| Brand Name |
Generic Name |
Description of Change |
Effective Date of Change |
Tier |
Utilization Management Notes |
| ABILIFY DISC TABLET 10MG, 15MG |
aripiprazole orally disintegrating tablet 10mg, 15mg |
Reduction in Preferred or Tiered Cost-Sharing Status |
3/1/2010 |
Tier 3 |
|
| ABILIFY SOLUTION 1MG/ML |
aripiprazole oral solution 1mg/ml |
Reduction in Preferred or Tiered Cost-Sharing Status |
3/1/2010 |
Tier 3 |
|
| ABILIFY TABLET 2MG, 5MG, 10MG, 15MG, 20MG, 30MG |
aripiprazole tablet 2mg, 5mg, 10mg, 15mg, 20mg, 30mg |
Reduction in Preferred or Tiered Cost-Sharing Status |
3/1/2010 |
Tier 3 |
|
| ACEON TABLET 2MG, 4MG, 8MG |
perindopril tablet 2mg, 4mg, 8mg |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| ACULAR LS OPHTHALMIC SOLUTION 0.5% |
ketorolac solution 0.5% |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| ACULAR OPHTHALMIC SOLUTION 0.4% |
ketorolac solution 0.4% |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| ALDARA CREAM 5% |
imiquimod cream 5% |
Formulary Addition |
6/1/2010 |
Tier 2 |
|
| AMANTADINE SYRUP 50MG/5ML |
amantadine syrup 50mg/5ml |
Formulary Addition |
6/1/2010 |
Tier 2 |
|
| AMINOSYN II M INJECTION 3.5%/D5W |
amino acid electrolyte infusion 3.5% in d5w |
Formulary Addition |
3/1/2010 |
Tier 4 |
B/D |
| AMITIZA CAPSULE 8MCG, 24MCG |
lubiprostone capsule 8mcg, 24mcg |
Reduction in Preferred or Tiered Cost-Sharing Status |
3/1/2010 |
Tier 3 |
PA removed, QL (62 capsule per 31 days), ST |
| ANAPROX DS TABLET 550MG |
naproxen sodium tablet 550mg |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| ANAPROX TABLET 275MG |
naproxen sodium tablet 275mg |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| APIDRA SOLOSTAR INJECTION |
insulin glulisine injection 100unit/ml |
Formulary Addition |
3/1/2010 |
Tier 3 |
|
| APIDRA U-100 INJECTION |
insulin glulisine injection 100unit/ml |
Formulary Addition |
3/1/2010 |
Tier 3 |
|
| APRISO CAPSULE 0.375GM |
mesalamine capsule sr 24hr 0.375 gm |
Formulary Addition |
7/1/2010 |
Tier 3 |
QL (124 capsules per 31 days) |
| ARZERRA 100MG/5ML |
ofatumumab concentrate for iv infusion 100mg/5ml |
Formulary Addition |
3/1/2010 |
Tier 5 |
PA |
| ASMANEX 30 AER 110MCG |
mometasone furoate inhalation powder 110mcg/inhalation |
Formulary Addition |
6/1/2010 |
Tier 4 |
QL (135 per 30 days), ST |
| ASTEPRO SPRAY 0.15% |
azelastine hcl nasal spray 0.15% |
Formulary Addition |
5/1/2010 |
Tier 3 |
QL (60ml per 31 days) |
| AUGMENTIN SUSPENSION 250MG/5ML |
amoxicillin & potassium clavulanate suspension 250mg/5ml |
Formulary Addition |
1/1/2010 |
Tier 2 |
|
| AUGMENTIN XR TABLET 12HR |
amoxicillin & potassium clavulanate tablet sr 12hr 1000-62.5mg |
Formulary Addition |
7/1/2010 |
Tier 2 |
|
| AVODART CAPSULE 0.5MG |
dutasteride capsule 0.5mg |
Removal of Utilization Management |
3/1/2010 |
Tier 3 |
ST removed, QL (31 capsules per 31 days) |
| AXID SOLUTION 15MG/ML |
nizatidine solution 15mg/ml |
Formulary Addition |
4/1/2010 |
Tier 4 |
|
| AZASITE SOLUTION 1% |
azithromycin ophthalmic solution 1% |
Formulary Addition |
3/1/2010 |
Tier 3 |
|
