Microsoft word - formulary changes 2008_0108.doc

Formulary Changes 2008

Formulary Additions

Accolate

Formulary Deletions
Formulary Alternatives
Moved to third tier coverage for selected plans
Abilify……………………………………………… Clozaril*, Risperdal, Seroquel
Actonel…………………………………………… Fosamax
Adderall XR (PA for ≥ 18 years of age)………….
Adderall*, Ritalin*, Ritalin SR*, Metadate ER*, Concerta Altace………………………………………………. Prinivil*, Lotensin*, Accupril*, Vasotec* Amerge……………………………………………. Imitrex, Androderm (PA)………………………………… . . Testim (PA) Androgel (PA)……………………………………. Anzemet…………………………………………… Arthrotec…………………………………………… Voltaren* plus Cytotec* Byetta (PA)…………………………………………. Amaryl*, Diabeta*, Glucotrol*, Glynase*, Micronase*, Celebrex…………………………………………… Motrin*, Naprosyn*, Mobic*, Voltaren*, Orudis*, Clinoril*, Disalcid*, Relafen* Cipro HC…………………………………………… Ciprodex Cosopt………………………………………………. Timoptic* plus Azopt Cozaar……………………………………………… Benicar, Cymbalta (PA)……………………………………… Celexa*, Prozac*, Zoloft*, Paxil* Detrol/Detrol LA…………………………………… Ditropan* Differin…………………………………………… . Diovan……………………………………………… Benicar, Diovan HCT………………………………………. Benicar HCT, Micardis HCT FemHRT……………………………………………. Prempro, Flomax……………………………………………… Cardura*, Hytrin*, Proscar*, Uroxatral Hyzaar……………………………………………… Benicar HCT, Micardis HCT Lamictal……………………………………………. phenobarbital, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Depakene*, Depakote, Depakote ER, Neurontin* Levaquin……………………………………………. Cipro*, Lipitor……………………………………………… Zocor*, Prevachol*, Mevacor*, AltoPrev, Crestor (5mg Formulary Deletions
Formulary Alternatives
Moved to third tier coverage for selected plans
Lyrica (PA)…………………………………………. phenobarbital, Tegretol*, Tegretol XR, Carbatrol,
Dilantin*, Depakene*, Depakote, Depakote ER, Neurontin* Nasacort…………………………………………… Nexium (ST)………………………………………. Prilosec OTC™ (covered with prescription for generic copay), Pataday……………………………………………. Alaway, Zaditor OTC (covered with prescription for generic copay) Patanol……………………………………………. . Alaway, Zaditor OTC (covered with prescription for Paxil CR (ST)……………………………………… Celexa*, Prozac*, Zoloft*, Paxil* Proventil HFA……………………………………… Proair HFA (generic copay) Provigil (PA)………………………………………. Restasis…………………………………………… Strattera……………………………………………. Ritalin*, Adderall*, Concerta Topamax……………………………………………. phenobarbital, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Depakene*, Depakote, Depakote ER, Neurontin* Tricor………………………………………………. Lofibra*, Lopid*, Triglide Tussionex…………………………………………. Robitussin AC*, Hycodan* Vagifem……………………………………………. Premarin Viagra……………………………………………… All Vigamox……………………………………………. Tobrex*, Xalatan……………………………………………. Lumigan, Zaditor……………………………………………… Zaditor (requires doctor’s prescription – generic copay) Zetia………………………………………………… Zocor*, Pravachol*, Niaspan, Vytorin (10/10mg ST) Zomig, Zomig ZMT………………………………. Imitrex, Maxalt Zyprexa (PA) ……………………………………… Risperdal, (PA) indicates prior authorization required Please refer to your health plan documents regarding any limitations or exclusions that * A generic equivalent is available at the lowest copay

Source: http://www.mutualsupplement.com/documents/formulary_changes_2008.pdf