Qvar, Asmanex HFA eszopiclone, zaleplon, zolpidem, amitriptyline, mirtazapine,

More information

November 5, 2015 Quarterly pharmacy formulary change notice

November 5, 2015 Quarterly pharmacy formulary change notice November 5, 2015 Quarterly pharmacy formulary change notice The formulary changes listed in the table below were reviewed and approved at the 2nd Quarter Pharmacy and Therapeutics (P&T) Committee meetings

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be

More information

2015 Medicare Part D Step Therapy Requirements. Effective: November 01, 2015

2015 Medicare Part D Step Therapy Requirements. Effective: November 01, 2015 2015 Medicare Part D Step Therapy Requirements Effective: November 01, 2015 Formulary ID 15293, Version 17 Last Updated: 10/27/2015 BISPHOSPHONATE THERAPY ACTONEL 30 MG TABLET ACTONEL 35 MG TABLET ACTONEL

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred Plus (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred Plus (HMO). Next year, there

More information

Drugs covered under Medicare Part B or Part D

Drugs covered under Medicare Part B or Part D LABEL_NAME GENERIC_NAME MESSAGE GEMZAR INJ 1 GM GEMCITABINE HCL FOR INJ 1 GM ALIMTA INJ 500MG PEMETREXED DISODIUM FOR IV SOLN 500 MG (BASE EQUIV) FUNGIZONE INJ 50MG AMPHOTERICIN B FOR INJ 50 MG KYTRIL

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 P.O. Box 52424, Phoenix, AZ 85072-2424 SilverScript Choice (PDP) offered by SilverScript Insurance Company Annual Notice of Changes for 2016 You are currently enrolled as a member of SilverScript Choice

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 P.O. Box 52424, Phoenix, AZ 85072-2424 SilverScript Choice (PDP) offered by SilverScript Insurance Company Annual Notice of Changes for 2015 You are currently enrolled as a member of BlueRx Standard (PDP).

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be

More information

First Health Part D Premier Plus (PDP) 2014 Formulary. (List of Covered Drugs)

First Health Part D Premier Plus (PDP) 2014 Formulary. (List of Covered Drugs) 2014 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/28/2014. For more recent information or other questions,

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Cigna HealthSpring Preferred (HMO) offered by Cigna HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna HealthSpring Preferred (HMO). Next year, there will be

More information

First Health Part D Value Plus (PDP) 2014 Formulary. (List of Covered Drugs)

First Health Part D Value Plus (PDP) 2014 Formulary. (List of Covered Drugs) 2014 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/28/2014. For more recent information or other questions,

More information

Napa and Sonoma Counties

Napa and Sonoma Counties Napa and Sonoma Counties Benefit Highlights Napa and Sonoma Counties SCAN Classic (HMO), SCAN Balance (HMO SNP), and Heart First (HMO SNP) 2015 Benefit Highlights Napa and Sonoma Counties Benefit Highlights

More information

Paramount Elite Standard Medical and Drug (HMO) offered by Paramount Care, Inc.

Paramount Elite Standard Medical and Drug (HMO) offered by Paramount Care, Inc. Paramount Elite Standard Medical and Drug (HMO) offered by Paramount Care, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of Paramount Elite Standard Medical and Drug (HMO).

More information

San Diego County. 2015 Benefit Highlights

San Diego County. 2015 Benefit Highlights San Diego County Scripps Classic offered by SCAN Health Plan(HMO) Scripps Signature offered by SCAN Health Plan (HMO) Scripps Heart First offered by SCAN Health Plan (HMO SNP) 2015 Benefit Highlights San

More information

$4, 30-day $10, 90-day

$4, 30-day $10, 90-day $4 Prescriptions - Choose from hundreds of generic drugs and over the counter medications. Free Home Delivery Mailed right to your home Free shipping Prescription Program includes up to a 30-day supply

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred KNX (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred KNX (HMO). Next year, there

More information

Orange County Benefit Highlights. Orange County. SCAN Classic (HMO), SCAN Balance (HMO SNP), and Heart First (HMO SNP) 2015 Benefit Highlights

Orange County Benefit Highlights. Orange County. SCAN Classic (HMO), SCAN Balance (HMO SNP), and Heart First (HMO SNP) 2015 Benefit Highlights Orange County Benefit Highlights Orange County SCAN Classic (HMO), SCAN Balance (HMO SNP), and Heart First (HMO SNP) 2015 Benefit Highlights Orange County Benefit Highlights Comprehensive Care SCAN CLASSIC