| BENZACLIN GEL 1-5% |
clindamycin phosphate-benzoyl peroxide gel 1-5% |
Formulary Addition |
1/1/2010 |
Tier 2 |
|
| BUDEPRION XL TABLET 150MG |
bupropion hcl tablet sr 24hr 150mg |
Reduction in Preferred or Tiered Cost-Sharing Status |
1/1/2010 |
Tier 2 |
QL (93 tablets per 31 days) |
| BUDEPRION XL TABLET 300MG |
bupropion hcl tablet sr 24hr 300mg |
Reduction in Preferred or Tiered Cost-Sharing Status |
4/1/2010 |
Tier 2 |
QL (31 tablets per 31 days) |
| BYETTA INJECTION 5MCG |
exenatide injection 250mcg/ml |
Formulary Addition |
3/1/2010 |
Tier 4 |
ST |
| CARDIZEM LA TABLET 180MG |
diltiazem hcl er tablet 180mg |
Formulary Addition |
7/1/2010 |
Tier 2 |
QL (93 tablets per 31 days) |
| CARDIZEM LA TABLET 240MG |
diltiazem hcl er tablet 240mg |
Formulary Addition |
7/1/2010 |
Tier 2 |
QL (62 tablets per 31 days) |
| CARDIZEM LA TABLET 300MG, 360MG, 420MG |
diltiazem hcl er tablet 300mg, 360mg, 420mg |
Formulary Addition |
7/1/2010 |
Tier 2 |
QL (31 tablets per 31 days) |
| CATAPRES-TTS-1 |
clonidine hcl patch 0.1mg/24hr |
Formulary Addition |
1/1/2010 |
Tier 2 |
QL (5 patches per 31 days) |
| CATAPRES-TTS-2 |
clonidine hcl patch 0.2mg/24hr |
Formulary Addition |
1/1/2010 |
Tier 2 |
QL (10 patches per 31 days) |
| CATAPRES-TTS-3 |
clonidine hcl patch 0.3mg/24hr |
Formulary Addition |
1/1/2010 |
Tier 2 |
QL (10 patches per 31 days) |
| CERVARIX INJECTION |
human papillomavirus (hpv) bivalent (type 16, 18) recombinant vaccine injection |
Formulary Addition |
3/1/2010 |
Tier 3 |
|
| CIMZIA KIT 200MG/ML |
certolizumab pegol injection kit 2 x 200mg/ml |
Formulary Addition |
4/1/2010 |
Tier 5 |
PA |
| CODEINE SULFATE TABLET 15MG, 30MG, 60MG |
codeine sulfate tablet 15mg, 30mg, 60mg |
Formulary Addition |
1/1/2010 |
Tier 2 |
PA |
| COGENTIN INJECTION 1MG/ML |
benztropine injection 1mg/ml |
Formulary Addition |
1/1/2010 |
Tier 2 |
|
| COZAAR TABLET 100MG |
losartan potassium tablet 100mg |
Formulary Addition |
7/1/2010 |
Tier 2 |
QL (31 tablets per 31 days), ST |
| COZAAR TABLET 25MG, 50MG |
losartan potassium tablet 25mg, 50mg |
Formulary Addition |
7/1/2010 |
Tier 2 |
QL (62 tablets per 31 days), ST |
| DARVON CAPSULE 65MG |
propoxyphene hcl capsule 65mg |
Removal of Utilization Management |
3/1/2010 |
Tier 2 |
QL removed |
| DARVON-N TABLET 100MG |
propoxyphene napsylate tablet 100mg |
Removal of Utilization Management |
3/1/2010 |
Tier 4 |
QL removed |
| DEXILANT DR CAPSULE 30MG, 60MG |
dexlansoprazole delayed release capsule 30mg, 60mg |
Formulary Addition |
37/1/2010 |
Tier 4 |
|
| DEXTROSE 5%/LACTATED RINGERS INJECTION |
dextrose 5% in lactated ringers |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| DIURIL IV INJECTION 500MG |
chlorothiazide injection 500mg |
Formulary Addition |
4/1/2010 |
Tier 4 |
|
| DOXYCYCLINE HYCLATE CAPSULE 100MG |
doxycycline hyclate capsule 100mg |
Formulary Addition |
3/1/2010 |
Tier |
|
| DUREZOL EMULSION 0.05% |
difluprednate ophthalmic emulsion 0.05% |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| EFFIENT TABLET 10MG |
prasugrel hcl tablet 10mg |
Formulary Addition |
3/1/2010 |
