Hoja de errata del formulario de Health Partners Medicare para 2014 (Lista de medicamentos cubiertos)

Transcripción

1 Hoja de errata del formulario de Health Partners Medicare para 2014 (Lista de medicamentos cubiertos) Esta carta tiene como fin informarle algunos cambios en su cuadernillo del formulario de Health Partners Medicare para Los cambios en el formulario de Health Partners Medicare se incluyen en el cuadro de abajo. Tenga en cuenta que seguiremos cubriendo cualquiera de los siguientes medicamentos eliminados durante el resto del año del plan en el caso de que usted sea miembro de Health Partners Medicare y esté tomando el medicamento en el momento de este cambio, siempre que el medicamento siga siendo médicamente necesario y que se lo recete su médico, excepto si se elimina del formulario por razones de seguridad. Usted no debe hacer nada. Si tiene alguna pregunta después de leer esta notificación, puede comunicarse con Health Partners Medicare al (TTY ) en cualquier momento, las 24 horas del día, los siete días de la semana. Fecha de entrada en vigencia de la HOJA DE ERRATA (MEDICARE): 1/1/2014 Cambios en el formulario: 1/1/2014 No se han realizado cambios. Fecha de entrada en vigencia de la HOJA DE ERRATA (MEDICARE): 2/11/2014 Cambios en el formulario: 2/11/2014 Cartia XT capsules (all strengths) Addition to formulary Effective date Clobetasol 0.05% cream Addition to formulary Effective date Digox tablets 125 mcg, 250 mcg Addition to formulary Effective date Diltiazem 24hr CD capsules (all strengths) Addition to formulary Effective date Diltiazem ER capsule (all strengths) Addition to formulary Effective date Doxycycline hyclate capsules and tablets (all Addition to formulary Effective date strengths) Doxycycline monohydrate capsules and tablets (all Addition to formulary Effective date strengths) Duloxetine HCl CD capsules 20 mg, 30 mg, 60 mg Addition to formulary Effective date (generic: Cymbalta) Endocet 10mg/325 mg, 7.5mg/325mg Addition to formulary Effective date Fluocinonide 0.05% cream Addition to formulary Effective date

2 Hydrocodone/acetaminophen solution 7.5 Addition to formulary Effective date mg/15ml Klor Con M tablets 15 meq Addition to formulary Effective date Lidocaine 5% patch (generic for Lidoderm) Addition to formulary Effective date Naproxen DR tablets 375 mg, 500 mg Addition to formulary Effective date Nifedical XL tablets 30 mg, 60 mg Addition to formulary Effective date Nifedipine ER tablet 30 mg, 60 mg, 90 mg Addition to formulary Effective date Oxycodone/Acetaminophen 10mg/325mg; Addition to formulary Effective date mg/325mg Potassium Cl ER 20 meq, 8 meq Addition to formulary Effective date Repaglinide tablets (all strengths; generic: Prandin) Addition to formulary Effective date Synthroid tablets (all strengths) Addition to formulary Effective date Fecha de entrada en vigencia de la HOJA DE ERRATA (MEDICARE): 3/11/2014 Cambios en el formulario: 3/11/2014 Abacavir/lamivudine/zidovudine tablet Addition to formulary Effective date /150/300 mg (generic: Trizir) Acamprosate tablet 333 mg (generic Campral) Addition to formulary Effective date Acitretin capsule 10 mg, 17.5 mg, 25 mg (generic Addition to formulary Effective date Soriatane) Adefovir tablet 10 mg (generic Hepsera) Addition to formulary Effective date Adrenalin injectable solution 1 mg/ml Addition to formulary Effective date Afinitor Disperz oral suspension 0.08 mg/ml, 0.12 Addition to formulary Effective date mg/ml, 0.2 mg/ml Astagraf capsule 0.5 mg, 1 mg, 5 mg Addition to formulary Effective date Azacitidine 25 mg/ml injectable solution (generic: Addition to formulary Effective date Vidaza) Brintellix tablet 5 mg, 10 mg, 20 mg Addition to formulary Effective date Brisdelle capsule 5 mg, 7.5 mg, 10 mg, 20 mg Addition to formulary Effective date Candesartan tablet 4 mg, 8 mg, 16 mg, 32 mg Addition to formulary Effective date (generic Atacand) Clemastine solution mg/ml Addition to formulary Effective date Clindamycin solution 15 mg/ml Addition to formulary Effective date Donepezil tablet 23 mg (generic Aricept) Addition to formulary Effective date Fetzima capsule and dosing pack 20 mg, 120 mg, Addition to formulary Effective date mg, 80 mg Fycompa tablet 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 Addition to formulary Effective date mg Gentamicin ophthalmic ointment mg/mg Addition to formulary Effective date Gilotrif tablet 20 mg, 30 mg, 40 mg Addition to formulary Effective date Imbruvica capsule 140 mg Addition to formulary Effective date Intelence tablet 25 mg Addition to formulary Effective date Khedezla tablet 50 mg, 100 mg Addition to formulary Effective date