More information

NOTICES DEPARTMENT OF HEALTH

NOTICES DEPARTMENT OF HEALTH NOTICES DEPARTMENT OF HEALTH Approved Drugs for ALS Ambulance Services [43 Pa.B. 3060] [Saturday, June 1, 2013] Under 28 Pa. Code 1005.11 (relating to drug use, control and security), the following drugs

More information

Berkshire Healthcare NHS Foundation Trust Becky White CHS Pharmacist April 2013

Berkshire Healthcare NHS Foundation Trust Becky White CHS Pharmacist April 2013 Berkshire Healthcare NHS Foundation Trust Becky White CHS Pharmacist April 2013 Access to palliative care drugs out of hours Agreement set up with local community pharmacy s to hold stock of commonly prescribed

More information

$10.00 PRESCRIPTION PROGRAM DETAILS

$10.00 PRESCRIPTION PROGRAM DETAILS $10.00 PRESCRIPTION PROGRAM DETAILS 1. The $10.00 program applies only to certain generic drugs at commonly prescribed 90 day usage dosages. (See list). 2. The Program may change without notification and

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring Preferred KNX (HMO) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring Premier KNX (HMO POS). Next year, there

More information

NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only

NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only Updated 5.5.14 NDC HCPCS HCPCS Description NDC Description Effective Date End Date X-Over Only 68152-0103-03 A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN ZEVALIN Y-90 VIAL 9/1/2013 12/31/2013 50419-0320-05

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna HealthSpring Preferred NGA (HMO) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna HealthSpring Premier NGA (HMO POS). Next year, there

More information

TOTAL PARENTERAL NUTRITION SOLUTIONS

TOTAL PARENTERAL NUTRITION SOLUTIONS TOTAL PARENTERAL NUTRITION SOLUTIONS TOTAL PARENTERAL NUTRITION SOLUTIONS Issued 6/98 NOTE: Because of the complexity of these solutions, the customary format of the Guide cannot be used. The double entry

More information

QUANTITY LIMITS TABLE

QUANTITY LIMITS TABLE S TABLE / TABLA DE ABILIFY ARIPIPRAZOLE ORAL SOLUTION 900 ML IN 30 DAYS ABILIFY DISCMELT 10 MG ARIPIPRAZOLE TAB RAPDIS 30 TABS IN 30 DAYS ABILIFY DISCMELT 15 MG ARIPIPRAZOLE TAB RAPDIS 60 TABS IN 30 DAYS

More information

!nnual Notice of Changes for 2015

!nnual Notice of Changes for 2015 Central Health Medi-Medi Plan (HMO SNP) offered by Central Health Plan of California!nnual Notice of Changes for 2015 You are currently enrolled as a member of Central Health Medi-Medi Plan (HMO SNP).

More information

of BenefitS Cigna-HealthSpring Preferred (Hmo) H4513-024 - 2 2014 Cigna H4513_15_19942 Accepted

of BenefitS Cigna-HealthSpring Preferred (Hmo) H4513-024 - 2 2014 Cigna H4513_15_19942 Accepted agesummary of BenefitS Cover erage Cigna-HealthSpring Preferred (Hmo) H4513-024 - 2 2014 Cigna H4513_15_19942 Accepted SeCtion i - introduction to Summary of BenefitS you have choices about how to get

More information

BeHealthy America, Inc. 2015 Formulary. (List of Covered Drugs)

BeHealthy America, Inc. 2015 Formulary. (List of Covered Drugs) BeHealthy America, Inc. 2015 Formulary (List of Covered Drugs) HPMS Approved Formulary File Submission ID: 15583 Version Number: 12 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER

More information

Home Delivery Prescription Program Drug List

Home Delivery Prescription Program Drug List Home Delivery Prescription Program Drug List Low-cost prescriptions, right in your mailbox. Now you can have your generic prescriptions mailed right to your home, no matter where you live. Because we think

More information

Directory of Generic Medications Eligible for Rx Savings Program Flat Fees

Directory of Generic Medications Eligible for Rx Savings Program Flat Fees Directory of Generic Medications Eligible for Rx Savings Program Flat Fees CONNECTICUT VERSION If you re already enrolled in the FREE* Rx Savings Program, use this guide to find your best choices. And,