Tier 3 |
QL (36 tablets per 31 days) |
| EFFIENT TABLET 5MG |
prasugrel hcl tablet 5mg |
Formulary Addition |
3/1/2010 |
Tier 3 |
QL (31 tablets per 31 days) |
| ENBREL INJECTION 25MG/0.5ML |
etanercept subcutaneous injection 50mg/ml |
Formulary Addition |
5/1/2010 |
Tier 5 |
PA |
| EVOCLIN AEROSOL 1% |
clindamycin phosphate foam 1% |
Formulary Addition |
7/1/2010 |
Tier 4 |
|
| FANAPT PAK |
iloperidone 1mg, 2mg, 4mg and 6mg tablet titratration pak |
Formulary Addition |
3/1/2010 |
Tier 4 |
QL (8 tablets per 31 days), ST |
| FANAPT TABLET 1MG, 2MG, 4MG, 6MG, 8MG, 10MG, 12MG |
iloperidone tablet 1mg, 2mg, 4mg, 6mg, 8mg, 10mg, 12mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
QL (62 tablets per 31 days), ST |
| FLOMAX CAPSULE 0.4MG |
tamsulosin hcl capsule 0.4mg |
Formulary Addition |
6/1/2010 |
Tier 2 |
QL (62 capsules per 31 days) |
| GAVILYTE-N FLAVOR PACK |
peg 3350-kcl-sodium bicarbonatenacl for solution 420gm |
Formulary Addition |
3/1/2010 |
Tier 1 |
QL (4000ml per 31 days) |
| GELNIQUE GEL 10% |
oxybutynin chloride transdermal gel 10% |
Formulary Addition |
3/1/2010 |
Tier 4 |
QL (1 sachet per 1 day) |
| HECTOROL CAPSULE 1MCG |
doxercalciferol capsule 1mcg |
Formulary Addition |
1/1/2010 |
Tier 3 |
|
| HUMIRA KIT 20MG/0.4ML |
adalimumab injection kit 20mg/0.4ml |
Formulary Addition |
3/1/2010 |
Tier 5 |
PA |
| HYZAAR TABLET 100-12.5, 100-25 |
losartan potassium & hydrochlorothiazide tablet 100-12.5mg, 100-25mg |
Formulary Addition |
7/1/2010 |
Tier 2 |
QL (31 tablets per 31 days), ST |
| HYZAAR TABLET 50-12.5 |
losartan potassium & hydrochlorothiazide tablet 50-12.5mg |
Formulary Addition |
7/1/2010 |
Tier 2 |
QL (62 tablets per 31 days), ST |
| IMITREX INJECTION 6MG/0.5ML |
sumatriptan injection 6mg/0.5ml |
Formulary Addition |
4/1/2010 |
Tier 2 |
QL (4ml per 30 days) |
| INVEGA TABLET 1.5MG |
paliperidone tablet sr 24hr 1.5mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| IOPIDINE OPHTHALMIC SOLUTION 0.5% |
apraclonidine ophthalmic solution 0.5% |
Formulary Addition |
1/1/2010 |
Tier 4 |
|
| ISTODAX INJECTION 10MG |
romidepsin for iv injection 10mg |
Formulary Addition |
5/1/2010 |
Tier 5 |
PA |
| IXIARO INJECTION |
japanese encephalitis vaccine inactivated adsorbed injection |
Formulary Addition |
7/1/2010 |
Tier 3 |
|
| KAPIDEX CAPSULE 30MG, 60MG |
dexlansoprazole delayed release capsule 30mg, 60mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| LACTATED RINGERS INJECTION |
lactated ringers injection |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| LIPOSYN II INJECTION 20% |
fat emulsion iv solution 20% |
Formulary Addition |
3/1/2010 |
Tier 4 |
B/D |
| LIPOSYN III INJECTION 30% |
fat emulsion iv solution 30% |
Formulary Addition |
3/1/2010 |
Tier 2 |
B/D |
| LOPROX SHAMPOO 1% |
ciclopirox shampoo 1% |
Formulary Addition |
4/1/2010 |
Tier 4 |
|
| LOSEASONIQUE TABLET |
levonorgestrel-ethinyl estradiol tablet0.1-0.02mg and ethinyl estradiol tablet 0.01mg |
Formulary Addition |
6/1/2010 |
Tier 4 |
|
| LOTREL CAPSULE 5-40MG, 10-40MG |
amlodipine besylate-benazepril hcl capsule 5-40mg, 10-40mg |
