2016 formulary annual notice of change medicare advantage plans (mapd) · annual notice of change ....

Updated: October 1, 2015

2016 Formulary

Annual Notice of Change

Medicare Advantage Plans (MAPD)

This is a listing of the changes that have occurred to the 2016 MAPD formulary. For a complete list, please refer to our website and review the 2016 MAPD Comprehensive Formulary (Drug List). Click here to view the comprehensive formulary. Please carefully review these changes. If you have any questions or need to obtain updated coverage determination and exception information, please contact Customer Service at 1.855.882.6467 or, for TTY users, 1.800.955.8771, weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 through February 15, we are available seven days a week from 8 a.m. to 8 p.m. or you may visit myFHCA.org. Please refer to your Evidence of Coverage for cost-sharing information. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and copayments/co-insurance may change on January 1 of each year. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. The Formulary and pharmacy network may change at any time. You will receive notice when necessary. Y0089_MPINFO4355FH (09/15)

MEDICATIONS DELETED FROM THE 2016 MAPD

http://www.myfhca.com/fhca/medicare/our_plans/mapd_2016/forms/2016_mapd_formulary_fhca.pdf

<Insert CMS Approval Number>

Medication Name Medication Name

ABILIFY 10 MG ORAL TABLET (BRAND) Intuniv TABLET EXTENDED RELEASE 24 HR* 3 MG ORAL (BRAND)

ABILIFY 15 MG ORAL TABLET (BRAND) Intuniv TABLET EXTENDED RELEASE 24 HR* 4 MG ORAL (BRAND)

ABILIFY 2 MG ORAL TABLET (BRAND) LaMICtal ODT TABLET DISPERSIBLE 100 MG ORAL (BRAND)




Abilify Discmelt TABLET DISPERSIBLE 10 MG ORAL Lodosyn TABLET 25 MG ORAL (BRAND) Actiq LOLLIPOP 1200 MCG BUCCAL (BRAND) LOTRONEX 0.5 MG ORAL TABLET (BRAND) Actiq LOLLIPOP 1600 MCG BUCCAL (BRAND) LOTRONEX 1 MG ORAL TABLET (BRAND)

Actiq LOLLIPOP 400 MCG BUCCAL (BRAND) Lovaza CAPSULE 1 GM ORAL (BRAND)

Actiq LOLLIPOP 600 MCG BUCCAL (BRAND) Malarone TABLET 62.5-25 MG ORAL (BRAND)

Actiq LOLLIPOP 800 MCG BUCCAL (BRAND) Mepron SUSPENSION 750 MG/5ML ORAL (BRAND)

ACTONEL {12 (RISEDRONATE SODIUM 35 MG ORAL TABLET) } PACK (BRAND) Mestinon TABLET 60 MG ORAL (BRAND) ACTONEL {4 (RISEDRONATE SODIUM 35 MG ORAL TABLET) } PACK (BRAND) Mycobutin CAPSULE 150 MG ORAL (BRAND) ACTONEL 30 MG ORAL TABLET (BRAND) NAFTIN 10 MG/ML TOPICAL CREAM (BRAND) ACTONEL RISEDRONATE SODIUM 5 MG ORAL TABLET (BRAND) Nardil TABLET 15 MG ORAL (BRAND)

Actonel TABLET 150 MG ORAL (BRAND) Niaspan TABLET EXTENDEDRELEASE* 1000 MG ORAL (BRAND)

Aldara CREAM 5 % EXTERNAL (BRAND) Niaspan TABLET EXTENDEDRELEASE* 500 MG ORAL(BRAND)

Alphagan P SOLUTION 0.15 % OPHTHALMIC (BRAND)

Niaspan TABLET EXTENDEDRELEASE* 750 MG ORAL (BRAND)

Alvesco Ofloxacin TABLET 300 MG ORAL Androxy TABLET 10 MG ORAL Olysio

Antabuse TABLET 250 MG ORAL (BRAND) Omaris

Antabuse TABLET 500 MG ORAL (BRAND) Opana ER

Aricept TABLET 23 MG ORAL (BRAND) Orapred ODT TABLET DISPERSIBLE 15 MG ORAL (BRAND)


