Changes to the Johns Hopkins Advantage MD (PPO) Formulary Please retain this with your formulary

Transcription

1 s to th Johns Hopkins Advantag MD (PPO) Plas rtain this with your mulary s may hav occurrd sinc th printing of th Johns Hopkins Advantag MD (PPO) mulary. Mdications addd or rmovd from th mulary ar listd blow. This is not a complt list of all mulary drugs covrd by th plan. For a complt listing, or if you nd additional inmation about th Johns Hopkins Advantag MD (PPO) mulary, plas viw our wbsit at or call Customr Srvic at (TTY: 711), 24 hours a day, svn days a wk. If you ar a currnt mmbr alrady taking th blow drug(s) b th ffctiv dat of th chang, w will continu to covr th drug th rmaindr of th plan yar as long as th drug continus to b mdically ncssary trating your condition and prscribd you by your prscribr, and was not rmovd safty rasons. Th tabl blow outlins changs to our mulary that may impact you. Cost- ARISTADA INITIO * PA - Prior Authorization, QL - Quantity Limits, ST - Stp Thrapy, NM - Not availabl at mail ordr, B/D - Covrd undr Mdicar B or D, LA - Limitd Accss, * - Not availabl as xtndd days supply Johns Hopkins Advantag MD is a Mdicar Advantag plan with a Mdicar contract offring HMO and PPO products. Enrollmnt in Johns Hopkins Advantag MD dpnds on contract rnwal. Th mulary, pharmacy ntwork and/or providr ntwork may chang at any tim. You will rciv notic whn ncssary. Y0124 _Errata_1017 Approvd 1017 AURYXIA TAB 210MG Add PA Bkyr Tab Addd to Tir 2 BRAFTOVI CAP ENSTILAR Addd to Tir 4 PA HEPARIN/NACL INJ Addd to Tir UNT HUMIRA PEN KIT CD/UC/HS and HUMIRA PEN KIT PS/UV Incassia Tab Addd to Tir 2

2 Ktoprofn Caps 75Mg LENVIMA CAP 4MG and LENVIMA CAP 12MG LYRICA CR TAB 82.5MG and LYRICA CR TAB 165MG LYRICA CR TAB 330MG From Addd to Tir 3 QL PA (90 tabs / 30 Addd to Tir 3 QL PA (60 tabs / 30 Flurbiprofn Tabs Cost- Tir 2 1/1/2019 MEKTOVI Nvirapin Susp 50 Addd to Tir 2 Mg/5Ml NM NIVA-PLUS Addd to Tir 3 NUPLAZID CAP 34MG NUPLAZID TABS 10MG * QL NM LA PA (30 caps / 30 * QL NM LA PA (30 tabs / 30 O-CAL FA Addd to Tir 3 ORKAMBI GRA and ORKAMBI GRA PNV FOLIC AC TAB + IRON PNV PRENATAL TAB PLUS PRENATAL TAB 27-1MG PRENATAL TAB PLUS PRENATAL VIT TAB LOW IRON PREPLUS TAB 27-1MG Addd to Tir 3 Addd to Tir 3 Addd to Tir 3 Addd to Tir 3 Addd to Tir 3 Addd to Tir 3 2

3 Cost- Subvnit Tab 25Mg Addd to Tir 1 and 100Mg SYMTUZA * NM TIBSOVO TAB 250MG TRANSDERM-SCOP Addd to Tir 4 QL PA (10 patchs / 30 TRICARE TAB PRENATAL Vstura Tab Addd to Tir 3 From Gianvi tab mg or Loryna tabs Tir 2 1/1/2019 VOL-PLUS TAB Addd to Tir 3 Abiratron Actat Tab 250Mg Afditab Cr Tab 60Mg Albndazol Tab 200Mg Cfotaxim Inj 2Gm Clobazam Sus and Tabs CLINIMIX INJ 2.75/D5W CLINIMIX INJ 4.25/D20 From * From Addd to Tir 2 PA From From COPIKTRA Dalfampridin Tab 10MG ER Nifdipin Tab 60Mg ER Cfotaxim Inj 500Mg CLINIMIX INJ 4.25/D5W CLINIMIX INJ 5%/D20W Tir 4 2/1/2019 Tir 4 2/1/2019 3