Reduction in Preferred or Tiered Cost-Sharing Status |
3/1/2010 |
Tier 3 |
QL (31 capsules per 31 days) |
| MAXAIR AUTOHALER |
pirbuterol acetate inhalation aerosol 200mcg/inhalation |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| MIRALAX POWDER 3350 NF |
polyethylene glycol powder 3350 nf |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| MIRAPEX TABLET 0.125MG, 0.25MG, 0.5MG, 1MG, 1.5MG |
pramipexole tablet 0.125mg, 0.25mg, 0.5mg, 1mg, 1.5mg |
Formulary Addition |
4/1/2010 |
Tier 2 |
|
| NEXT CHOICE TABLET 0.75MG |
levonorgestrel tablet 0.75mg |
Formulary Addition |
1/1/2010 |
Tier 2 |
|
| NITROSTAT SUBLINGUAL TABLET 0.3MG, 0.4MG, 0.6MG |
nitroglycerin sublingual tablet 0.3mg, 0.4mg, 0.6mg |
Formulary Addition |
6/1/2010 |
Tier 3 |
|
| NUTROPIN AQ INJECTION 10MG/2ML, 20MG/2ML |
somatropin injection 10mg/2ml, 20mg/2ml |
Formulary Addition |
3/1/2010 |
Tier 5 |
PA |
| ONGLYZA TABLET 2.5MG, 5MG |
saxagliptin hcl tablet 2.5mg, 5mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
QL (31 tablets per 31 days), ST |
| OPTIVAR DROPS 0.05% |
azelastine drops 0.05% |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| OVIDE LOTION 0.5% |
malathion lotion 0.5% |
Formulary Addition |
1/1/2010 |
Tier 4 |
|
| PHENYTEK CAPSULE 200MG, 300MG |
phenytoin ex capsule 200mg, 300mg |
Formulary Addition |
5/1/2010 |
Tier 2 |
|
| PREVACID CAPSULE 15MG, 30MG DR |
lansoprazole capsule 15mg, 30mg |
Formulary Addition |
3/1/2010 |
Tier 2 |
ST |
| PRIVIGEN INJECTION 20GM |
immune globulin (human) iv solution 10% |
Formulary Addition |
5/1/2010 |
Tier 5 |
B/D, PA |
| PROGRAF CAPSULE 0.5MG |
tacrolimus capsule 0.5mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| PROGRAF CAPSULE 1MG |
tacrolimus capsule 1mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| PROGRAF CAPSULE 5MG |
tacrolimus capsule 5mg |
Formulary Addition |
3/1/2010 |
Tier 5 |
B/D, PA |
| PROZAC WEEKLY CAPSULE 90MG |
fluoxetine hcl delayed release capsule 90mg |
Formulary Addition |
7/1/2010 |
Tier 4 |
QL (5 capsules per 31 days), ST |
| PULMICORT SUSPENSION 0.25MG/2ML, 0.5MG/2ML |
budesonide suspension 0.25mg/2ml, 0.5mg/2ml |
Formulary Addition |
5/1/2010 |
Tier 2 |
B/D |
| RAPAFLO CAPSULE 4MG, 8MG |
silodosin capsule 4mg, 8mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
QL (31 capsules per 31 days) |
| RAZADYNE SOLUTION 4MG/ML |
galantamine solution 4mg/ml |
Formulary Addition |
1/1/2010 |
Tier 2 |
|
| REBIF INJECTION 22MCG/0.5ML, 44MCG/0.5ML |
interferon beta-1a injection 22mcg/0.5ml, 44mcg/0.5ml |
Removal of Utilization Management |
3/1/2010 |
Tier 5 |
ST removed |
| REBIF TITRATION PACK |
interferon beta-1a injection 6 x 8.8mcg/0.2ml & 6 x 22mcg/0.5ml |
Removal of Utilization Management |
3/1/2010 |
Tier 5 |
ST removed |
| RENAGEL TABLET 400MG, 800MG |
sevelamer hcl tablet 400mg, 800mg |
Formulary Addition |
3/1/2010 |
Tier 3 |
|
| RENVELA PAK 0.8GM, 2.4GM |
sevelamer carbonate packet 0.8gm, 2.4gm |
Formulary Addition |
1/1/2010 |
Tier 3 |
|
| REVATIO INJECTION |
sildenafil citrate iv solution 10mg/12.5ml |
Formulary Addition |
5/1/2010 |
