ACTUALIZACION DE CAMBIOS AL FORMULARIO 2015: El siguiente resumen describe los cambios a los Formularios de la Parte D desde enero hasta marzo del año 2015. Afectado INCIVEK ORAL TAB. 35 MG Telaprevir del formulario Removido por CMS ORTHO EVRA TRANSDERMAL PATCH Ethinyl estradiol/norelgestromin del formulario (b) Removido por CMS PRIFTIN ORAL TAB 150 MG Rifapentin del formulario Removido por CMS Cyclophosphamide Oral Tab 25 mg, 50 mg Cyclophosphamide del formulario Removido por CMS Heparin Sodium Porcine 2 Units/ml Heparin Sodium Porcine del formulario Removido por CMS Lidocaine HCl Inj. Sol. 10 mg/ml Lidocaine Hydrochloride del formulario Removido por CMS ANDROGEL TOPICAL GEL 20.25 MG/1.25 GM (1.62%) Testosterone 2 (a), 3 (b,c)
Afectado ANDROGEL TOPICAL GEL 40.5 MG/2.5 GM (1.62%) ANORO ELLIPTA INH. POWDER 62.5-25 MCG BELEODAQ INJ. SOL. 500 MG BREO ELLIPTA INH. POWDER 100-25 MCG DEMEROL INJ. SOL 50 MG/ML FYCOMPA ORAL TAB 12 MG GARDASIL 9 INJ SUSP Testosterone Umeclinidium/Vilanterol Belinostat Fluticasone furoate/ Vilanterol Meperidine Hydrochloride Perampanel Human Papillomavirus Type, Vaccine 2 (a), 3 (b,c) PA, QL, 2 (a), 3 (b,c) PA, B vs D 3 (a), PA, QL, 2 (a), 3 (b,c) PA, 2 (a,b), 3 (c) PA, 2 (a), 3 (b,c) 2 (a,b), 3 (c)
Afectado HETLIOZ ORAL CAP 20 MG HUMIRA PREFILLED SYRINGE 10 MG/0.2 ML ICLUSIG ORAL TAB 15 MG INTRON A INJ SOL 18 MU 50 MU IPOL INACTIVATED PREFILLED SYRINGE 80-16-64 UNITS /ML KEYTRUDA SOL 50 MG VIAL ORFADIN ORAL CAP 10MG, 2 MG, 5 MG Tasimelteon Adalimumab Ponatinib Interferon Alfa - 2B Poliovirus Vaccine Inactivated Pembrolizumab Nitisinone PA, QL, 3 (a), PA, QL, 3 (a), PA, 3 (a), PA, 3 (a), 2 (a), 3 (b,c) PA, B vs D 3 (a), PA, 3 (a),
Afectado OTEZLA ORAL TAB 30 MG OTEZLA STARTER THERAPY PACK 10/20/30 PLEGRIDY STARTER PACK INJ PEN 63 MCG-94 MCG/0.5 ML PLEGRIDY PREFILLED SYRINGE 125 MCG/0.5 ML/ PLEGRIDY PEN INJECTOR 125 MCG/0.5 ML PURIXAN ORAL SUSPENSION 2000 MG/100 ML (20 MG/ML) RECOMBIVAX HB PREFILLED SYRINGE 10 MCG/ML 5 MCG/ML SILENOR ORAL TAB 3MG, 6 MG Apremilast Apremilast Peginterferon Beta 1A Peginterferon Beta 1A Mercaptopurine Hepatitis B Surface Antigen Vaccine Doxepin PA, QL, 3 (a), PA, QL, 3 (a), 4 (a,b) PA, 3 (a), PA, 3 (a), 2 (a), 3 (b,c) BvsD, 2 (a,b ), 3 (c) ST, QL, 2 (a), 3 (b,c)
Afectado SIMBRINZA OPH SUSP 1-0.2% SIVEXTRO ORAL TAB 200 MG SIVEXTRO INJ SOL 200 MG SOMAVERT INJ SOL 25 MG/ML 200 MG/ML SPIRIVA SPR RESPIMAT METERED DOSE INH 2.5 MCG/ ACT STRIVERDI RESPIMAT 2.5 MCG/ACT METERED DOSE INH Brimonidine tartrate/ Brinzolamide Tedizolid Phosphate Tedizolid Phosphate Pegvisomant Tiotropium Olodaterol QL 3 (a), 3 (b,c) PA, QL, 3 (a), PA, QL, 3 (a), PA, 3 (a), QL, 2 (a,b), 3 (c) PA, QL, 2 (a,b), 3 (c)
