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Formulary Change Notice
 Formulary
The following changes to the Health Choice Formulary were approved by the HCA Pharmacy and Therapeutics Committee. These changes are also reflected in the hard copy (in pdf format) posted above.
Health Choice may add or remove drugs from our formulary during the year. The formulary is current as of October, 2008. To get updated information about the drugs covered by Health Choice, call Member Services at 1-800-322-8670, Monday through Friday, 6 am - 6 pm. TTY/TDD users should call 1-800-842-4681.
July 2010
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Capsaisin Topical Cream |
Add Capsaisin to Formulary |
7/1/2010 |
| Add |
Losartan & Losartan/HCTZ |
Add generics to Formulary; Remove the Cozaar and Hyzaar brand |
7/1/2010 |
| Add |
Metronidazole 0.75% Top. Cr |
Add Metronidazole to Formulary |
7/1/2010 |
| Add |
Diclofenac 0.5% Eye Solution |
Add Diclofenac Eye Drops to Formulary |
7/1/2010 |
| Delete |
Viokase |
FDA removed Viokase from market |
7/1/2010 |
| Delete |
Creon |
FDA removed Creon from market |
7/1/2010 |
April 2010
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Savella 12.5, 24, 50, 100 mg tablets |
Drug added for Fibromyalgia therapy |
4/1/2010 |
| Delete |
Lyrica 25, 50, 75, 100, 150, 200, 225 & 300 mg capsules |
Drug deleted for Formulary status; existing prior authorizations are grandfathered |
4/1/2010 |
| Notice |
Generic prancreatic enzymes have been removed from the market |
Brand name pancreatic enzymes that remain are: Creon, Ultrase, Viokase and Pangestyme |
1/1/2010 |
January 2010
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Relpax 20 & 40 mg oral tablets |
Add, with a Quantity Limit of #9 per 30 days |
1/1/2010 |
| Add |
Glimepriride 1, 2, & 4 mg oral tablets |
Add, with a Quantity Limit of #30 per 30 days |
1/1/2010 |
| Add |
Prevacid 15 mg oral tablet OTC |
Add, with a Quantity Limit of up to #60 per days (30 mg per day). PA required (Omeprazole 20 mg OTC remains 1st line option without PA |
1/1/2010 |
| Delete |
Maxalt, Maxalt MLT |
Delete, with grandfathering granted for those members already on Maxalt |
1/1/2010 |
| Delete |
Vytorin 10/10, 10/20, 10/40 & 10/80 |
Delete, with 120 day notice given to current members on Vytorin (and to their providers) with their formulary options |
1/1/2010 |
| Delete |
Crestor 5, 10, 20 & 40 mg |
Delete, with grandfathering granted for those members already on Crestor |
1/1/2010 |
| Delete |
Prevacid 15 & 30 mg oral tablets |
Delete – See addition of Prevacid 15 mg OTC above |
1/1/2010 |
| Change |
Lipitor 10, 20, 40 & 80 mg oral tablets |
Remove PA requirement, Quantity Limit remains #30 per 30 days |
1/1/2010 |
| Change |
Diastat Acudial rectal gel |
Remove PA requirement, with a Quantity Limit of 1 twinpak per fill |
1/1/2010 |
| Change |
Bupropion 75 & 100 mg regular release oral tablets |
Remove PA requirement |
1/1/2010 |
| Change |
CiproDex Otic suspension |
Remove PA requirement, with Step Therapy added (after 5 days therapy with a formulary first line otic product) |
1/1/2010 |
| Change |
Alprazolam, Chlordiazepam, diazepam, lorazepam & oxazepam |
Add Quantity Limits of #120 each or collectively per 30 days |
1/1/2010 |
| Change |
Januvia 25, 50 & 100 mg oral tablets |
Remove PA requirement, with a Quantity Limit #30 per 30 days |
1/1/2010 |
October 2009
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Tev-Tropin Growth Hormone Nutropin & Genotropin deleted |
Tev-Tropin added |
10/1/2009 |
| Deletion |