MEDICATIONS DELETED FROM THE 2016 MAPD Medication Name Medication Name Arixtra SOLUTION 10 MG/0.8ML SUBCUTANEOUS * (BRAND) Oxsoralen Ultra CAPSULE 10 MG ORAL (BRAND) Arixtra SOLUTION 2.5 MG/0.5ML SUBCUTANEOUS* (BRAND) Phenytek CAPSULE 200 MG ORAL (BRAND) Arixtra SOLUTION 5 MG/0.4ML SUBCUTANEOUS* (BRAND) Phenytek CAPSULE 300 MG ORAL (BRAND) Arixtra SOLUTION 7.5 MG/0.6ML SUBCUTANEOUS*(BRAND) Prandin TABLET 0.5 MG ORAL (BRAND) Atrovent SOLUTION 0.03 % NASAL (BRAND) Prandin TABLET 1 MG ORAL (BRAND) Atrovent SOLUTION 0.06 % NASAL (BRAND) Prandin TABLET 2 MG ORAL (BRAND)

Avandamet TABLET 2-1000 MG ORAL Pred Forte SUSPENSION 1 % OPHTHALMIC (BRAND)

Avandamet TABLET 4-500 MG ORAL Protopic OINTMENT 0.03 % EXTERNAL (BRAND) Avandaryl TABLET 4-1 MG ORAL Protopic OINTMENT 0.1 % EXTERNAL (BRAND) Avandaryl TABLET 4-2 MG ORAL Proventil Avandaryl TABLET 8-4 MG ORAL Reserpine TABLET 0.25 MG ORAL Avandia TABLET 2 MG ORAL Rilutek TABLET 50 MG ORAL (BRAND) Avandia TABLET 4 MG ORAL Scopolamine TD Patch 72HR 1 MG/3DAYS Avandia TABLET 8 MG ORAL Silvadene CREAM 1 % EXTERNAL Baraclude TABLET 0.5 MG ORAL (BRAND) Sodium Fluoride TABLET 2.2 (1 F) MG ORAL Baraclude TABLET 1 MG ORAL (BRAND) Solaraze 3 % TRANSDERMAL (BRAND) Campral TABLET DELAYED RELEASE 333 MG ORAL Soriatane CAPSULE 10 MG ORAL (BRAND) CeleBREX CAPSULE 100 MG ORAL (BRAND) Soriatane CAPSULE 17.5 MG ORAL (BRAND) CeleBREX CAPSULE 200 MG ORAL (BRAND) Soriatane CAPSULE 25 MG ORAL (BRAND) CeleBREX CAPSULE 400 MG ORAL (BRAND) Stromectol TABLET 3 MG ORAL (BRAND) CeleBREX CAPSULE 50 MG ORAL (BRAND) TASMAR 100 MG ORAL TABLET (BRAND) CellCept SUSPENSION RECONSTITUTED 200 MG/ML ORAL (BRAND) Tekamlo TABLET 150-10 MG ORAL Cleocin CREAM 2 % VAGINAL (BRAND) Tekamlo TABLET 150-5 MG ORAL Cleocin in D5W SOLUTION 300 MG/50ML INTRAVENOUS* (BRAND) Tekamlo TABLET 300-10 MG ORAL Cleocin in D5W SOLUTION 600 MG/50ML INTRAVENOUS* (BRAND) Tekamlo TABLET 300-5 MG ORAL Cleocin in D5W SOLUTION 900 MG/50ML INTRAVENOUS* (BRAND)

Tetanus Toxoid Adsorbed SOLUTION 5 LFU INTRAMUSCULAR*

Cyklokapron SOLUTION 100 MG/ML INTRAVENOUS* (BRAND)

Tobi NEBULIZATION SOLUTION 300 MG/5ML INHALATION (BRAND)

Dilantin Infatabs TABLET CHEWABLE 50 MG ORAL (BRAND)

TobraDex SUSPENSION 0.3-0.1 % OPHTHALMIC (BRAND)


MEDICATIONS DELETED FROM THE 2016 MAPD Medication Name Medication Name Dilt-XR CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL Toviaz Dilt-XR CAPSULE EXTENDED RELEASE 24 HOUR 180 MG ORAL Treximet Dilt-XR CAPSULE EXTENDED RELEASE 24 HOUR 240 MG ORAL Trizivir TABLET 300-150-300 MG ORAL (BRAND) Diovan TABLET 160 MG ORAL (BRAND) Valcyte TABLET 450 MG ORAL (BRAND) Diovan TABLET 320 MG ORAL (BRAND) Victrelis

Diovan TABLET 40 MG ORAL (BRAND) Vidaza SUSPENSION RECONSTITUTED 100 MG INJECTION (BRAND)

Diovan TABLET 80 MG ORAL (BRAND) Viramune XR TABLET EXTENDED RELEASE 24 HR* 400 MG ORAL (BRAND)