Tier 5 |
PA |
| RISPERDAL M TABLET 1MG |
risperidone odt tablet 1mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| ROXANOL SOLUTION 20MG/ML |
morphine sulfate solution 20mg/ml |
Formulary Addition |
4/1/2010 |
Tier 1 |
|
| SABRIL POWDER 500MG |
vigabatrin powder pack 500mg |
Formulary Addition |
3/1/2010 |
Tier 5 |
PA |
| SABRIL TABLET 500MG |
vigabatrin tablet 500mg |
Formulary Addition |
3/1/2010 |
Tier 5 |
PA |
| SAMSCA TABLET 15MG |
tolvaptan tablet 15mg |
Formulary Addition |
3/1/2010 |
Tier 5 |
PA, QL (31 tablets per 31 days) |
| SAMSCA TABLET 30MG |
tolvaptan tablet 30mg |
Formulary Addition |
3/1/2010 |
Tier 5 |
PA, QL (62 tablets per 31 days) |
| SANCUSO PATCH 3.1MG |
granisetron transdermal patch 3.1mg/24hr |
Formulary Addition |
3/1/2010 |
Tier 3 |
QL (5 patches per 31 days) |
| SAPHRIS SUBLINGUAL TABLET 5MG, 10MG |
asenapine maleate sublingual tablet 5mg, 10mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| SAVELLA TABLET 12.5MG, 25MG, 50MG, 100MG |
milnacipran hcl tablet 12.5mg, 25mg, 50mg, 100mg |
Formulary Addition |
3/1/2010 |
Tier 3 |
QL (62 tablets per 31 days) |
| SAVELLA TITRATION PAK |
milnacipran hcl tablet 12.5mg (5) & 25mg (8) & 50mg (42) titration pak |
Formulary Addition |
3/1/2010 |
Tier 3 |
QL (55 tablets per 31 days) |
| SKELAXIN TABLET 800MG |
metaxalone tablet 800mg |
Formulary Addition |
7/1/2010 |
Tier 4 |
|
| SODIUM BICARBONATE INJECTION 8.4% |
sodium bicarbonate injection 8.4% |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| SOMATULINE INJECTION 60MG/0.2ML |
lanreotide acetate extended release injection 60mg/0.2ml |
Formulary Addition |
5/1/2010 |
Tier 5 |
PA |
| SORIATANE CAPSULE 17.5MG, 22.5MG |
acitretin capsule 17.5mg, 22.5mg |
Formulary Addition |
7/1/2010 |
Tier 4 |
|
| SOTALOL HCL INJECTION 150MG/10ML |
sotalol hcl injection 150mg/10ml |
Formulary Addition |
5/1/2010 |
Tier 4 |
|
| STARLIX TABLET 60MG, 120MG |
nateglinide tablet 60mg, 120mg |
Formulary Addition |
3/1/2010 |
Tier 2 |
QL (93 tablets per 31 days), ST |
| SUBOXONE SUBLINGUALTABLET 2-0.5MG, 8-2MG |
buprenorphine hcl-naloxone hcl sublingual tablet 2-0.5mg, 8-2mg |
Reduction in Preferred or Tiered Cost-Sharing Status |
7/1/2010 |
Tier 3 |
QL (93 tablets per 31 days) |
| SUBUTEX SUBLINGUAL TABLET 2MG |
buprenorphine sublingual tablet 2mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
QL (16 tablets per 31 days) |
| SUBUTEX SUBLINGUAL TABLET 8MG |
buprenorphine sublingual tablet 8mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
QL (8 tablets per 31 days) |
| SYMLINPEN 120 |
pramlintide acetate injection 1000mcg/ml |
Formulary Addition |
3/1/2010 |
Tier 4 |
PA |
| TOPAMAX SPRINKLE 15MG, 25MG |
topiramate capsule 15mg, 25mg |
Reduction in Preferred or Tiered Cost-Sharing Status |
1/1/2010 |
Tier 2 |
PA removed |
| TOPAMAX SPRINKLE 15MG, 25MG |
topiramate capsule 15mg, 25mg |
Removal of Utilization Management |
1/1/2010 |
Tier 4 |
PA removed |
| TOPAMAX TABLET 25MG, 50MG, 100MG, 200MG |
topiramate tablet 25mg, 50mg, 100mg, 200mg |
Removal of Utilization Management |
1/1/2010 |
Tier 2 |
