February



Provider Partners Health Plan of Ohio February 2020Formulary AddendumBelow is a list formulary changes for the benefit year 2020. This is not a complete list of drugs covered by the Part D plan. The formulary changes are reflected in the 2020 downloadable formulary on the Provider Partners Health Plan website.For a complete list of drugs covered by Provider Partners Health Plan, please visit our website at , or call Member Services at 1-800-405-9681, 8:00 am to 8:00 pm, 7 days a week. TTY/TDD users should call 711.BvsD – Part B vs. Part D, NF - Non-Formulary, PA - Prior Authorization (1=all members, 2=new starts),QL – Quantity Limit per 30 days, ST - Step Therapy (1=all members, 2=new starts),LA - This prescription may be available only at certain pharmacies.2020 FORMULARY CHANGESDrug NameCurrentDrug TierNew Drug TierReason For ChangeAlternative Drug, Alternative Drug TierEFFECTIVE 01/01/2020Abilify MyCite Tablet 10 MG OralNF1 + QL 30 + ST2Formulary EnhancementN/AAbilify MyCite Tablet 15 MG OralNF1 + QL 30 + ST2Formulary EnhancementN/AAbilify MyCite Tablet 2 MG OralNF1 + QL 60 + ST2Formulary EnhancementN/AAbilify MyCite Tablet 20 MG OralNF1 + QL 30 + ST2Formulary EnhancementN/AAbilify MyCite Tablet 30 MG OralNF1 + QL 30 + ST2Formulary EnhancementN/AAbilify MyCite Tablet 5 MG OralNF1 + QL 60 + ST2Formulary EnhancementN/AAvonex Kit 30 MCG Intramuscular1 + PA2NFCMS Required DeletionN/ABivigam Solution 10 GM/100ML Intravenous1 + PA1NFCMS Required DeletionN/ACefixime Capsule 400 MG OralNF1Formulary EnhancementN/ACorlanor Solution 5 MG/5ML OralNF1 + QL 450 + PA1Formulary EnhancementN/AEnbrel Mini Solution Cartridge 50 MG/ML SubcutaneousNF1 + PA1Formulary EnhancementN/AErythromycin Base Tablet Delayed Release 250 MG OralNF1Formulary EnhancementN/AErythromycin Base Tablet Delayed Release 333 MG OralNF1Formulary EnhancementN/AErythromycin Base Tablet Delayed Release 500 MG OralNF1Formulary EnhancementN/AFasenra Solution Prefilled Syringe 30 MG/ML SubcutaneousNF1 + PA1Formulary EnhancementN/AFebuxostat Tablet 40 MG OralNF1 + PA1Formulary EnhancementN/AFebuxostat Tablet 80 MG OralNF1 + PA1Formulary EnhancementN/AFluticasone-Salmeterol Aerosol Powder Breath Activated 100-50 MCG/DOSE InhalationNF1Formulary EnhancementN/AFluticasone-Salmeterol Aerosol Powder Breath Activated 250-50 MCG/DOSE InhalationNF1Formulary EnhancementN/AFluticasone-Salmeterol Aerosol Powder Breath Activated 500-50 MCG/DOSE InhalationNF1Formulary EnhancementN/AInrebic Capsule 100 MG OralNF1 + PA2Formulary EnhancementN/AJolivette Tablet 0.35 MG Oral1NFCMS Required DeletionN/AMetaproterenol Sulfate Tablet 10 MG Oral1NFCMS Required DeletionN/AMetaproterenol Sulfate Tablet 20 MG Oral1NFCMS Required DeletionN/AMonoNessa Tablet 0.25-35 MG-MCG Oral1NFCMS Required DeletionN/AMorphine Sulfate SOLUTION 2 MG/ML Injection1 + BvsDNFCMS Required DeletionN/AMorphine Sulfate SOLUTION 5 