Doxycycline Monohydrate CAPSULE 50 MG ORAL Xopenex HFA

Dyrenium CAPSULE 100 MG ORAL Zerit SOLUTION RECONSTITUTED 1 MG/ML ORAL (BRAND)

Dyrenium CAPSULE 50 MG ORAL Zetonna Ella TABLET 30 MG ORAL Ziagen TABLET 300 MG ORAL (BRAND)

Epivir HBV TABLET 100 MG ORAL (BRAND) Zometa CONCENTRATE 4 MG/5ML INTRAVENOUS* (BRAND)

Epivir SOLUTION 10 MG/ML ORAL (BRAND) Zomig TABLET 2.5 MG ORAL (BRAND) FAZACLO 150 MG DISINTEGRATING ORAL TABLET (BRAND) Zomig TABLET 5 MG ORAL (BRAND) FAZACLO 200 MG DISINTEGRATING ORAL TABLET (BRAND)

Zomig ZMT TABLET DISPERSIBLE 2.5 MG ORAL (BRAND)

Fortaz SOLUTION RECONSTITUTED 2 GM INJECTION (BRAND)

Zomig ZMT TABLET DISPERSIBLE 5 MG ORAL (BRAND)

Fortaz SOLUTION RECONSTITUTED 6 GM INJECTION (BRAND)

Zosyn SOLUTION RECONSTITUTED 3-0.375 GM (BRAND)INTRAVENOUS*

Golytely SOLUTION RECONSTITUTED 236 GM ORAL (BRAND) Zovirax OINTMENT 5 % EXTERNAL (BRAND) Hepsera TABLET 10 MG ORAL (BRAND) Zymaxid SOLUTION 0.5 % OPHTHALMIC (BRAND) Intuniv TABLET EXTENDED RELEASE 24 HR* 1 MG ORAL (BRAND) ZYVOX 600 MG ORAL TABLET (BRAND) Intuniv TABLET EXTENDED RELEASE 24 HR* 2 MG ORAL (BRAND)

Zyvox SOLUTION 2 MG/ML INTRAVENOUS* (BRAND)

MEDICATIONS ADDED TO THE 2016 MAPD

Medication Name Benefit

Tier Quantity

Limit Prior Authorization

Requirement Step

Therapy




Tier Quantity


Requirement Step

Therapy Abraxane SUSPENSION RECONSTITUTED 100 MG INTRAVENOUS* Tier 5 B/D PA

Acitretin CAPSULE 10 MG ORAL Tier 5 PA Applies

(SORIATANE)

Acitretin CAPSULE 17.5 MG ORAL Tier 5 PA Applies

(SORIATANE)

Acitretin CAPSULE 25 MG ORAL Tier 5 PA Applies

(SORIATANE)

Adempas TABLET 0.5 MG ORAL Tier 5 PA Applies

(ADEMPAS)

Adempas TABLET 1 MG ORAL Tier 5 PA Applies

(ADEMPAS)


(ADEMPAS)

Adempas TABLET 2 MG ORAL Tier 5 PA Applies

(ADEMPAS)


(ADEMPAS)

Alclometasone Dipropionate OINTMENT 0.05 % EXTERNAL Tier 4

Alcohol Prep with Benzocaine PAD 6-70 % EXTERNAL Tier 2

Amantadine HCl CAPSULE 100 MG ORAL Tier 3 Aminosyn II SOLUTION 10 % INTRAVENOUS* Tier 4

Aminosyn II SOLUTION 15 % INTRAVENOUS* Tier 3

Aminosyn II SOLUTION 7 % INTRAVENOUS* Tier 3

Aminosyn II SOLUTION 8.5 % INTRAVENOUS* Tier 4

Aminosyn II/Electrolytes SOLUTION 8.5 % INTRAVENOUS* Tier 3

Aminosyn M SOLUTION 3.5 % INTRAVENOUS* Tier 3




Tier Quantity


Requirement Step

Therapy Aminosyn-HBC SOLUTION 7 % INTRAVENOUS* Tier 3

Aminosyn-PF SOLUTION 10 % INTRAVENOUS* Tier 4 Aminosyn-PF SOLUTION 7 % INTRAVENOUS* Tier 4 Amoxicillin-Pot Clavulanate ER TABLET EXTENDED RELEASE 12 HR* 1000-62.5 MG ORAL Tier 3

Anadrol-50 TABLET 50 MG ORAL Tier 5 PA Applies

(ANADROL-5)