Nutropin & Genotropin |
Tev-Tropin added |
10/1/2009 |
| Deletion |
Caduet |
Caduet deleted; Formulary continues to cover separate Amlodipine and Formulary cholesterol drug options |
10/1/2009 |
| Deletion |
Cenestin |
Cenestin deleted, Formulary continues to cover estradiol tablets and patches, Premarin and estropipate |
10/1/2009 |
| Deletion |
Pulmicort Turbohaler |
Manufacturer has stopped Turbohaler production. Formulary continues to cover Pulmicort Flexhaler |
10/1/2009 |
July 2009
|
Action |
Drug Name |
Change Description |
Effective Date |
| Removal of Prior Authorization |
Carvedilol |
Prior Authorization requirement removed |
7/1/2009 |
| Add |
Strattera |
Add Strattera to Formulary, with Prior Authorization requirement |
7/1/2009 |
April 2009
|
Action |
Drug Name |
Change Description |
Effective Date |
| Delete |
Mirapex |
Brand Mirapex deleted, current users grandfathered; generic Requip (ropinirole) retained |
4/1/2009 |
| Delete |
Kineret
|
Kineret deleted, current users grandfathered
|
4/1/2009 |
| Delete |
Norditropin/Nordiflex, Humatrope and Saizen
|
Norditropin/Nordiflex, Humatrope & Saizen deleted, current users grandfathered; Nutropin & Genotropin retained
|
4/1/2009 |
| Removal of Prior Authorization |
Hydrocodone/Acetaminophen
|
Prior Authorization requirement removed
|
4/1/2009 |
| Removal of Prior Authorization |
Lovenox & Fragmin
|
Prior Authorization requirement for up to a 10 day supply removed. PA required for over a 10 day supply
|
4/1/2009 |
| Add/Delete |
Fenofibrate (generic all strengths) added; Tricor deleted
|
Fenofibrate 54, 67, 107, 134 & 200 mg added; Tricor all stengths deleted with Tricor patient use reported to their providers, for 90 day transition to Fenofibrate.
|
4/1/2009 |
| Add/Delete |
Topiramate tablets/capsules (sprinkles) added; Topamax tablets/capsules (sprinkles) deleted
|
generic topiramate, all strengths tablets and sprinkles added; Brand Topamax, all strengths tablets and sprinkles deleted
|
4/1/2009 |
| Add |
Age restrictions added to HCA Formulary CNS Stimulants: Amphetamine/dextroamphetamine, dextroamphetamine, and methylphenidate
|
Add coverage age restriction of 5 years to 20 years of age
|
2/1/2009 |
January 2009
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Meloxicam 7.5, 15 mg tablets (generic Mobic) |
Add to HCA Formulary without Prior Authorization |
1/1/2009 |
| Add |
Etodolac 200, 300, 400 and 500 mg tablets/capsules (generic Lodine)
|
Add to HCA Formulary without Prior Authorization
|
1/1/2009 |
| Add |
Balsalazide 750 capsules
|
Add to HCA Formulary without Prior Authorization
|
1/1/2009 |
| Add |
Suprax (cefixime) 400 mg
|
Add to HCA Formulary without Prior Authorization, Quantity Limit #1 tablet per fill per month
|
1/1/2009 |
| Change to Step Therapy, Prior Authorization removed |
Alendronate, all strengths, 1st line drug;
Actonel, all strengths, 2nd line drug
|
Step Therapy requirement is: member must use Alendronate first. If Alendronate is documented tried/failed, 2nd line Actonel is provided, without Prior Authorization
|
1/1/2009 |
| Change to Step Therapy |
Fluticasone Nasal Spray, 50 mcg/spray, 16 Grams, 1st line drug;
Nasonex Nasal Spray or Rhinocort Aqua, 32 mcg/spray, 8.6 Grams, 2nd line drugs
|
Step Therapy requirement is: member must use Fluticasone Nasal Spray first. If Fluticasone is documented tried/failed,2nd line Nasonex or Rhinocort Aqua is provided.
|
1/1/2009 |
| Change/Removal
Of Prior Authorization
|
Ofloxacin Otic 0.3%, 5, 10 ml (5 ml for 1 ear therapy & 10 ml for both ears.
