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 2014. 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 1-866-901-8000 (TTY 1-877-454-8477) 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 2 1 2014 Clobetasol 0.05% cream Addition to formulary Effective date 2 1 2014 Digox tablets 125 mcg, 250 mcg Addition to formulary Effective date 2 1 2014 Diltiazem 24hr CD capsules (all strengths) Addition to formulary Effective date 2 1 2014 Diltiazem ER capsule (all strengths) Addition to formulary Effective date 2 1 2014 Doxycycline hyclate capsules and tablets (all Addition to formulary Effective date 2 1 2014 strengths) Doxycycline monohydrate capsules and tablets (all Addition to formulary Effective date 2 1 2014 strengths) Duloxetine HCl CD capsules 20 mg, 30 mg, 60 mg Addition to formulary Effective date 2 1 2014 (generic: Cymbalta) Endocet 10mg/325 mg, 7.5mg/325mg Addition to formulary Effective date 2 1 2014 Fluocinonide 0.05% cream Addition to formulary Effective date 2 1 2014
Hydrocodone/acetaminophen solution 7.5 Addition to formulary Effective date 2 1 2014 325mg/15ml Klor Con M tablets 15 meq Addition to formulary Effective date 2 1 2014 Lidocaine 5% patch (generic for Lidoderm) Addition to formulary Effective date 2 1 2014 Naproxen DR tablets 375 mg, 500 mg Addition to formulary Effective date 2 1 2014 Nifedical XL tablets 30 mg, 60 mg Addition to formulary Effective date 2 1 2014 Nifedipine ER tablet 30 mg, 60 mg, 90 mg Addition to formulary Effective date 2 1 2014 Oxycodone/Acetaminophen 10mg/325mg; Addition to formulary Effective date 2 1 2014 7.5mg/325mg Potassium Cl ER 20 meq, 8 meq Addition to formulary Effective date 2 1 2014 Repaglinide tablets (all strengths; generic: Prandin) Addition to formulary Effective date 2 1 2014 Synthroid tablets (all strengths) Addition to formulary Effective date 2 1 2014 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 3 1 2014 300/150/300 mg (generic: Trizir) Acamprosate tablet 333 mg (generic Campral) Addition to formulary Effective date 3 1 2014 Acitretin capsule 10 mg, 17.5 mg, 25 mg (generic Addition to formulary Effective date 3 1 2014 Soriatane) Adefovir tablet 10 mg (generic Hepsera) Addition to formulary Effective date 3 1 2014 Adrenalin injectable solution 1 mg/ml Addition to formulary Effective date 3 1 2014 Afinitor Disperz oral suspension 0.08 mg/ml, 0.12 Addition to formulary Effective date 3 1 2014 mg/ml, 0.2 mg/ml Astagraf capsule 0.5 mg, 1 mg, 5 mg Addition to formulary Effective date 3 1 2014 Azacitidine 25 mg/ml injectable solution (generic: Addition to formulary Effective date 3 1 2014 Vidaza) Brintellix tablet 5 mg, 10 mg, 20 mg Addition to formulary Effective date 3 1 2014 Brisdelle capsule 5 mg, 7.5 mg, 10 mg, 20 mg Addition to formulary Effective date 3 1 2014 Candesartan tablet 4 mg, 8 mg, 16 mg, 32 mg Addition to formulary Effective date 3 1 2014 (generic Atacand) Clemastine solution 0.134 mg/ml Addition to formulary Effective date 3 1 2014 Clindamycin solution 15 mg/ml Addition to formulary Effective date 3 1 2014 Donepezil tablet 23 mg (generic Aricept) Addition to formulary Effective date 3 1 2014 Fetzima capsule and dosing pack 20 mg, 120 mg, Addition to formulary Effective date 3 1 2014 40 mg, 80 mg Fycompa tablet 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 Addition to formulary Effective date 3 1 2014 mg Gentamicin ophthalmic ointment 0.003 mg/mg Addition to formulary Effective date 3 1 2014 Gilotrif tablet 20 mg, 30 mg, 40 mg Addition to formulary Effective date 3 1 2014 Imbruvica capsule 140 mg Addition to formulary Effective date 3 1 2014 Intelence tablet 25 mg Addition to formulary Effective date 3 1 2014 Khedezla tablet 50 mg, 100 mg Addition to formulary Effective date 3 1 2014
Latuda tablet 60 mg Addition to formulary Effective date 3 1 2014 Lomustine 10 mg, 40 mg, 100 mg capsule (generic Addition to formulary Effective date 3 1 2014 CeeNU) Methylphenidate ER tablet 18 mg (generic: Addition to formulary Effective date 3 1 2014 Concerta) Metronidazole gel 0.01 mg/mg Addition to formulary Effective date 3 1 2014 Norethindrone tablet 0.35 mg (generic Addition to formulary Effective date 3 1 2014 Camila/Errin) Notriptyline solution 2 mg/ml Addition to formulary Effective date 3 1 2014 Noxafil tablet 100 mg tablet Addition to formulary Effective date 3 1 2014 Nuvigil tablet 150 mg Addition to formulary Effective date 3 1 2014 Olysio tablet 150 mg PA required Addition to formulary Effective date 3 1 2014 Onfi suspension 25 mg/ml Addition to formulary Effective date 3 1 2014 Oxtellar tablet 10 mg, 300 mg, 600 mg Addition to formulary Effective date 3 1 2014 Oxycodone solution 1 mg/ml Addition to formulary Effective date 3 1 2014 Revlimid capsule 2.5 mg, 20 mg Addition to formulary Effective date 3 1 2014 Sovaldi tablet 400 mg PA required Addition to formulary Effective date 3 1 2014 Tivicay tablet 50 mg Addition to formulary Effective date 3 1 2014 Tobramycin for nebulization 300 mg/5 ml in Addition to formulary Effective date 3 1 2014 0.225% sodium chloride (generic: TOBI) Tobramycin IV piggyback 60 mg/50 ml in 0.9% Addition to formulary Effective date 3 1 2014 sodium chloride Triamterene/HCTZ capsule 50/25 mg Addition to formulary Effective date 3 1 2014 Trokendi capsule 25 mg. 50 mg, 100 mg, 200 mg Addition to formulary Effective date 3 1 2014 Voriconazole suspension 40 mg/ml (generic: Addition to formulary Effective date 3 1 2014 Vfend) Zinacef injectable solution 90 mg/ml, 95 mg/ml, Addition to formulary Effective date 3 1 2014 225 mg/ml Kayexalate Remove from formulary Not a covered benefit Effective date 3 25 2014 Tyzine Remove from formulary Not a covered benefit Effective date 3 25 2014 Fecha de entrada en vigencia de la HOJA DE ERRATA (MEDICARE): 4/11/2014 Cambios en el formulario: 4/11/2014 24 HR niacin tablet 500 mg, 750 mg, 1000 mg Addition to formulary Effective date 4 1 2014 (generic: Niaspan) 24 HR tolterodine capsule 2 mg, 4 mg(generic: Addition to formulary Effective date 4 1 2014 Detrol LA) Dicyclomine oral solution 10mg/5ml Addition to formulary Effective date 4 1 2014 Erwinaze (erwina asparaginase) injectable solution Addition to formulary Effective date 4 1 2014 Generic Prenatal Vitamins Addition to formulary Effective date 4 1 2014 Horizant tablet 300 mg Addition to formulary Effective date 4 1 2014
Janumet tablet 50/500 mg, 50/1000 mg Addition to formulary Effective date 4 1 2014 Janumet XR tablet 50/500 mg, 50/1000 mg, Addition to formulary Effective date 4 1 2014 100/1000 mg Januvia tablet 25 mg, 50 mg, 100 mg Addition to formulary Effective date 4 1 2014 Lamivudine tablet 100 mg (generic: Epivir HBV) Addition to formulary Effective date 4 1 2014 Metronidazole capsule 375 mg Addition to formulary Effective date 4 1 2014 Mycophenolic acid tablet 180 mg, 360 mg (generic: Addition to formulary Effective date 4 1 2014 Myfortic) Oncaspar injectable solution 750 unit/ml PA Addition to formulary Effective date 4 1 2014 required ProAir HFA inhaler 90 mcg/actuation Addition to formulary Effective date 4 1 2014 Sirolimus tablet 0.5 mg (generic: Rapamune) Addition to formulary Effective date 4 1 2014 Spiriva removal of step therapy Addition to formulary Effective date 4 1 2014 Zenchent tablet 28 day Addition to formulary Effective date 4 1 2014 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
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