Zenpep CAPSULE DELAYED RELEASE PARTICLES 40000-136000 1 NF CMS Required Deletion N/A UNIT Oral Zmax SUSPENSION 1 NF CMS Required Deletion N/A RECONSTITUTED 2 GM ORAL EFFECTIVE 07/01/2018 Benznidazole TABLET 100 MG Oral NF 1 Formulary Enhancement N/A Benznidazole TABLET 12.5 MG Oral NF 1 Formulary Enhancement N/A Cetraxal SOLUTION 0.2 % OTIC NF 1 Formulary Enhancement N/A Clopidogrel Bisulfate TABLET 300 MG 1 NF CMS Required Deletion N/A Oral Gildagia TABLET 0.4-35 MG-MCG 1 NF CMS Required Deletion N/A Oral Humira Pediatric Crohns Prefilled Syringe Kit 80 MG/0.8ML & NF 1 Formulary Enhancement N/A 40MG/0.4ML Subcutaneous Humira Pediatric Crohns Prefilled Syringe Kit 80 MG/0.8ML NF 1 Formulary Enhancement N/A Subcutaneous Humira Pen Pen-Injector Kit 40 NF 1 Formulary Enhancement N/A MG/0.4ML Subcutaneous Humira Prefilled Syringe Kit 10 NF 1 Formulary Enhancement N/A MG/0.1ML Subcutaneous Humira Prefilled Syringe Kit 40 NF 1 Formulary Enhancement N/A MG/0.4ML Subcutaneous Intrarosa INSERT 6.5 MG Vaginal NF 1 + PA1 Formulary Enhancement N/A
Zenpep CAPSULE DELAYED RELEASE PARTICLES 40000-136000 UNIT Oral 1 NF CMS Required Deletion N/A Zmax SUSPENSION RECONSTITUTED 2 GM ORAL 1 NF CMS Required Deletion N/A EFFECTIVE 07/01/2018 Benznidazole TABLET 100 MG Oral NF 1 Formulary Enhancement N/A Benznidazole TABLET 12.5 MG Oral NF 1 Formulary Enhancement N/A Cetraxal SOLUTION 0.2 % OTIC NF 1 Formulary Enhancement N/A Clopidogrel Bisulfate TABLET 300 MG Oral 1 NF CMS Required Deletion N/A Gildagia TABLET 0.4-35 MG-MCG Oral 1 NF CMS Required Deletion N/A Humira Pediatric Crohns Prefilled Syringe Kit 80 MG/0.8ML & 40MG/0.4ML Subcutaneous NF 1 Formulary Enhancement N/A Humira Pediatric Crohns Prefilled Syringe Kit 80 MG/0.8ML Subcutaneous NF 1 Formulary Enhancement N/A Humira Pen Pen-Injector Kit 40 MG/0.4ML Subcutaneous NF 1 Formulary Enhancement N/A Humira Prefilled Syringe Kit 10 MG/0.1ML Subcutaneous NF 1 Formulary Enhancement N/A Humira Prefilled Syringe Kit 40 MG/0.4ML Subcutaneous NF 1 Formulary Enhancement N/A Intrarosa INSERT 6.5 MG Vaginal NF 1 + PA1 Formulary Enhancement N/A
AgeWell-1-Tier_2018_Addendum_Eff_08012018.docx