4 DAPTOMYCIN SOL 350MG * DELSTRIGO TAB * NM EPIDIOLEX SOL 100MG/ML * QL NM LA PA (600 ml / 30 Cost- Flac Oil 0.01% Addd to Tir 2 GENOTROPIN MINIQUICK.2mg GRANIX INJ 300/1ML and 480/1.6 ML HEXALEN CAP 50MG Kimidss Tab Movd from Tir 4 to Tir 3 From From Consult your Halthcar Providr 2/1/2019 Kariva Tab M-NATAL PLUS Addd to Tir 3 Molindon Hcl Addd to Tir 2 Mondoxyn Nl Cap 100Mg NORVIR CAP 100MG Addd to Tir 2 From Ritonavir 200Mg NOVOLIN INJ Addd to Tir 3 FLEXPEN PIFELTRO TAB 100MG * NM Sotalol AF Tab 120Mg Addd to Tir 2 TALZENNA CAP VERSACLOZ SUS 50MG/ML From VIZIMPRO TAB Mdicar will no longr covr Clozapin Tab 25Mg ODT 4

5 Cost- XARELTO TAB 2.5MG Addd to Tir 3 ZORTRESS TAB 1MG * B/D NM Afditab Tab 30Mg CR From Albutrol Sulfat AERS Addd to Tir 2 QL (2 inhalrs / 30 Cinacalct Hcl 30mg, 90mg * B/D QL NM (120 tabs / 30 Cinacalct Hcl 60mg * B/D QL NM (60 tabs / 30 Granistron Inj 0.1Mg/Ml INVANZ INJ 1GM INVIRASE CAP 200MG LORBRENA 25MG, 100MG LYNPARZA CAP 50MG From From From From Nifdipin Tab 30MG ER Granistron Inj 1Mg/Ml Ertapnm Inj 1Gm INVIRASE CAP 500MG Tir 5 3/1/2019 LYNPARZA TAB Tir 5 3/1/2019 Msalamin Sup 1000mg Addd to Tir 2 Mtipranolol Soln 0.3% Oph From PANZYGA Btaxolol Soln 0.5% Ophth 5

6 Polythyln Glycol 3350 Pack; Powd From Lactulos Soln 10Gm/15 Ml Cost- Tri-Estarylla Addd to Tir 2 VITRAKVI CAPS 25MG, 100MG, and SOL 20MG/ML XOLAIR INJ Znchnt Tab From ZERIT SOL 1MG/ML ALBENZA TAB 200MG AMPYRA TAB 10MG BILTRICIDE TAB 600MG CANASA SUPP 1000MG FARESTON TAB 60MG INVANZ INJ 1GM ONFI SUSP 2.5MG/ML ONFI TAB 10MG From From From From From From From From From Vyfmla Tab Stavudin Cap Albndazol Tab 200 Mg Dalfampridin Tab 10Mg ER Praziquantl Tab 600Mg Msalamin Supp 1000 Mg Tormifn Citrat Tab 60 Mg Ertapnm Inj 1Gm Clobazam Susp 2.5 Mg/Ml Clobazam Tab 10Mg Tir 5 5/1/2019 Tir 5 5/1/2019 Tir 2 5/1/2019 Tir 2 5/1/2019 Tir 5 5/1/2019 Tir 2 5/1/2019 Tir 2 5/1/2019 Tir 2 5/1/2019 6

7 ONFI TAB 20MG SABRIL TAB 500MG WELCHOL PACK 3.75GM ZYTIGA TAB 250MG From From From From Clobazam Tab 20Mg Vigabatrin Tab 500 Mg Colsvlam Pak 3.75 Gm Abiratron Tab 250Mg Cost- Tir 2 5/1/2019 Tir 5 5/1/2019 Tir 2 5/1/2019 Tir 5 5/1/2019 7