Afectado SUPREP BOWEL ORAL SOL PACK SUTENT ORAL CAP 37.5 MG TREANDA INJ SOL 45 MG/0.5 ML (90 MG/ML) TRIUMEQ ORAL TAB 600-50-300 TRUMENBA PREFILLED SYRINGE TYBOST ORAL TAB 150 MG VALCHLOR TOPICAL GEL 0.016% Magnesium Sulfate/Potassium Sulfate/Sodium Sulfate Sunitinib Bendamustine Hydrochloride Abacavir/Dolutegravir/Lamivudine Meningococcal Group B Vaccine Cobicistat Mechlorethamine 2 (a), 3 (b,c) PA, 3 (a), PA, B vs D 3 (a), 3 (a), 2 (a,b), 3 (c) 2 (a), 3 (b,c) PA, 3 (a),
Afectado VAQTA PREFILLED SYRINGE 25 UNITS/0.5 ML 50 UNITS/ML XARELTO STARTER PACK 15MG-20MG ZYDELIG ORAL TAB 100 MG, 150 MG Acetaminophen/Hydrocodone Bitartrate Oral tab 325-2.5 mg Adapalene Topical Gel 0.3 % Amlodipine/Valsartan/Hydrochloro thiazode Oral Tab. 10/160/12.5 mg, 10/160/25 mg, 10/320/25 mg, 5/160/12.5 mg 5/160/25 mg Amlodipine/Valsartan Oral Tab 10/160 mg, 10/320 mg, 5/160 mg, 5/320 mg Hepatitis A Vaccine Rivaroxaban Idelalisib Hydrocodone Bitartrate/Acetaminophen Adapalene Amlodipine/Valsartan/Hydrochlorothi azide Amlodipine/Valsartan PA, 2 (a), 3 (b,c) PA, 2 (a,b), 3 (c) PA, QL 3 (a), 1 (a,b), PA 1 (a,b), QL QL
Afectado Atovaquone Oral Susp 150 mg/ml Fluorouracil Topical Cream 5 mg/ml Entecavir Oral Tab 0.5 mg, 1 mg Atropine Sulfate Ophthalmic Soln 1% Furosemide 10 mg/ml Prefilled Suringe Budesonide Nasal Inhaler 32 mcg/act Carbidopa/Entacapone/Levodopa Oral tab. 12.5/200/50 mg, 18.75/200/75 mg, 25/200/100 mg, 31.25/200/125 mg, 37.5/200/150 mg, 50mg/200mg/200mg Atovaquone Fluorouracil Entecavir Atropine Sulfate Furosemide Budesonide Carbidopa/Entacapone/Levodopa PA, 3(a), 4(b,c) 3 (a), 1(a,b), 2(c) 1(a,b), 2(c)
Afectado Ciprofloxacin Oral Susp 100 mg/ml, 50 mg/ml Fluorometholone Ophthalmic Susp 1 mg/ml Ibandronic Acid Inj Soln 1 mg/ml Cefaclor Oral Suspension 125mg/5ml (25mg/ml), 250 mg/ml (50 mg/5 ml), 375 mg/5 ml (75 mg/ml) Celecoxib Oral Cap 100mg, 200 mg, 400 mg, 50 mg Lidocaine Inj. Soln 2% Magnesium Sulfate Inj 4 meq/ml 50% Meperidine HCl Inj Soln 100 mg/ ml, 25 mg/ ml Ciprofloxacin Fluorometholone Ibandronic Acid Cefaclor Celecoxib Lidocaine hydrochloride Magnesium Sulfate Meperidine Hydrochloride 1 (a,b), PA, QL 1 (a,b), 1 (a,b), PA, 1(a,b), 2(c)
Afectado Methoxsalen Oral Cap 10 mg Morphine Sulfate Prefilled Syringe 10 mg/ml, 2 mg/ ml, 4 mg/ ml 8 mg/ml Moxifloxacin Oral Tab 400 mg Mycophenolate Mofetil Oral Susp 200 mg/ ml Nevirapine Extended Release Oral Tab 400 mg Potassium Citrate ER Oral Tab Prednisolone Acetate Ophthalmic Susp 1% Methoxsalen Morphine Sulfate Moxifloxacin Mycophenolate Mofetil Nevirapine Extended Release Potassium Citrate Extended Release Prednisolone Acetate Raloxifene HCl Oral Tab 60 mg Raloxifene Hydrochloride PA, 3 (a), B vs D, 1 (a,b), QL, 1 (a,b), B vs D, 1 (a,b),