PA removed |
| TOPAMAX TABLET 25MG, 50MG, 100MG, 200MG |
topiramate tablet 25mg, 50mg, 100mg, 200mg |
Removal of Utilization Management |
1/1/2010 |
Tier 4 |
PA removed |
| TRILEPTAL SUSPENSION 300MG/5ML |
oxcarbazepine suspension 300mg/5ml |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| TWYNSTA TABLET 40-5MG, 40-10MG, 80-5MG, 80-10MG |
telmisartan-amlodipine tablet 40-5mg, 40-10mg, 80-5mg, 80-10mg |
Formulary Addition |
5/1/2010 |
Tier 4 |
QL (31 tablets per 31 days), ST |
| ULORIC TABLET 40MG, 80MG |
febuxostat tablet 40mg, 80mg |
Formulary Addition |
3/1/2010 |
Tier 3 |
QL (31 tablets per 31 days), ST |
| ULTRAM ER TABLET 100MG |
tramadol hcl er tablet 100mg |
Formulary Addition |
3/1/2010 |
Tier 2 |
QL (31 tablets per 31 days) |
| ULTRAM ER TABLET 200MG |
tramadol hcl er tablet 200mg |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| ULTRAM ER TABLET 200MG |
tramadol hcl er tablet 200mg |
Removal of Utilization Management |
3/1/2010 |
Tier 4 |
QL removed |
| VAGIFEM TABLET 10MCG |
estradiol vaginal tablet 10mcg |
Formulary Addition |
5/1/2010 |
Tier 3 |
|
| VALCYTE SOLUTION 50MG/ML |
valganciclovir hcl for solution 50mg/ml |
Formulary Addition |
5/1/2010 |
Tier 5 |
|
| VALTREX TABLET 500MG, 1GM |
valacyclovir tablet 500mg, 1gm |
Formulary Addition |
3/1/2010 |
Tier 4 |
|
| VALTURNA TABLET 150-160MG, 300-320MG |
aliskiren-valsartan tablet 150-160mg, 300-320mg |
Formulary Addition |
3/1/2010 |
Tier 3 |
QL (31 tablets per 31 days), ST |
| VOLTAREN GEL 1% |
diclofenac sodium gel 1% |
Formulary Addition |
3/1/2010 |
Tier 3 |
|
| VOTRIENT TABLET 200MG |
pazopanib hcl tablet 200mg |
Formulary Addition |
3/1/2010 |
Tier 5 |
PA |
| VPRIV INJECTION 400UNIT |
velaglucerase alfa for injection 400unit |
Formulary Addition |
7/1/2010 |
Tier 5 |
PA |
| WELCHOL PAK 3.75GM |
colesevelam hcl packet for suspension 3.75gm |
Formulary Addition |
5/1/2010 |
Tier 3 |
QL (31 packets per 31 days) |
| XOPENEX CONCENTRATE NEBULIZER SOLUTION 1.25MG/0.5ML |
levalbuterol nebulizer solution 1.25mg/0.5ml |
Formulary Addition |
4/1/2010 |
Tier 4 |
B/D, ST |
| ZEMPLAR INJECTION 2MCG/ML |
paricalcitol iv solution 2mcg/ml |
Reduction in Preferred or Tiered Cost-Sharing Status |
3/1/2010 |
Tier 4 |
|
| ZETIA TABLET 10MG |
ezetimibe tablet 10mg |
Reduction in Preferred or Tiered Cost-Sharing Status |
1/1/2010 |
Tier 3 |
QL (31 tablets per 31 days) |
| ZIPSOR CAPSULE 25MG |
diclofenac potassium capsule 25mg |
Formulary Addition |
3/1/2010 |
Tier 4 |
QL (124 capsules per 31 days) |
| ZOSYN INJECTION 3-0.375GM |
piperacillin/tazobactam sodium injection 3-0.375gm |
Formulary Addition |
3/1/2010 |
Tier 2 |
|
| ZYLET SUSPENSION 0.5-0.3% |
loteprednol etabonate-tobramycin ophthalmic suspension 0.5-0.3% |
Reduction in Preferred or Tiered Cost-Sharing Status |
3/1/2010 |
Tier 3 |
|
| ZYPREXA RELPREVV INJECTION 405MG |
olanzapine pamoate for extended release im suspension 405mg |
Formulary Addition |
6/1/2010 |
Tier 5 |
QL (1 vial per 28 days) |
|
QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B/D determination;
Covered drug is indicated in bold.
