BD - Part B vs. Part D, HRM – High Risk Medication, LA - This prescription may be available only at certain pharmacies, NF - Non-Formulary, PA - Prior Authorization, QL – Quantity Limit per 30 days, ST - Step Therapy. 2018 FORMULARY CHANGES Drug Name Current Drug Tier New Drug Tier Reason For Change Alternative Drug, Alternative Drug Tier EFFECTIVE 01/01/2018 AMNESTEEM CAP 10MG NF 1 Formulary Enhancement N/A AMNESTEEM CAP 20MG NF 1 Formulary Enhancement N/A AMNESTEEM CAP 40MG NF 1 Formulary Enhancement N/A Austedo TAB 12 MG NF 1 Formulary Enhancement N/A Austedo TAB 6 MG NF 1 Formulary Enhancement N/A Austedo TAB 9 MG NF 1 Formulary Enhancement N/A Benlysta SOL Auto-injector 200 MG/ML SUBQ NF 1 Formulary Enhancement N/A Benlysta SOL PFS 200 MG/ML SUBQ NF 1 Formulary Enhancement N/A Caspofungin ACET SOL RECON 50 MG IV NF 1 Formulary Enhancement N/A Caspofungin ACET SOL RECON 70 MG IV NF 1 Formulary Enhancement N/A DESO/ETHINYL TAB ESTRADIO NF 1 Formulary Enhancement N/A DiazePAM GEL 10 MG RCT NF 1 Formulary Enhancement N/A DiazePAM GEL 2.5 MG RCT NF 1 Formulary Enhancement N/A ELETRIPTAN TAB 20MG NF 1 + QL 9 Formulary Enhancement N/A ELETRIPTAN TAB 40MG NF 1 + QL 9 Formulary Enhancement N/A Estradiol TAB 10 MCG VAG NF 1 Formulary Enhancement N/A IDHIFA TAB 100 MG NF 1 + PA2 Formulary Enhancement N/A IDHIFA TAB 50 MG NF 1 + PA2 Formulary Enhancement N/A Isentress HD TAB 600 MG NF 1 Formulary Enhancement N/A ISIBLOOM TAB 0.15-30 NF 1 Formulary Enhancement N/A JADENU SPRKL GRA 180MG NF 1 Formulary Enhancement N/A JADENU SPRKL GRA 360MG NF 1 Formulary Enhancement N/A JADENU GRA 90MG NF 1 Formulary Enhancement N/A
Glatiramer Acetate Solution Prefilled Syringe 40 MG/ML Subcutaneous NF 1 + PA1 Formulary Enhancement N/A Gocovri CAPSULE EXTENDED RELEASE 24 HOUR 137 MG Oral NF 1 + PA1 Formulary Enhancement N/A Gocovri CAPSULE EXTENDED RELEASE 24 HOUR 68.5 MG Oral NF 1 + PA1 Formulary Enhancement N/A Haloperidol Decanoate SOLUTION 100 MG/ML Intramuscular 1 ML NF 1 Formulary Enhancement N/A Havrix SUSPENSION 1440 EL U/ML Intramuscular (prefilled syringe) NF 1 Formulary Enhancement N/A Havrix SUSPENSION 720 EL U/0.5ML Intramuscular (prefilled syringe) NF 1 Formulary Enhancement N/A Juluca TABLET 50-25 MG Oral NF 1 Formulary Enhancement N/A Kadcyla SOLUTION RECONSTITUTED 160 MG Intravenous NF 1 Formulary Enhancement N/A Klor-Con PACKET 20 MEQ Oral NF 1 Formulary Enhancement N/A Lartruvo SOLUTION 190 MG/19ML Intravenous NF 1 + PA2 Formulary Enhancement N/A Levonorgest-Eth Est & Eth Est TABLET 42-21-21-7 DAYS Oral NF 1 Formulary Enhancement N/A Levo-T TABLET 100 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 112 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 125 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 137 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 150 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 175 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 200 MCG ORAL NF 1 Formulary Enhancement N/A
Tenofovir Disoproxil Fumarate TABLET 300 MG Oral NF 1 Formulary Enhancement N/A Zenpep CAPSULE DELAYED RELEASE PARTICLES 20000 UNIT Oral 1 NF CMS Required Deletion N/A Zenpep CAPSULE DELAYED RELEASE PARTICLES 40000-126000 UNIT Oral NF 1 Formulary Enhancement N/A EFFECTIVE 05/01/2018 Abacavir Sulfate SOLUTION 20 MG/ML Oral NF 1 Formulary Enhancement N/A Biktarvy TABLET 50-200-25 MG Oral NF 1 + QL 30 Formulary Enhancement N/A Brisdelle CAPSULE 7.5 MG Oral 1 NF Formulary Update paroxetine mesylate 7.5 mg, 1 Cancidas SOLUTION RECONSTITUTED 50 MG Intravenous 1 NF Formulary Update caspofungin acetate 50 mg, 1 Cancidas SOLUTION RECONSTITUTED 70 MG Intravenous 1 NF Formulary Update caspofungin acetate 70 mg, 1 Copaxone Solution Prefilled Syringe 20 MG/ML Subcutaneous 1 + PA1 NF Formulary Update glatiramer acetate 20 mg/ml, 1 + PA1 Copaxone Solution Prefilled Syringe 40 MG/ML Subcutaneous 1 + PA1 NF Formulary Update glatiramer acetate 40 mg/ml, 1 + PA1
Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral NF 1 Formulary Enhancement N/A Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral NF 1 Formulary Enhancement N/A Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral NF 1 Formulary Enhancement N/A Methotrexate Sodium SOLUTION 250 MG/10ML INJECTION NF 1 + BD Formulary Enhancement N/A Naloxone HCl Solution Cartridge 0.4 MG/ML Injection NF 1 Formulary Enhancement N/A Nitrofurantoin Macrocrystal CAPSULE 100 MG Oral 1 + PA1 1 Formulary Enhancement N/A Nitrofurantoin Macrocrystal CAPSULE 25 MG ORAL 1 + PA1 1 Formulary Enhancement N/A Nitrofurantoin Macrocrystal Capsule 50 MG Oral 1 + PA1 1 Formulary Enhancement N/A Nitrofurantoin Monohyd Macro CAPSULE 100 MG Oral 1 + PA1 1 Formulary Enhancement N/A Relpax TABLET 20 MG Oral 1 + QL 9 NF Formulary Update eletriptan 20 mg, 1 + QL 9 Relpax TABLET 40 MG Oral 1 + QL 9 NF Formulary Update eletriptan 40 mg, 1 + QL 9 Renvela TABLET 800 MG Oral 1 NF Formulary Update sevelamer carbonate 800 mg, 1
Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 14 MG Oral 1 NF Formulary Update memantine hydrochloride er 14 mg, 1 Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral 1 NF Formulary Update memantine hydrochloride er 21 mg, 1 Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral 1 NF Formulary Update memantine hydrochloride er 28 mg, 1 Namenda XR CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral 1 NF Formulary Update memantine hydrochloride er 7 mg, 1 Osphena TABLET 60 MG ORAL NF 1 + PA1 Formulary Enhancement N/A Sustiva CAPSULE 200 MG Oral 1 NF Formulary Update efavirenz 200 mg, 1 Sustiva TABLET 600 MG Oral 1 NF Formulary Update efavirenz 600 mg, 1 Syeda Tablet 3-0.03 MG Oral NF 1 Formulary Enhancement N/A Syprine CAPSULE 250 MG Oral 1 NF Formulary Update trientine hydrochloride 250 mg, 1 Tasigna Capsule 50 MG Oral NF 1 Formulary Enhancement N/A Toujeo Max SoloStar Solution 300 UNIT/ML Subcutaneous NF 1 Formulary Enhancement N/A Tri-VyLibra TABLET 0.18/0.215/0.25 MG-35 MCG Oral NF 1 Formulary Enhancement N/A VyLibra TABLET 0.25-35 MG-MCG Oral NF 1 Formulary Enhancement N/A
LaMICtal Starter KIT 25 (42)-100 (7) MG Oral 1 NF Formulary Update lamotrigine starter kit 100 mg / 25 mg, 1 LaMICtal Starter KIT 25 (84)-100(14) MG Oral 1 NF Formulary Update lamotrigine starter kit 100 mg / 25 mg, 1 Methotrexate Sodium (PF) SOLUTION 1 GM/40ML Injection 1 + BD NF CMS Required Deletion N/A Mili Tablet 0.25-35 MG-MCG Oral NF 1 Formulary Enhancement N/A Norvir Packet 100 MG Oral NF 1 Formulary Enhancement N/A Norvir Tablet 100 MG Oral 1 NF Formulary Update ritonavir 100 mg, 1 Ozempic Solution Pen-injector 0.25 or 0.5 MG/DOSE Subcutaneous NF 1 Formulary Enhancement N/A Ozempic Solution Pen-injector 1 MG/DOSE Subcutaneous NF 1 Formulary Enhancement N/A Symfi Tablet 600-300-300 MG Oral NF 1 + QL 30 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 10-1000 MG Oral NF 1 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 12.5-1000 MG Oral NF 1 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 25-1000 MG Oral NF 1 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 5-1000 MG Oral NF 1 Formulary Enhancement N/A Triamterene-HCTZ CAPSULE 50-25 MG Oral 1 NF CMS Required Deletion N/A Tri-Mili Tablet 0.18/0.215/0.25 MG-35 MCG Oral NF 1 Formulary Enhancement N/A