Afectado Rifabutin Oral Cap 150 mg Rifabutin Risedronate Sodium Oral Tab 150 mg Risedronate Sodium Sirolimus Oral Tab 1 mg Sirolimus Sirolimus Oral Tab 2 mg Sirolimus Tacrolimus Topical Ointment 0.3%(0.0003 mg/mg) 0.1%(0.0001 mg/mg) Tacrolimus Testosterone Topical Gel 1% ( 50mg/5gm) Testosterone Testosterone Topical Gel 2% ( 10mg/ act.) Testosterone Theophylline Oral Soln 80 mg/ 15 ml (5.33 mg/ml) Theophylline QL, 1 (a,b), B vs D, 1 (a,b), B vs D, 3 (a), ST, 1 (a,b), 1
Afectado Topiramate Oral Cap Extended Release 100mg, 150mg, 200 mg, 25mg, 50mg Topiramate Extended Release Valganciclovir Oral tab 450 mg Valganciclovir Valsartan Oral Tab 160mg, 320mg, 40mg, 80mg Valsartan 3 (a), Azithromycin Oral Susp 100 mg/5 ml (20 mg/ml) Azithromycin en QL Quetiapine Oral Tab 100 mg, 200 mg, 300 mg, 400 mg Quetiapine en PA Rozerem Oral Tab 8 mg Ramelteon en ST Enoxaparin Sodium Prefilled Syringe 100 mg/ml-0.3ml Enoxaparin Sodium Prefilled Syringe 100 mg/ml-0.4ml Enoxaparin Sodium Enoxaparin Sodium en QL en QL Se cambia de; 30/5 a; 75/5 PA el ST Se cambia de; 8.4/30 a; 9/30 Se cambia de; 11.2/30 a; 12/30
Afectado Enoxaparin Sodium Prefilled Syringe 100 mg/ml-0.6ml Enoxaparin Sodium Prefilled Syringe 100 mg/ml-0.8ml, 50 mg/ml-0.8ml Enoxaparin Sodium Prefilled Syringe 100 mg/ml- 1ml, 150mg/ml 1 ml Enoxaparin Sodium Enoxaparin Sodium Enoxaparin Sodium en QL en QL en QL Enoxaparin Sodium Inj Sol Vial 100mg/ml-3 ml vial(300mg) Enoxaparin Sodium en QL Azelastine HCl Nasal Inhaler 0.137 mg/act Azelastine Hydrochloride en QL CELEBREX ORAL CAP 100MG, 200 MG, 400 MG, 50 MG Celecoxib VALCYTE ORAL TAB 450 MG Valganciclovir BARACLUDE ORAL TAB 0.5 MG Entecavir Se cambia de; 16.8/30 a; 18/30 Se cambia de; 22.4/30 a; 24/30 Se cambia de; 28/30 a; 30/30 Se cambia de; 28/30 a; 30/30 Se cambia de; 30/30 a; 25/30 de, de, de, Celecoxib Oral Cap 100 mg, 200 mg, 400 mg, 50 mg PA, QL Valgancyclovir Oral Tab 450 mg Entecavir Oral Tab 0.5 mg 2(a,b), 3(c) 3(a), 4(b,c) 3(a), 4(b,c)
Afectado PROTOPIC TOPICAL OINT 0.0003 MG/MG; 0.001 MG/MG Tacrolimus de, Tacrolimus Topical Oint 0.001 mg/mg; 0.0003 mg/mg RAPAMUNE ORAL TAB 1MG Pilocarpine hydrochloride Ophthalmic Soln 10 mg/ml, 20 mg/ml, 40 mg/ ml RAPAMUNE ORAL TAB 2MG Sirolimus Pilocarpine Hydrochloride Sirolimus EVISTA ORAL TAB 60 MG Raloxifene Hydrochloride OXSORALEN ULTRA ORAL CAP 10 MG Methoxsalen MYCOBUTIN ORAL CAP 150 MG Rifabutin 1(a,b), 2(c) de, de, de, de, de, Sirolimus Oral Tab 1 mg, PA B vs D 1 (a,b), Sirolimus Oral Tab 2 mg, PA B vs D Raloxifene HCl 60 mg Methoxsalen Oral Cap 10 mg, PA Rifabutin Oral Cap 150 mg 3(a), 4(b,c) 1(a,b), 2(c) 3(a), 4(b,c) 1(a,b), 2(c)