Updated: 06/10/2010
|
| Brand Name |
Generic Name |
Description of Change |
Reason for Change |
Effective Date of Change |
Alternative Drugs
(Brand drugs appear in upper case, generic drugs appear in lower case)
|
Tier
(Alternative Drug Co-pay/ Coinsurance)
|
| ACEON TABLET 2MG, 4MG, 8MG |
perindopril tablet 2mg,4mg, 8mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
perindopril tablet 2mg, 4mg, 8mg |
Tier 2 |
| ACULAR LS OPHTHALMIC SOLUTION 0.4% |
ketorolac solution 0.4% |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
ketorolac solution 0.4% |
Tier 2 |
| ACULAR OPHTHALMIC SOLUTION 0.5% |
ketorolac solution 0.5% |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
ketorolac solution 0.5% |
Tier 2 |
| ALKERAN INJECTION 50MG |
melphalan hcl injection 50mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
melphalan hcl injection 50mg |
Tier 5 |
| AUGMENTIN SUSPENSION 250MG/5ML |
amoxicillin & potassium clavulanate suspension 250mg/5ml |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
amoxicillin & potassium clavulanate suspension 250mg/5ml |
Tier 2 |
| AUGMENTIN XR 12HR TABLET |
amoxicillin & potassium clavulanate tablet sr 12hr 1000-62.5mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
11/1/2010 |
amoxicillin & potassium clavulanate tablet sr 12hr 1000-62.5mg |
Tier 2 |
| AXID SOLUTION 15MG/ML |
nizatidine 15mg/ml |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
nizatidine 15mg/ml |
Tier 4 |
| BLEOMYCIN INJECTION 30UNIT |
bleomycin sulfate for injection 30unit |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
9/1/2010 |
N/A |
N/A |
| CARDIZEM LA TABLET 180MG, 240MG, 300MG, 360MG, 420MG |
diltiazem hcl er tablet 180mg, 240mg, 300mg, 360mg, 420mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
11/1/2010 |
diltiazem hcl er tablet 180mg, 240mg, 300mg, 360mg, 420mg |
Tier 2 with QL |
| CATAPRES-TTS PATCH 0.1/24HR, 0.2/24HR, 0.3/24HR |
clonidine hcl patch 0.1/24hr, 0.2/24hr, 0.3/24hr |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
clonidine hcl patch 0.1/24hr, 0.2/24hr, 0.3/24hr |
Tier 2 with QL |
| COGENTIN INJECTION 1MG/ML |
benztropine injection 1mg/ml |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
benztropine injection 1mg/ml |
Tier 2 |
| COZAAR TABLET 25MG, 50MG, 100MG |
losartan potassium tablet 25mg, 50mg, 100mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
11/1/2010 |
losartan potassium tablet 25mg, 50mg, 100mg |
Tier 2 with QL, ST |
| CYTARABINE INJECTION 20MG/ML, 100MG/ML |
cytarabine injection 20mg/ml, 100mg/ml |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
9/1/2010 |
N/A |
N/A |
| CYTARABINE INJECTION 500MG |
cytarabine injection 500mg |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
9/1/2010 |
N/A |
N/A |
| DIURIL IV INJECTION 500MG |
chlorothiazide injection 500mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
8/1/2010 |
chlorothiazide injection 500mg |
Tier 4 |
| ELOXATIN INJECTION 100MG |
oxaliplatin injection 100mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
oxaliplatin injection 100mg |
Tier 5 |
| EVOCLIN AEROSOL 1% |
clindamycin phosphate foam 1% |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
11/1/2010 |
clindamycin phosphate foam 1% |
Tier 4 |
| FLUOROURACIL INJECTION 500MG/10ML |
fluorouracil injection 500mg/10ml |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
9/1/2010 |
N/A |
N/A |
| HYZAAR TABLET 50-12.5MG, 100-12.5MG, 100-25MG |
losartan potassium & hydrochlorothiazide tablet 50-12.5mg, 100-12.5mg, 100-25mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
11/1/2010 |
losartan potassium & hydrochlorothiazide tablet 50-12.5mg, 100-12.5mg, 100-25mg |
Tier 2 with QL, ST |
| IOPIDINE OPHTHALMIC SOLUTION 0.5% |
apraclonidine ophthalmic solution 0.5% |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
apraclonidine ophthalmic solution 0.5% |
Tier 4 |
| LEUSTATIN INJECTION 1MG/ML |
cladribine injection 1mg/ml |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
9/1/2010 |
N/A |
N/A |
| LOPROX SHAMPOO 1% |
ciclopirox shampoo 1% |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
8/1/2010 |
ciclopirox shampoo 1% |
Tier 4 |
| MOBAN TABLET 5MG, 10MG, 25MG, 50MG |
molindone hcl tablet 5mg, 10mg, 25mg, 50mg |
Drug Not Available |
Drug Discontinued by Manufacturer. |
6/1/2010 |
Consult Your Doctor |
N/A |
| NITROSTAT SUBLINGUAL TABLET 0.3MG, 0.4MG, 0.6MG |
nitroglycerin sublingual tablet 0.3mg, 0.4mg, 0.6mg |
