Formulary Changes
Here you will find a listing of the drugs that have been changed on our formulary for the current year.
Drug Name: ACULAR
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| ketorolac solution |
Generic |
|
Other Ophthalmic Drugs |
Drug Name: ACULAR
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| ketorolac solution |
Generic |
|
Other Ophthalmic Drugs |
Drug Name: ACULAR LS
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| ketorolac solution |
Generic |
|
Other Ophthalmic Drugs |
Drug Name: ACULAR LS
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| ketorolac solution |
Generic |
|
Other Ophthalmic Drugs |
Drug Name: ALDARA
Post Date:
06/11/2010
Effective Date:
09/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic available.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| imiquimod |
Generic |
|
Topical Dermatological Drugs |
Drug Name: ALDARA
Post Date:
06/11/2010
Effective Date:
09/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic available
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| imiquimod |
Generic |
|
Topical Dermatological Drugs |
Drug Name: COTAZYM
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: COTAZYM
Post Date:
07/01/2010
Effective Date:
09/01/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: COZAAR
Post Date:
08/01/2010
Effective Date:
10/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| losartan |
Generic |
More Info |
Angiotensin II Receptor Antagonists |
Drug Name: COZAAR
Post Date:
07/30/2010
Effective Date:
09/30/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| losartan |
Generic |
More Info |
Angiotensin II Receptor Antagonists |
Drug Name: CREON
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: CREON
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: CREON
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: CREON EC
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: DYGASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: DYGASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: ENZYCAP
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: ENZYCAP
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: FLOMAX
Post Date:
06/11/2010
Effective Date:
09/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic available.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| tamsulosin |
Generic |
|
Other Genitourinary Products |
Drug Name: FLOMAX
Post Date:
06/11/2010
Effective Date:
09/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic available.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| tamsulosin |
Generic |
|
Other Genitourinary Products |
Drug Name: HYZAAR
Post Date:
07/30/2010
Effective Date:
09/30/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| losartan |
Generic |
More Info |
Angiotensin II Receptor Antagonists |
Drug Name: HYZAAR
Post Date:
07/30/2010
Effective Date:
09/30/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| losartan - hctz |
Generic |
More Info |
Angiotensin II Receptor Antagonists |
Drug Name: HYZAAR
Post Date:
08/01/2010
Effective Date:
10/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| losartan - hctz |
Generic |
More Info |
Angiotensin II Receptor Antagonists |
Drug Name: KU-ZYME
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: KU-ZYME
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: KUTRASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: KUTRASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: LAPASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: LAPASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: lipram
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Preferred Brand |
|
Other GI Drugs |
Drug Name: LIPRAM CR
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: lipram-pn10
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram-pn10
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram-pn16
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram-pn16
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram-pn20
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram-pn20
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram-ul12
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram-ul12
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: lipram-ul18
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: lipram-ul18
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: lipram-ul20
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: lipram-ul20
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: MIRAPEX
Post Date:
05/01/2010
Effective Date:
07/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| pramipexole |
Generic |
|
Other Antiparkinson Drugs |
Drug Name: MIRAPEX
Post Date:
05/01/2010
Effective Date:
07/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| pramipexole |
Generic |
|
Other Antiparkinson Drugs |
Drug Name: PALCAPS
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PALCAPS
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PALIPASE EC, MT
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PALIPASE MT
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PALPEON DR, MT
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PALPEON DR, MT
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PALTRASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PALTRASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCREASE EC
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MS
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT 10
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT 16
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT 20
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT 4
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT-10
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT-16
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT-20
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCREASE MT-4