3 Latuda tablet 60 mg Addition to formulary Effective date Lomustine 10 mg, 40 mg, 100 mg capsule (generic Addition to formulary Effective date CeeNU) Methylphenidate ER tablet 18 mg (generic: Addition to formulary Effective date Concerta) Metronidazole gel 0.01 mg/mg Addition to formulary Effective date Norethindrone tablet 0.35 mg (generic Addition to formulary Effective date Camila/Errin) Notriptyline solution 2 mg/ml Addition to formulary Effective date Noxafil tablet 100 mg tablet Addition to formulary Effective date Nuvigil tablet 150 mg Addition to formulary Effective date Olysio tablet 150 mg PA required Addition to formulary Effective date Onfi suspension 25 mg/ml Addition to formulary Effective date Oxtellar tablet 10 mg, 300 mg, 600 mg Addition to formulary Effective date Oxycodone solution 1 mg/ml Addition to formulary Effective date Revlimid capsule 2.5 mg, 20 mg Addition to formulary Effective date Sovaldi tablet 400 mg PA required Addition to formulary Effective date Tivicay tablet 50 mg Addition to formulary Effective date Tobramycin for nebulization 300 mg/5 ml in Addition to formulary Effective date % sodium chloride (generic: TOBI) Tobramycin IV piggyback 60 mg/50 ml in 0.9% Addition to formulary Effective date sodium chloride Triamterene/HCTZ capsule 50/25 mg Addition to formulary Effective date Trokendi capsule 25 mg. 50 mg, 100 mg, 200 mg Addition to formulary Effective date Voriconazole suspension 40 mg/ml (generic: Addition to formulary Effective date Vfend) Zinacef injectable solution 90 mg/ml, 95 mg/ml, Addition to formulary Effective date mg/ml Kayexalate Remove from formulary Not a covered benefit Effective date Tyzine Remove from formulary Not a covered benefit Effective date Fecha de entrada en vigencia de la HOJA DE ERRATA (MEDICARE): 4/11/2014 Cambios en el formulario: 4/11/ HR niacin tablet 500 mg, 750 mg, 1000 mg Addition to formulary Effective date (generic: Niaspan) 24 HR tolterodine capsule 2 mg, 4 mg(generic: Addition to formulary Effective date Detrol LA) Dicyclomine oral solution 10mg/5ml Addition to formulary Effective date Erwinaze (erwina asparaginase) injectable solution Addition to formulary Effective date Generic Prenatal Vitamins Addition to formulary Effective date Horizant tablet 300 mg Addition to formulary Effective date

4 Janumet tablet 50/500 mg, 50/1000 mg Addition to formulary Effective date Janumet XR tablet 50/500 mg, 50/1000 mg, Addition to formulary Effective date /1000 mg Januvia tablet 25 mg, 50 mg, 100 mg Addition to formulary Effective date Lamivudine tablet 100 mg (generic: Epivir HBV) Addition to formulary Effective date Metronidazole capsule 375 mg Addition to formulary Effective date Mycophenolic acid tablet 180 mg, 360 mg (generic: Addition to formulary Effective date Myfortic) Oncaspar injectable solution 750 unit/ml PA Addition to formulary Effective date required ProAir HFA inhaler 90 mcg/actuation Addition to formulary Effective date Sirolimus tablet 0.5 mg (generic: Rapamune) Addition to formulary Effective date Spiriva removal of step therapy Addition to formulary Effective date Zenchent tablet 28 day Addition to formulary Effective date Fecha de entrada en vigencia de la HOJA DE ERRATA (MEDICARE): Cambios en el formulario: Cerubidine 20 IV solution Doxycycline hyclate 100 mg IV solution Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet BCG, live vaccine Diastat 2.5 mg rectal kit Diastat AcuDial 5 mg-7.5 mg-10 mg rectal kit Diastat AcuDial 12.5 mg-15 mg-17.5 mg-20 mg rectal kit Removal of prior authorization step edit on Restasis 0.05% eye drops Eliminar del formulario: En vigencia desde el Eliminar del formulario: En vigencia desde el Removal of prior authorization edit effective

5 Removal of Crestor step-edit with lovastatin 10, 20, 40 mg tablets; simvastatin 5, 10, 20, 40, 80 mg tablets; atorvastatin 10, 40 mg tablets; pravastatin 10, 20, 40, 80 mg tablets; Crestor 5, 10, 20, 40 mg tablets Removal of Lumigan step-edit with Travatan Z 0.004% eye drops, Latanoprost 0.005% eye drops, and Lumigan 0.01% eye drops Removal of Namenda XR step-edit with Namenda XR 5 & 10 mg tablets; Namenda XR 7, 14, 21,28 mg capsule sprinkle ER 24 hr; Namenda XR 7mg- 14mg-21mg-28 mg capsule, sprinkle, ER 24 hr dose pack; Namenda Titration Pak 5 mg-10 mg tablets in dose pack; Namenda 10 mg/5 ml oral solution Removal of step-edit effective Removal of step-edit effective Removal of step-edit effective H9207_PHMA0112SP Aprobado 3/2014