Drug Not Available |
Product No Longer Available |
9/12/2010 |
NITROSTAT SUBLINGUAL TABLET 0.3MG, 0.4MG, 0.6MG |
Tier 3 |
| NULYTELY FLAVORED PACK |
peg 3350-kcl-sodium bicarbonate-nacl for solution 420gm |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
Gavilyte-N Solution Flavored Pack |
Tier 1 with QL |
| OPTIVAR DROPS 0.05% |
azelastine drops 0.05% |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
azelastine drops 0.05% |
Tier 2 |
| OVIDE LOTION 0.5% |
malathion lotion 0.5% |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
malathion lotion 0.5% |
Tier 4 |
| PLAN B |
levonorgestrel tablet 0.75mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
Next Choice Tablet 0.75mg |
Tier 2 |
| PREVACID CAPSULE 15MG, 30MG DR |
lansoprazole capsule 15mg, 30mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
lansoprazole capsule 15mg, 30mg |
Tier 2 with ST |
| PROGRAF CAPSULE 0.5MG, 1MG |
tacrolimus capsule 0.5mg, 1mg |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
8/1/2010 |
N/A |
N/A |
| PROGRAF CAPSULE 0.5MG, 1MG |
tacrolimus capsule 0.5mg, 1mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
tacrolimus capsule 0.5mg, 1mg |
Tier 4 |
| PROGRAF CAPSULE 5MG |
tacrolimus capsule 5mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
tacrolimus capsule 5mg |
Tier 5, PA, B/D |
| PROZAC WEEKLY CAPSULE 90MG |
fluoxetine hcl delayed release capsule 90mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
11/1/2010 |
fluoxetine hcl delayed release capsule 90mg |
Tier 4 with QL, ST |
| PULMICORT SUSPENSION 0.25MG/2ML, 0.5MG/2ML |
budesonide 0.25mg/2ml, 0.5mg/2ml |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
budesonide 0.25mg/2ml, 0.5mg/2ml |
Tier 2 with B/D |
| RAZADYNE SOLUTION 4MG/ML |
galantamine solution 4mg/ml |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
6/1/2010 |
galantamine solution 4mg/ml |
Tier 2 |
| SKELAXIN TABLET 800MG |
metaxalone tablet 800mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
11/1/2010 |
metaxalone tablet 800mg |
Tier 4 |
| STARLIX TABLET 60MG, 120MG |
nateglinide tablet 60mg, 120mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
nateglinide tablet 60mg, 120mg |
Tier 2 with QL, ST |
| SUBUTEX SUBLINGUAL TABLET 2MG, 8MG |
buprenorphin sublingual tablet 2mg, 8mg |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
buprenorphin sublingual tablet 2mg, 8mg |
Tier 4 wth QL |
| TRILEPTAL SUSPENSION 300MG/5ML |
oxcarbazepin suspension 300mg/5ml |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
oxcarbazepin suspension 300mg/5ml |
Tier 4 |
| ULTRAM ER TABLET 100MG |
tramadol hcl tablet 100mg er |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
tramadol hcl tablet 100mg er |
Tier 2 with QL |
| ULTRAM ER TABLET 200MG |
tramadol hcl tablet 200mg er |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
tramadol hcl tablet 200mg er |
Tier 2 |
| Unapproved Pancreatic Enzyme Products (PEPs)* |
amylase-lipase-protease |
Drug Not Available |
Product No Longer Available |
4/28/2010 |
CREON 12000UNIT, CREON 24000UNIT, CREON 6000UNIT |
Tier 3 |
| VALTREX TABLET 500MG, 1GM |
valacyclovir tablet 500mg, 1gm |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
valacyclovir tablet 500mg, 1gm |
Tier 4 |
| VINBLASTINE INJECTION 10MG |
vinblastine sulfate for injection 10mg |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
9/1/2010 |
N/A |
N/A |
| VINCASAR PFS INJECTION 1MG/ML |
vincristine sulfate iv solution 1mg/ml |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
9/1/2010 |
N/A |
N/A |
| VINCRISTINE INJECTION1MG/ML |
vincristine sulfate ivsolution 1mg/ml |
Addition of Utilization Management |
Requires Prior Authorization for Part B/D Coordination |
9/1/2010 |
N/A |
N/A |
| ZOSYN INJECTION 3-0.375GM |
piperacillin/tazobactam sodium 3-0.375gm |
Formulary Removal |
Available in Generic. Only Generic is Covered. |
7/1/2010 |
piperacillin/tazobactam sodium 3-0.375gm |
Tier 2 |
|
*The following is a list of FDA unapproved PEPs: Creon 5/10/20, Dygase, Kutrase, Ku-Zyme, Ku-Zyme-HP, Lapase, Lipram, Lipram-PN, Lipram-UL, Palcaps, Pancrease MT,
Pancrecarb MS, Pancrelipase, Pancrelipase MST, Pancron Panges CN, Panges MT, Panges UL, Pangestym EC, Panocaps, Panocaps MT, Panokase, Plaretase, Ultracaps MT, Ultrase,
Viokase
|
|
QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B/D determination
Affected drug is indicated in bold.
Updated: 05/25/2010
|