More information

NO-COST PREVENTIVE CARE DRUGS

NO-COST PREVENTIVE CARE DRUGS NO-COST PREVENTIVE CARE DRUGS INFORMATION FOR NON-GRANDFATHERED ASO GROUPS The Affordable Care Act (ACA) requires that certain preventive care drugs and drug categories be covered at no cost to health

More information

PREFERRED GENERIC DRUG LIST

PREFERRED GENERIC DRUG LIST These discount programs are NOT health insurance policies and are not intended as a substitute for insurance. The programs do not qualify as a minimum creditable coverage under Massachusetts law or where

More information

2015 Formulary (List of Covered Drugs)

2015 Formulary (List of Covered Drugs) Blue Cross Medicare Advantage Basic (HMO) SM Blue Cross Medicare Advantage Premier Plus (HMO-POS) SM 015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS

More information

Auvi-Q (epinephrine injection) 0.15mg and 0.3mg (Sanofi)

Auvi-Q (epinephrine injection) 0.15mg and 0.3mg (Sanofi) Auvi-Q (epinephrine injection) 0.15mg and 0.3mg (Sanofi) On Oct. 28, 2015, Sanofi recalled all lots (numbered between 2299596 and 3037230; expiring between March 2016 and December 2016) of both strengths

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Cigna HealthSpring Premier (HMO POS) offered by Cigna HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna HealthSpring Premier (HMO POS). Next year, there will

More information

for Extended Stability Parenteral Drugs Third Edition Caryn M. Bing, R.Ph., M.S., FASHP Editor

for Extended Stability Parenteral Drugs Third Edition Caryn M. Bing, R.Ph., M.S., FASHP Editor Extended Stability for Parenteral Drugs Third Edition Editor Caryn M. Bing, R.Ph., M.S., FASHP 1 American Society of Health-System Pharmacists Bethesda, Maryland Contents Preface Acknowledgments x/ Dedication

More information

The Impact of IV Automation on Improving Safety, Efficiency and Workflow

The Impact of IV Automation on Improving Safety, Efficiency and Workflow The Impact of IV Automation on Improving Safety, Efficiency and Workflow David Webster, RPh, MSBA University of Rochester Medical Center Department of Pharmacy Associate Director of Operations Director,

More information

Anthem Blue MedicareRx Standard (PDP) 2015 Formulary (List of Covered Drugs)

Anthem Blue MedicareRx Standard (PDP) 2015 Formulary (List of Covered Drugs) Anthem Blue MedicareRx Standard (PDP) 0 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on August,

More information

2015 Comprehensive Formulary Coventry Health Care

2015 Comprehensive Formulary Coventry Health Care 2015 Comprehensive Formulary Coventry Health Care (List of Covered Drugs) Saver Formulary 1 PLEASE READ: This document contains information about the drugs we cover in this plan This formulary was updated

More information

Empire MediBlue Plus (HMO) 2015 Formulary (List of Covered Drugs)

Empire MediBlue Plus (HMO) 2015 Formulary (List of Covered Drugs) Empire MediBlue Plus (H) 0 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on October, 0. For more

More information

Dosage Calculations INTRODUCTION. L earning Objectives CHAPTER

Dosage Calculations INTRODUCTION. L earning Objectives CHAPTER CHAPTER 5 Dosage Calculations L earning Objectives After completing this chapter, you should be able to: Solve one-step pharmaceutical dosage calculations. Set up a series of ratios and proportions to

More information

AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan

AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan 2016 List of Covered Drugs/Formulary Aetna Better Health of Ohio, a MyCare Ohio plan (Medicare-Medicaid Plan) is a health plan that contracts with Medicare

More information

Palliative Coverage Drug Benefit Supplement

Palliative Coverage Drug Benefit Supplement Palliative Coverage Drug Benefit Supplement Effective April 1, 2015 Inquiries should be directed to: Pharmacy Services Alberta Blue Cross 10009 108 Street NW Edmonton AB T5J 3C5 Telephone Number: (780)

More information

Palliative Care Drug Plan (Plan P) Formulary List of drugs PharmaCare covers

Palliative Care Drug Plan (Plan P) Formulary List of drugs PharmaCare covers Palliative Care Drug Plan (Plan P) Formulary List of drugs PharmaCare covers Important Notes: Last Updated: May 11, 2015 Pharmacists must submit a claim on PharmaNet at the time of purchase to enable coverage.