|
Prior authorization requirement removed
|
1/1/2009 |
| Change/Removal
Of Prior Authorization
|
Amphetamine Mixed Salts (generic products only), 5, 10, 20 & 30 mg immediate release only – quantity limit # 60
|
Prior authorization requirement removed
|
1/1/2009 |
| Change/Removal
Of Prior Authorization
|
Dextroamphetamine (generic products only), 5, 10 mg, immediate release tablets, quantity limit # 60; extended release 5, 10, 15 mg capsules, quantity limit #30
|
Prior authorization requirement removed
|
1/1/2009 |
| Change/Removal
Of Prior Authorization
|
Methylphenidate (generic products only), 5, 10 & 20 mg immediate release tablets, quantity limit #60; 20 mg extended release tablets, quantity limit # 30.
|
Prior authorization requirement removed
|
1/1/2009 |
| Add/Delete
|
Calcium Acetate 333.5, 667 mg added; PhosLo deleted
|
FDA approved generic added; brand PhosLo deleted
|
1/1/2009 |
| Add/Delete
|
Levetiracetam 250, 500, 750 mg added; Keppra deleted. PA remains.
|
FDA approved generic added; brand Keppra deleted
|
1/1/2009 |
| Add/Delete
|
Sumatriptan 4, 6 mg per 0.5 ml syringe added; Imitrex syringe deleted. Quantity limit is 4 syringes.
|
FDA approved generic added; brand Imitrex deleted
|
1/1/2009 |
| Add/Delete
|
Terbinafine 250 mg added; Lamisil deleted. PA remains
|
FDA approved generic added; brand Lamisil deleted
|
1/1/2009 |
| Add/Delete
|
Alendronate 5, 10, 35, 40, 70 mg added; Fosamax deleted
|
FDA approved generic added; brand Fosamax deleted
|
1/1/2009 |
| Add/Delete
|
Oxcarbazepine 150, 300, 600 mg added; Trileptal deleted. PA remains
|
FDA approved generic added; brand Trileptal deleted
|
1/1/2009 |
| Add/Delete
|
Lamotrigine 25, 100, 150 & 200 mg added; Lamictal deleted. PA remains.
|
FDA approved generic added; brand Lamictal deleted
|
1/1/2009 |
| Add/Delete
|
Robinirole 0.25, 0.5, 1, 2, 3, 4 & 5 mg added; Requip deleted. PA remains
|
FDA approved generic added; Requip deleted
|
1/1/2009 |
October 2008
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Pantoprazole 20, 40 mg |
Omeprazole 20 mg OTC remains as 1st line drug, at up to #60 per 30 days, without Prior Authorization, up to #120 per 30 days, with Prior Authorization; 2nd line drugs include pantoprazole, Nexium, Prevacid, up to #30 per 30 days, with Prior Authorization |
10/1/2008 |
| Add |
New Tobacco Cessation Benefit: with Prior Authorization, HCA approved products are covered for 12 weeks per 6 month period:
1st line drugs: Nicotine 7 mg, 14mg, 21mg Patches, #30 / 30 days; Nicotine Gum 2mg, 4 mg, up to #108 pieces / 30 days; Bupropion ER 150 mg #60 / 30 days.
With documentation of trial/failure, 2nd line drug is Chantix 0.5mg, or 1 mg kit, 1 kit per 30 days
|
First line drugs, from contracted HCA provider are covered for up to 12 weeks/3 months per rolling 6 month period.
After 6 months, with 1st line drug documentation of trial/failure, member has option of using another 1st line drug or using 2nd line drug, for up to 6 months. Members are encouraged to use AZ Department of Health Services Tobacco Cessation counseling services in support of the HCA Tobacco Cessation drug coverage.