AndroGel 20.25 MG/1.25GM (1.62%) TRANSDERMAL Tier 3

PA Applies (Testosterone

replacement topical)

AndroGel 25 MG/2.5GM (1%) TRANSDERMAL Tier 3



AndroGel 40.5 MG/2.5GM (1.62%) TRANSDERMAL Tier 3



AndroGel Pump 12.5 MG/ACT (1%) TRANSDERMAL Tier 3


replacement topical) Azelastine HCl SOLUTION 0.15 % NASAL Tier 3

BCG Vaccine Inj Tier 3

BD Eclipse Shielded Needle 18G X 1-1/2" Tier 2

QL(100 EA per 30 days)

Benlysta SOLUTION RECONSTITUTED 120 MG INTRAVENOUS* Tier 5 PA (BENLYSTA)

Betamethasone Dipropionate Aug 0.05 % EXTERNAL Tier 3

Betamethasone Dipropionate Aug OINTMENT 0.05 % EXTERNAL Tier 3

Betamethasone Valerate LOTION 0.1 % EXTERNAL Tier 3

Bexsero INTRAMUSCULAR* Tier 4




Tier Quantity


Requirement Step

Therapy

Butalbital-Acetaminophen TABLET 50-325 MG ORAL Tier 2

QL186 EA per 31 days);

PA Applies (BUTALBITAL CONTAINING PRODUCTS)

Butalbital-APAP-Caffeine CAPSULE 50-300-40 MG ORAL Tier 2



Butalbital-APAP-Caffeine CAPSULE 50-325-40 MG ORAL Tier 2



Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL Tier 2



Butalbital-Aspirin-Caffeine CAPSULE 50-325-40 MG ORAL Tier 3



Carbaglu TABLET 200 MG ORAL Tier 5 PA Applies

(CARBAGLU)

Cayston SOLUTION RECONSTITUTED 75 MG INHALATION Tier 5 PA Applies (CAYSTON) CefOXitin Sodium SOLUTION RECONSTITUTED 1 GM INTRAVENOUS* Tier 3

CefOXitin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION Tier 3 CefOXitin Sodium SOLUTION RECONSTITUTED 2 GM INTRAVENOUS* Tier 3 CefOXitin Sodium-Dextrose SOLUTION RECONSTITUTED 1-4 GM-% INTRAVENOUS* Tier 3 CefOXitin Sodium-Dextrose SOLUTION RECONSTITUTED 2-2.2 GM-% INTRAVENOUS* Tier 3

Cefprozil TABLET 250 MG ORAL Tier 3

Clinimix E/Dextrose (2.75/10) SOLUTION 2.75 % INTRAVENOUS* Tier 4




Tier Quantity


Requirement Step

Therapy Clinimix E/Dextrose (2.75/5) SOLUTION 2.75 % INTRAVENOUS* Tier 4




Clinimix E/Dextrose (5/15) SOLUTION 5 % INTRAVENOUS* Tier 4



Clinimix/Dextrose (2.75/5) SOLUTION 2.75 % INTRAVENOUS* Tier 4





Clinimix/Dextrose (5/15) SOLUTION 5 % INTRAVENOUS* Tier 4



Clinisol SF SOLUTION 15 % INTRAVENOUS* Tier 3

Dextrose-NaCl SOLUTION 5-0.45 % INTRAVENOUS* Tier 2




Tier Quantity


Requirement Step

Therapy Dextrose-NaCl SOLUTION 5-0.9 % INTRAVENOUS* Tier 2

Doxycycline Hyclate CAPSULE 100 MG ORAL Tier 4

Doxycycline Hyclate CAPSULE 50 MG ORAL Tier 3 Doxycycline Hyclate SOLUTION RECONSTITUTED 100 MG INTRAVENOUS* Tier 3

DOXYCYCLINE MONOHYDRATE 100 MG ORAL CAPSULE Tier 2

Entecavir TABLET 0.5 MG ORAL Tier 5


Entecavir TABLET 1 MG ORAL Tier 5


Esbriet CAPSULE 267 MG ORAL Tier 5 PA Applies (ESBRIET)

Estradiol PATCH BIWEEKLY 0.025 MG/24HR TRANSDERMAL Tier 4

PA Applies (HRM – ORAL AND

TRANSDERMAL ESTROGENS AND

PROGESTINS)




PROGESTINS)




PROGESTINS)




PROGESTINS)







Tier Quantity


Requirement Step

Therapy PROGESTINS)