MG/ML INJECTION1NFCMS Required DeletionN/ANubeqa Tablet 300 MG OralNF1 + QL 120 + PA2Formulary EnhancementN/APregabalin Capsule 100 MG OralNF1 + QL 120Formulary EnhancementN/APregabalin Capsule 150 MG OralNF1 + QL 120Formulary EnhancementN/APregabalin Capsule 200 MG OralNF1 + QL 120Formulary EnhancementN/APregabalin Capsule 225 MG OralNF1 + QL 120Formulary EnhancementN/APregabalin Capsule 25 MG OralNF1 + QL 120Formulary EnhancementN/APregabalin Capsule 300 MG OralNF1 + QL 60Formulary EnhancementN/APregabalin Capsule 50 MG OralNF1 + QL 120Formulary EnhancementN/APregabalin Capsule 75 MG OralNF1 + QL 120Formulary EnhancementN/APregabalin Solution 20 MG/ML OralNF1 + QL 900Formulary EnhancementN/ARamelteon Tablet 8 MG OralNF1Formulary EnhancementN/ARinvoq Tablet Extended Release 24 Hour 15 MG OralNF1 + PA1Formulary EnhancementN/ASkyrizi (150 MG Dose) Prefilled Syringe Kit 75 MG/0.83ML SubcutaneousNF1 + PA1Formulary EnhancementN/ASoliqua Solution Pen-injector 100-33 UNT-MCG/ML Subcutaneous1 + QL 18 + ST11 + QL 18Formulary EnhancementN/ASymdeko Tablet Therapy Pack 50-75 & 75 MG OralNF1 + PA1Formulary EnhancementN/ATheophylline ER Tablet Extended Release 12 Hour 100 MG Oral1NFCMS Required DeletionN/ATheophylline ER Tablet Extended Release 12 Hour 200 MG Oral1NFCMS Required DeletionN/ATOLAZamide Tablet 250 MG Oral1NFCMS Required DeletionN/ATOLAZamide Tablet 500 MG Oral1NFCMS Required DeletionN/ATuralio Capsule 200 MG OralNF1 + PA2Formulary EnhancementN/AXpovio (100 MG Once Weekly) Tablet Therapy Pack 20 MG OralNF1 + PA2Formulary EnhancementN/AXpovio (60 MG Once Weekly) Tablet Therapy Pack 20 MG OralNF1 + PA2Formulary EnhancementN/AXpovio (80 MG Once Weekly) Tablet Therapy Pack 20 MG OralNF1 + PA2Formulary EnhancementN/AXpovio (80 MG Twice Weekly) Tablet Therapy Pack 20 MG OralNF1 + PA2Formulary EnhancementN/AXultophy Solution Pen-injector 100-3.6 UNIT-MG/ML Subcutaneous1 + QL 15 + ST11 + QL 15Formulary EnhancementN/APaliperidone ER Tablet Extended Release 24 Hour 1.5 MG Oral1 + QL 60 + ST21 + QL 60Formulary EnhancementN/APaliperidone ER Tablet Extended Release 24 Hour 3 MG Oral1 + QL 60 + ST21 + QL 60Formulary EnhancementN/APaliperidone ER Tablet Extended Release 24 Hour 6 MG Oral1 + QL 60 + ST21 + QL 60Formulary EnhancementN/APaliperidone ER Tablet Extended Release 24 Hour 9 MG Oral1 + QL 30 + ST21 + QL 30Formulary EnhancementN/APosaconazole Tablet Delayed Release 100 MG OralNF1 + PA1Formulary EnhancementN/ARozlytrek Capsule 100 MG OralNF1 + PA2Formulary EnhancementN/ARozlytrek Capsule 200 MG OralNF1 + PA2Formulary EnhancementN/AFerriprox Tablet 1000 MG OralNF1 + PA1 + LAFormulary EnhancementN/AEFFECTIVE 02/01/2020Ciprofloxacin-Fluocinolone PF Solution 0.3-0.025 % OticNF1Formulary EnhancementN/ADeferasirox Tablet 360 MG OralNF1 + PA1Formulary EnhancementN/ADeferasirox Tablet 90 MG OralNF1 + PA1Formulary EnhancementN/ADelyla TABLET 0.1-20 MG-MCG