|
10/1/2008 |
| Change/Removal of Prior Authorization |
Benzoyl Peroxide 5, 10 %, 60 Grams; Clincamycin 1% Topical Solution, 60 ml;
Metronidazole 0.75% Vaginal Gel, 70 Grams;
Gabapentin 100, 300, 400, 600, & 800 mg tablets/capsules, up to #90 per 30 days;
Precose 25, 50, 100 mg tablets;
Prandin 0.5, 1, & 2 mg tablets;
Dantrolene 25, 50, 100 mg capsules;
Bethanechol 5, 10, 25, & 50 mg tablets;
EpiPen, EpiPen Jr. coverage expanded to up to 2 twin packs per rolling year. (Prior Authorization needed for member need of more than 2 twin packs per year)
|
Prior Authorization requirement removed
|
10/1/2008 |
July 2008
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Cetirizine 10 mg tablets and 5mg/5ml Syrup |
Generic Zyrtec tablets and syrup added to HCA Formulary without Prior Authorization |
7/1/2008 |
| Add |
Symbicort 160/4.5 and 80/4.5 Inhaler |
Additional oral steroid plus long acting rescue medication inhaler
|
7/1/2008 |
| Add |
Fragmin - all strengths |
Additional injectible anticoagulant
|
7/1/2008 |
| Add |
Osmoprep #32 tablets |
Change of product name only. Visicol name changed to Osmoprep
|
7/1/2008 |
April 2008
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add/Delete |
Alendronate (Fosamax) |
The generic Alendronate drug, for brand Fosamax, has been FDA approved and added to the HCA formulary, with Prior Authorization. The brand Fosamax product has been deleted from the HCA formulary. |
4/1/2008 |
| Add/Delete |
Cetirizine (Zyrtec) |
The generic Cetirizine drug, for brand Zyrtec, has been FDA approved and added to the HCA formulary, with Prior authorization. The brand Zyrtec product has been deleted from the HCA formulary.
|
4/1/2008 |
November 2007
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Simvastatin (Zocor) All strengths |
Addition Statin drug added as part of a Step Therapy implementation (generic simvastatin, lovastatin, or pravastatin to be used as 1st line HMG-CoA Reductase Inhibitors, before Lipitor 10 or 20 mg, Crestor 5 or 10 mg, Caduet 5 or 10mg/ 10 or 20mg or Vytorin 10 or 20 mg/10mg product strengths. Lipitor 40 & 80 mg, Crestor 20 & 40 mg, etc. products remain available without Step Therapy or Prior Authorization requirements |
11/01/2007 |
|
Delete |
Atacand/Atacand HCT |
Deletion of one Angiotensin II Receptor Antagonist (ARB) drug, as a part of a Step Therapy implementation (where a HCA Formulary ACE Inhibitor (ACEI) drug - benazepril, captopril, enalapril, lisinopril, or quinapril; must be used as the 1st line hypertension treatment drug, before Avapro/Avalide oe Cozaar/Hyzaar (Formulary ARB options) are used. |
11/01/2007
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October 2007
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Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Terbinafine 250 mg |
Added to the Formulary with Prior Authorization requirement |
10/01/2007 |
| Add |
Selzentry 150, 300 mg |
New HIV/Aids drug added to Formulary |
10/01/2007 |
|
Delete |
Duradrin (acetaminophen/
dichloralphenazone/
isometheptene) and
other like generic formulations |
All the Drug Efficacy Study Implementation (DESI) status drugs are no longer covered by AHCCCS or CMS |
10/01/2007 |
July 2007
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Action |
Drug Name |
Change Description |
Effective Date |
| Add |
Januvia |
Add new 2nd line oral Diabetes II drug (with prior authorization needed) |
7/1/2007 |
|
Add |
Pulmicort Flexhaler
|
Add new Pulmicort inhaler type, older Pulmicort Turbuhaler inhaler remains |
7/2/2007 |
April 2007 Informational Notice ONLY:
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Action |
Drug Name |
Change Description |
Effective Date |
| Delete |
Zelnorm |
Non-formulary drug recalled by FDA |
4/1/2007 |
February 2007
|
Action |
Drug Name |
Change Description |
Effective Date |
| Add |
AccuCheck Aviva Glucometer |
Add new Blood Glucose Test Meter Kit |
2/1/2007 |
|
Add |
AccuCheck Aviva
Test strips
|
Add new Blood Glucose Test Strips – Maximum Quantity of 200 strips per 30 days |
2/1/2007 |
January 2007
|
Action |
Drug Name |
Change Description |
Effective Date |
|
Add
|
albuterol HFA(ProAir HFA)
|
Also add to MDL listing: ProAir HFA - 2 8.5 Gm inhalers per 30 days
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1/1/2007
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