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCRECARB MS
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANCRECARB MS-16
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
Drug Name: PANCRECARB MS-16
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: PANCRECARB MS-4
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: PANCRECARB MS-8
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: pancrelipase
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: pancrelipase
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: pancrelipase ec
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: pancrelipase ec
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: pancrelipase mt-16
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: pancrelipase mt-16
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: pancrelipase mt-16
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: pancron 10
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: pancron 10
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: pancron 20
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: pancron 20
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON |
Brand |
|
Other GI Drugs |
Drug Name: pangestyme
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANGESTYME
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANOCAPS
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANOCAPS
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANOKASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PANOKASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PLARETASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PLARETASE
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: PROGRAF 0.5 MG CAPSULE, -1 MG CAPSULE [G]
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| tacrolimus |
Generic |
More Info |
Antineoplastic / Immunosuppressant Drugs |
Drug Name: PROGRAF 0.5 MG CAPSULE, -1 MG CAPSULE [G]
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| tacrolimus |
Generic |
More Info |
Antineoplastic / Immunosuppressant Drugs |
Drug Name: PROGRAF 5 MG CAPSULE [G]
Post Date:
04/01/2010
Effective Date:
06/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| tacrolimus |
Generic |
More Info |
Antineoplastic / Immunosuppressant Drugs |
Drug Name: propoxyphene hcl
Post Date:
05/01/2010
Effective Date:
07/01/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Drug removed due to FDA action.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| hydrocodone-acetaminophen |
Generic |
More Info |
Class III Narcotics |
| tramadol hcl |
Generic |
|
Analgesics |
Drug Name: propoxyphene hcl-apap
Post Date:
05/01/2010
Effective Date:
07/01/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Medication removed due to FDA action.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| hydrocodone-acetaminophen |
Generic |
More Info |
Class III Narcotics |
| tramadol hcl |
Generic |
|
Analgesics |
Drug Name: RENVELA POWDER
Post Date:
02/01/2010
Effective Date:
03/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Improved formulary positioning - lower member copay.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
Drug Name: RISPERDAL M-TAB [G]
Post Date:
05/01/2010
Effective Date:
07/01/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Drug removed due to FDA action.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| risperidone |
Generic |
More Info |
Antipsychotic Drugs |
Drug Name: RISPERDAL M-TAB 1 MG ODT
Post Date:
05/01/2010
Effective Date:
07/01/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Drug removed due to FDA action.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| risperidone |
Generic |
More Info |
Antipsychotic Drugs |
Drug Name: SAVELLA
Post Date:
02/01/2010
Effective Date:
03/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Improved formulary positioning - lower member copay.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
Drug Name: SKELAXIN
Post Date:
07/30/2010
Effective Date:
09/30/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| metaxalone |
Generic |
|
CNS Muscle Relaxants |
Drug Name: SKELAXIN
Post Date:
08/01/2010
Effective Date:
10/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| metaxalone |
Generic |
|
CNS Muscle Relaxants |
Drug Name: STARLIX
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| nateglinide |
Generic |
|
Oral Hypoglycemics & Combos |
Drug Name: STARLIX
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| nateglinide |
Generic |
|
Oral Hypoglycemics & Combos |
Drug Name: SUBUTEX
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| buprenorphine tablets |
Generic |
|
Class III Narcotics |
Drug Name: SUBUTEX
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| buprenorphine tablets |
Generic |
|
Class III Narcotics |
Drug Name: TRILEPTAL SUSPENSION
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Drug removed
Reason Changed:
Generic added to formulary.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| oxcarbazepine suspension |
Generic |
|
Carbamazepines |
Drug Name: TRILEPTAL SUSPENSION
Post Date:
03/02/2010
Effective Date:
06/01/2010
Type of Change:
Cost sharing change
Reason Changed:
Generic added to formulary
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| oxcarbazepine suspension |
Generic |
|
Carbamazepines |
Drug Name: ULTRACAPS
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Value+Rx Plan (HMO)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: ULTRACAPS
Post Date:
07/22/2010
Effective Date:
09/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.
Applies To:
Explorer+Rx Plan (PPO), Traditional+Rx Plan (HMO-POS)
| Drug |
Tier |
Restrictions |
Therapy Class |
| CREON DR |
Preferred Brand |
|
Other GI Drugs |
Drug Name: ULTRASE
Post Date:
06/01/2010
Effective Date:
08/22/2010
Type of Change:
Drug removed - Deemed unsafe by FDA
Reason Changed:
Unapproved producted removed by CMS.