Afectado VIRAMUNE EXTENDED RELEASE ORAL TAB 400 MG Nevirapine Extended Release MEPRON ORAL SUSP 150 MG/ML Atovaquone BONIVA INJ SOLN 1 MG/ML Ibandronic Acid FAZACLO DISINTEGRATING TAB 100 MG, 12.5 MG, 25 MG Clozapine de, de, de, de, Nevirapine Extended Release Oral Tab 400mg Atovaquone Oral Susp 150 mg/ml, PA Ibandronic Acid Inj Soln 1 mg/ml, PA B vs D Clozapine Disintegrating Tab 100 mg, 12.5 mg, 25 mg 1(a,b), 2(c) 3(a), 2(b,c) 1(a,b), 2(c) 1(a,b), 2(c) PALGIC ORAL SOLUTION 0.8 MG/ML Carbinoxamine maleate Removido por CMS PALGIC ORAL TAB 4 MG Carbinoxamine maleate Removido por CMS QVAR 0.08 MG/ACTUAT Beclomethasone dipropionate Removido por CMS LYNPARZA ORAL CAP 50 MG Olapanib PA, 3 (a),
Afectado NAMENDA ORAL TAB 10 MG, 5 MG Memantine hydrochloride PA, 2 (a,b), 3 (c) NAMENDA TRETINOIN PACK OPDIVO INJ. SOLUTION 10 MG/ ML REYATAZ ORAL POWDER 50 MG RUCONEST INJ. SOLUTION 150 UNITS/ ML Colchicine Oral Cap 0.6 mg Colchicine Oral Tab 0.6 mg Memantine hydrochloride Nivolumab Atazanavir Esterase inhibitor (Recombinant) Colchicine Colchicine PA, 2 (a,b), 3 (c) PA, B vs D 3 (a), 3 (a), PA, B vs D 3 (a),
Afectado Lamivudine Oral Soln. 10 mg/ ml Linezolid Inj. Sol 2 mg/ml Testosterone Topical Gel 0.01 mg/mg Metformin HCl Oral Tab 500 mg COLCRYS ORAL TAB 0.6 MG EPIVIR ORAL SOL 10 MG/ML ZYVOX INJ. SOLN 2 MG/ML Lamivudine Linezolid Testosterone Metformin Hydrochloride Colchicine Lamivudine Linezolid 1 (a,b), 3 (a), (b, c) 4 1 (a, b), en QL Se cambia de 60 /30 a 90/30 de, de, de, 09/01/2015 09/01/2015 09/01/2015 Colchicine Oral Tab. 0.6 mg Lamivudine Oral Soln. 10 mg/ml Linezolid Inj. Soln 2 mg/ml 3 (a), (a)aplica a: Elite Ultra, Diamante Choice Platino, Diamante Extra Platino, Diamante Excel Platino. (b) Aplica a: Elite Excel Select, Elite Excel Plus, Único, Único Extra, ELA Flex Bronce, ELA Plus Plata Flex, ELA Relax Oro Flex, ELA Excel Rubí Flex. (c) Aplica a: Supremo
Para radicar una solicitud deberá proveer la evidencia de necesidad médica escrita por el médico que prescribe. Para más información puede hacer referencia a la sección Cómo puedo solicitar una excepción al formulario?, en la Evidencia de Cubierta. Para más información, comuníquese con nuestro Departamento de Servicios al Afiliado al (787) 620-2397 (Área Metro), 1-866-333-5470 (libre de cargos) ó al 1-866-333-5469 TTY (audioimpedidos), de lunes a domingo de 8:00 a.m. a 8:00 p.m.