More information

SUMMARY OF BENEFITS. Cigna-HealthSpring. Preferred (HMO) H2108-022. January 1, 2016 - December 31, 2016. 2015 Cigna H2108_16_32731 Accepted

SUMMARY OF BENEFITS. Cigna-HealthSpring. Preferred (HMO) H2108-022. January 1, 2016 - December 31, 2016. 2015 Cigna H2108_16_32731 Accepted SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Preferred (HMO) H2108-022 2015 Cigna H2108_16_32731 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet gives

More information

Annual Notice of Changes for 2014

Annual Notice of Changes for 2014 First Health Part D Premier Plus (PDP) offered by Cambridge Life Insurance Company Annual Notice of Changes for 2014 Dear Member, You are currently enrolled as a member of First Health Part D Premier Plus

More information

Formulary. List of Covered Drugs. premera.com/ma. Version 17. PLEASE READ: This document contains information about the drugs we cover in this plan.

Formulary. List of Covered Drugs. premera.com/ma. Version 17. PLEASE READ: This document contains information about the drugs we cover in this plan. 2015 Formulary List of Covered Drugs premera.com/ma Version 17 Premera Blue Cross Medicare Advantage (HMO) Premera Blue Cross Medicare Advantage Plus (HMO) Premera Blue Cross Medicare Advantage (HMO-POS)

More information

Blue Shield Medicare Basic Plan (PDP) Blue Shield Medicare Enhanced Plan (PDP)

Blue Shield Medicare Basic Plan (PDP) Blue Shield Medicare Enhanced Plan (PDP) Summary of Benefits Blue Shield Medicare Basic Plan (PDP) January 1, 2015 December 31, 2015 State of California This booklet gives you a summary of what we cover and what you pay. It doesn't list every

More information

AvMed Medicare Choice

AvMed Medicare Choice AvMed Medicare Choice 2016 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary

More information

Listing does not indicate formulary coverage. Please refer to membership materials to determine if medication is covered under your selected plan.

Listing does not indicate formulary coverage. Please refer to membership materials to determine if medication is covered under your selected plan. ACCUNEB Inhalation SOLN ACETYLCYSTEINE VIAL ALBUTEROL 0.083% INHAL SOLN ALBUTEROL 5 MG/ML ALBUTEROL SUL Inhalation SOL ANZEMET ATGAM 50 MG/ML AMPUL AZASAN AZATHIOPRINE VIAL AZATHIOPRINE BLEOMYCIN SULFATE

More information

NLPDP Coverage Status Table December 2015. Initial and maintenance fills are limited to a maximum 30 days

NLPDP Coverage Status Table December 2015. Initial and maintenance fills are limited to a maximum 30 days Coverage Table December 2015 02238646 282 MEP TABLET OPEN No 500 0.2103 02234510 282 TABLET OPEN No 500 0.0726 02238645 292 TABLET OPEN No 50 0.1877 02192691 3TC 10 MG/ML SOLUTION OPEN No 240 0.3454 02192683

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Blue Cross Medicare Advantage Basic (HMO) offered by GHS Health Maintenance Organization, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of Blue Cross Medicare Advantage

More information

MVP Health Care 2016 Comprehensive Medicare Part D Formulary (List of Covered Drugs)

MVP Health Care 2016 Comprehensive Medicare Part D Formulary (List of Covered Drugs) MVP Health Care 2016 Comprehensive Medicare Part D Formulary (List of Covered Drugs) PLEASE READ: This document contains information about the drugs we cover in this plan. This formulary was updated in

More information

List of Covered Drugs (Formulary)

List of Covered Drugs (Formulary) Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Member Services: 1-855-878-1784

More information

SUMMARY OF BENEFITS. Cigna-HealthSpring Traditions (HMO SNP) H2108-020. January 1, 2016 - December 31, 2016. 2015 Cigna H2108_16_32732 Accepted

SUMMARY OF BENEFITS. Cigna-HealthSpring Traditions (HMO SNP) H2108-020. January 1, 2016 - December 31, 2016. 2015 Cigna H2108_16_32732 Accepted SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Traditions (HMO SNP) H2108-020 2015 Cigna H2108_16_32732 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet

More information

ICD-10 Compliance Date

ICD-10 Compliance Date ICD-10 Implementation Frequently Asked Questions Updated September 2015 ICD-10 Compliance Date The U.S. Department of Health and Human Services (HHS) issued a rule on July 31, 2014 finalizing October 1,

More information