Download Formulary changes - AmeriHealth New Jersey Health Insurance

PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES
Generic Additions
These generic drugs recently became available in the marketplace. When these generic drugs became available,
we began covering them at the appropriate generic formulary level of cost-sharing:
Generic drug
Brand drug
Formulary chapter
Effective date
acitretin
Soriatane
Chapter 5. Skin Medications
July 25, 2013
alendronate sodium solution Fosamax® solution
Chapter 10. Female, Hormone Replacement, & Birth Control
April 26, 2013
candesartan cilexetil
Atacand
Chapter 4. Heart, Blood Pressure, & Cholesterol
May 23, 2013
chorionic gonadotropin
Novarel®/Pregnyl®
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
dihydrocodeine/aspirin/
caffeine
fenofibric acid (choline)
Synalgos -DC
Chapter 3. Pain, Nervous System, & Psych
May 31, 2013
Trilipix®
Chapter 4. Heart, Blood Pressure, & Cholesterol
July 19, 2013
metronidazole topical gel
Metrogel®
Chapter 5. Skin Medications
July 3, 2013
omeprazole suspension
First®-Omeprazole
Chapter 8. Stomach, Ulcer, & Bowel Meds
June 28, 2013
quazepam
Doral®
Chapter 3. Pain, Nervous System, & Psych
July 12, 2013
repaglinide
Prandin®
July 25, 2013
riluzole
Rilutek®
Chapter 7. Diabetes, Thyroid, Steroids, & Other
Miscellaneous Hormones
Chapter 3. Pain, Nervous System, & Psych
zolmitriptan
Zomig , Zomig-ZMT
Chapter 3. Pain, Nervous System, & Psych
May 17, 2013
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June 7, 2013
Brand Additions
These brand drugs were added to the formulary as of the dates indicated below and are covered at the appropriate brand formulary level of
cost-sharing:
Brand drug
Formulary chapter
Effective date
Advate
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Alphanate®
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Alphanine SD
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Bebulin®
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
BeneFIX
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Chapter 13. Urinary & Prostate Meds
October 1, 2013
Feiba NF
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Helixate® FS
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Hemofil M
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Humate-P®
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Koate -DVI
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Kogenate® FS
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Lialda
Chapter 3. Pain, Nervous System, & Psych
November 1, 2013
Chapter 4. Heart, Blood Pressure, & Cholesterol
November 1, 2013
Monoclate-P
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Mononine®
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
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Cialis®
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Liptruzet™
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NovoSeven® RT
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Profilnine® SD
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Recombinate™
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Vascepa®
Chapter 4. Heart, Blood Pressure, & Cholesterol
November 1, 2013
Wilate®
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Xarelto®
Chapter 4. Heart, Blood Pressure, & Cholesterol
November 1, 2013
Xyntha®
Chapter 15. Diagnostics & Miscellaneous
January 1, 2014
Brand Deletions
These brand drugs will be covered at the appropriate non-formulary level of cost-sharing:
Effective January 1, 2014
Formulary Therapeutic
Brand drug
Formulary chapter
Alternatives
hydrocortisone
Chapter 9. Bone, Joint, & Muscle
Cortef® 5mg, 10 mg
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Efudex
fluorouracil
Chapter 5. Skin Medications
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Lanoxin
digoxin
Chapter 4. Heart, Blood Pressure, & Cholesterol
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Metrogel
metronidazole topical gel
Chapter 5. Skin Medications
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Prandin
repaglinide
Chapter 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
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Trilipix
fenofibric acid (choline)
Chapter 4. Heart, Blood Pressure, & Cholesterol
The generic drugs for the above brand drugs are on our formulary and available at the generic formulary level of cost-sharing.
Drugs Requiring Prior Authorization
The prior authorization requirement for the following non-formulary drugs was effective at the time the drugs
became available in the marketplace.
Brand drug
Generic drug
Drug category
Effective date
Mekinist®
Tafinlar®
Vecamyl™
N/A
N/A
N/A
Cancer & Organ Transplant Drugs
Cancer & Organ Transplant Drugs
Heart, Blood Pressure, & Cholesterol
June 21, 2013
June 14, 2013
May 3, 2013
Drugs Requiring Prior Authorization
The following non-formulary drugs have been added to the list of drugs requiring prior authorization.
Members taking these drugs prior to the effective date are not affected:
Effective January 1, 2014
Brand drug
Adrenaclick , Auvi-Q
Alodox®
Avidoxy™, Monodox®, Adoxa®
Doryx® DR, Vibramycin®
Esomeprazole Strontium
Minocin®
Novarel®, Pregnyl®
Rescula®
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Generic drug
Drug category
epinephrine pen
doxycycline
doxycycline monohydrate
doxycycline hyclate
N/A
minocycline hcl
chorionic gonadotropin, human
N/A
Allergy, Cough & Cold, Lung Meds
Antibiotics & Other Drugs Used for Infection
Antibiotics & Other Drugs Used for Infection
Antibiotics & Other Drugs Used for Infection
Stomach, Ulcer, & Bowel Meds
Antibiotics & Other Drugs Used for Infection
Diagnostics & Miscellaneous
Eye Medications
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Drugs With Quantity Limits
Quantity limits will be added to the following drugs:
Effective January 1, 2014
Brand drug
Generic drug
Quantity limit
All applicable products
blood glucose monitors
1 per year
All applicable products
diabetic test strips
200 per 30 days
All applicable products
lancets
200 per 30 days
All applicable products
insulin injecting devices
2 per year
All applicable products
insulin syringes and pen needles
200 per 30 days
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Ella
ulipristal acetate
3 per 30 days
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Firazyr
N/A
27 ml per 30 days (9 syringes)
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My Way , Next Choice One Dose, Plan B One-Step
levonorgestrel 1.5 mg
3 per 30 days
N/A
hydrocodone/chlorpheniramine
450 ml per 30 days
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Nicotrol NS
nicotine nasal spray
80 ml per 30 days
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Plan B
levonorgestrel .075 mg
6 per 30 days
Drugs No Longer Requiring Prior Authorization
Prior Authorization has been removed for the following drugs:
Brand drug
Generic drug
Drug category
Effective date
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Vascepa
N/A
Chapter 4. Heart, Blood Pressure, & Cholesterol
January 1, 2014
Other Important Information
Reminder about the Preventive Medication Program included in your Prescription drug plan.
Certain Preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA), including generic products and
those brand products that do not have a generic equivalent are covered without cost sharing with a doctor’s prescription when provided by
a participating retail or mail order pharmacy. Coverage includes certain products within the following drug categories: (1) aspirin to prevent
cardiovascular disease for men age 45-79 and women age 55-79, (2) breast cancer chemo prevention for women, (3) fluoride supplementation for
children 6 months thru 6 years, (4) Folic acid supplementation for women planning or capable of pregnancy (5) iron supplementation for children
ages 6 to 12 months who are at increased risk for iron deficiency anemia (6) tobacco interventions for adults who use tobacco products, and
(7) vitamin D supplementation for ages 65 and over to prevent falls. Contraceptives, mandated by the Women’s Preventive Services provision of
the PPACA, are covered at 100% when provided by a Participating Provider for generic products and for those brand products that do not have a
generic equivalent. Brand Contraceptive products with a generic equivalent are covered at the brand cost sharing level for your plan.
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AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey