HRM High Risk Medication, LA - This prescription may be available only at certain BD - Part B vs. Part D, – pharmacies, NF - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy. – 2018 FORMULARY CHANGES Alternative Current New Drug, Drug Reason For Change Drug Tier Alternative Tier Drug Tier Drug Name 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 NF 1 Formulary Enhancement N/A MG/ML SUBQ Benlysta SOL PFS 200 MG/ML SUBQ NF 1 Formulary Enhancement N/A Caspofungin ACET SOL RECON 50 NF 1 Formulary Enhancement N/A MG IV Caspofungin ACET SOL RECON 70 NF 1 Formulary Enhancement N/A MG IV 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
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
AgeWell_1-Tier_2018_Addendum_Eff_090120181.docx