ORAL1NFCMS Required DeletionN/ADextrose-NaCl SOLUTION 5-0.33 % Intravenous1 + BvsDNFCMS Required DeletionN/ADrizalma Sprinkle Capsule Delayed Release Sprinkle 20 MG OralNF1 + QL 60Formulary EnhancementN/ADrizalma Sprinkle Capsule Delayed Release Sprinkle 30 MG OralNF1 + QL 60Formulary EnhancementN/ADrizalma Sprinkle Capsule Delayed Release Sprinkle 40 MG OralNF1 + QL 60Formulary EnhancementN/ADrizalma Sprinkle Capsule Delayed Release Sprinkle 60 MG OralNF1 + QL 60Formulary EnhancementN/AFasenra Pen Solution Auto-Injector 30 MG/ML SubcutaneousNF1 + PA1Formulary EnhancementN/AFiasp PenFill Solution Cartridge 100 UNIT/ML SubcutaneousNF1Formulary EnhancementN/AGaviLyte-G SOLUTION RECONSTITUTED 236 GM ORAL1NFCMS Required DeletionN/AImvexxy Maintenance Pack Insert 10 MCG VaginalNF1Formulary EnhancementN/AImvexxy Maintenance Pack Insert 4 MCG VaginalNF1Formulary EnhancementN/AImvexxy Starter Pack Insert 10 MCG VaginalNF1Formulary EnhancementN/AImvexxy Starter Pack Insert 4 MCG VaginalNF1Formulary EnhancementN/AKaterzia Suspension 1 MG/ML OralNF1Formulary EnhancementN/AKCl in Dextrose-NaCl Solution 20-5-0.33 MEQ/L-%-% Intravenous1 + BvsDNFCMS Required DeletionN/AMethyclothiazide Tablet 5 MG Oral1NFCMS Required DeletionN/AMetoprolol Tartrate Tablet 37.5 MG OralNF1Formulary EnhancementN/AMetoprolol Tartrate Tablet 75 MG OralNF1Formulary EnhancementN/AMimvey Lo TABLET 0.5-0.1 MG ORAL1NFCMS Required DeletionN/ANadolol-Bendroflumethiazide Tablet 40-5 MG Oral1NFCMS Required DeletionN/ANayzilam Solution 5 MG/0.1ML NasalNF1Formulary EnhancementN/ANorlyroc TABLET 0.35 MG ORAL1NFCMS Required DeletionN/AOxervate Solution 0.002 % Ophthalmic1 + PA1NFCMS Required DeletionN/APromethazine HCl SUPPOSITORY 50 MG Rectal1NFCMS Required DeletionN/ARebetol Solution 40 MG/ML Oral1NFCMS Required DeletionN/ARibasphere CAPSULE 200 MG ORAL1NFCMS Required DeletionN/ARibasphere RibaPak Tablet 600 MG Oral1NFCMS Required DeletionN/ARibasphere RibaPak Tablet Therapy Pack 400 & 600 MG Oral1NFCMS Required DeletionN/ARibasphere Tablet 600 MG Oral1NFCMS Required DeletionN/AThyrolar-1 Tablet 60 (12.5-50) MG (MCG) Oral1NFCMS Required DeletionN/AThyrolar-1/2 Tablet 30 (6.25-25) MG (MCG) Oral1NFCMS Required DeletionN/AThyrolar-1/4 Tablet 15 (3.1-12.5) MG (MCG) Oral1NFCMS Required DeletionN/AThyrolar-2 Tablet 120 (25-100) MG (MCG) Oral1NFCMS Required DeletionN/AThyrolar-3 Tablet 180 (37.5-150) MG (MCG) Oral1NFCMS Required DeletionN/ATiadylt ER Capsule Extended Release 24 Hour 360 MG OralNF1Formulary EnhancementN/ATrelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG/INH Inhalation1 + ST11Formulary EnhancementN/ATrikafta Tablet Therapy Pack 100-50-75 & 150 MG OralNF1 + PA1Formulary EnhancementN/AVyndamax Capsule 61 MG OralNF1 + QL 30 + PA1Formulary EnhancementN/AZykadia CAPSULE 150 MG ORAL1 + PA2NFCMS Required DeletionN/A ................
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