FORMULARY UPDATES Exchanges January 1, 2016 Dear Provider: Please review the formulary changes which pertain to the Pharmacy Benefit unless denoted otherwise. If you have questions, contact Affinity Health Plan’s Provider line7 days a week, 24 hours a day at 1-855-3440930. Information can also be found on our website at www.affinityplan.org. PA = Prior Authorization QL = Quantity Limits Date Effective 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 1/1/16 ST = Step Therapy AL = Age Limits Key HRM = High risk med requires PA for age 65 and older OTC = Over the Counter Product Name Change OXYMORPHONE TAB 5MG ER OXYMORPHONE TAB 7.5MG ER OXYMORPHONE TAB 10MG ER OXYMORPHONE TAB 15MG ER OXYMORPHONE TAB 20MG ER OXYMORPHONE TAB 30MG ER OXYMORPHONE TAB 40MG ER PANDA MASK MIS PEDIATRI HYDROMORPHON TAB 8MG ER HYDROMORPHON TAB 12MG ER HYDROMORPHON TAB 16MG ER HYDROMORPHON TAB 32MG ER UM CHANGE UM CHANGE UM CHANGE UM CHANGE UM CHANGE UM CHANGE UM CHANGE ADD UM CHANGE UM CHANGE UM CHANGE UM CHANGE CEFUROXIME SUS 125/5ML TERM SIVEXTRO INJ 200MG TERM XTANDI CAP 40MG TERM TASIGNA CAP 150MG TERM TASIGNA CAP 200MG TERM AXIRON SOL 30MG/ACT TERM ANDRODERM DIS 2MG/24HR TERM ANDRODERM DIS 4MG/24HR TERM SP = Specialty Drug with Network Requirement B/D = PA needed to determine Part B vs. D coverage Comments ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA ADD POST LIMIT PA Product no longer covered - Use Ceftin or generic cephalosporin Product no longer covered - Contact Physician Product no longer covered -Contact Physician Product no longer covered -Contact Physician Product no longer covered -Contact Physician Product no longer covered - Use generic Testosterone Product no longer covered - Use generic Testosterone Product no longer covered - Use generic
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