Etodolac CAPSULE Tier 2

Etodolac ER TABLET EXTENDED RELEASE 24 HR Tier 3

Exel Pen Needles 1/2" 29G X 12MM Tier 2

Ferriprox TABLET 500 MG ORAL Tier 5 PA Applies

(FERRIPROX)

Fluorometholone SUSPENSION 0.1 % OPHTHALMIC Tier 4

Gardasil 9 INTRAMUSCULAR* Tier 3 PA Applies

(GARDASIL)

Gardasil 9 SUSPENSION INTRAMUSCULAR* Tier 3

PA Applies (GARDASIL)

Gattex KIT 5 MG SUBCUTANEOUS* Tier 5 PA Applies (GATTEX)

Halobetasol Propionate CREAM 0.05 % EXTERNAL Tier 4

Halobetasol Propionate OINTMENT 0.05 % EXTERNAL Tier 4

Hepatamine SOLUTION 8 % INTRAVENOUS* Tier 4 Herceptin SOLUTION RECONSTITUTED 440 MG INTRAVENOUS* Tier 5 B/D PA

Hetlioz CAPSULE 20 MG ORAL Tier 5 PA Applies (HETLIOZ)

Humira 10 MG/0.2ML SUBCUTANEOUS* Tier 5

QL (2 EA per 28 days) PA Applies (HUMIRA)

Hydrocortisone Butyrate OINTMENT 0.1 % EXTERNAL Tier 4

Hydrocortisone Butyrate SOLUTION 0.1 % EXTERNAL Tier 4




Tier Quantity


Requirement Step

Therapy Hydrocortisone Valerate CREAM 0.2 % EXTERNAL Tier 4

HYDROmorphone HCl PF SOLUTION 500 MG/50ML INJECTION Tier 4

Juxtapid CAPSULE 10 MG ORAL Tier 5 PA Applies

(JUXTAPID)


(JUXTAPID)


(JUXTAPID)

JUXTAPID LOMITAPIDE 30 MG ORAL CAPSULE [JUXTAPID] Tier 5

PA Applies (JUXTAPID)





Korlym TABLET 300 MG ORAL Tier 5

QL (120 EA per 30

days)

Kynamro 200 MG/ML SUBCUTANEOUS* Tier 5

PA Applies (KYNAMRO)

Levoleucovorin Calcium SOLUTION 175 MG/17.5ML INTRAVENOUS* Tier 4 B/D PA

Lidocaine HCl 2 % EXTERNAL Tier 2



Linezolid SOLUTION 2 MG/ML INTRAVENOUS* Tier 5

Lithium Carbonate TABLET 300 MG ORAL Tier 2

Methoxsalen Rapid CAPSULE 10 MG ORAL Tier 5




Tier Quantity


Requirement Step

Therapy MethylPREDNISolone TABLET 16 MG ORAL Tier 2

MethylPREDNISolone TABLET 32 MG ORAL Tier 2

Minocycline HCl TABLET 100 MG ORAL Tier 4



Mometasone Furoate SOLUTION 0.1 % EXTERNAL Tier 2

Morphine Sulfate (PF) SOLUTION 10 MG/ML INTRAVENOUS* Tier 3




Nalbuphine HCl SOLUTION 10 MG/ML INJECTION Tier 4

QL (240 ML per 30

days)

Nalbuphine HCl SOLUTION 20 MG/ML INJECTION Tier 4

QL (120 ML per 30

days)

Natpara 100 MCG SUBCUTANEOUS* Tier 5 PA Applies (NATPARA)




NephrAmine SOLUTION 5.4 % INTRAVENOUS* Tier 4




Tier Quantity


Requirement Step

Therapy

Northera CAPSULE 100 MG ORAL Tier 5 PA Applies

(NORTHERA)


(NORTHERA)


(NORTHERA)

Ofev CAPSULE 100 MG ORAL Tier 5 PA Applies (OFEV)

Ofev CAPSULE 150 MG ORAL Tier 5 PA Applies (OFEV)

ondansetron 24 mg Tier 2 B/D PA

Opsumit TABLET 10 MG ORAL Tier 5 PA Applies (OPSUMIT)

Orencia 125 MG/ML SUBCUTANEOUS* Tier 5 PA Applies (ORENCIA)

Orencia SOLUTION RECONSTITUTED 250 MG INTRAVENOUS* Tier 5 PA Applies (ORENCIA)

OxyCODONE HCl TABLET 20 MG ORAL Tier 2


Oxymorphone HCl ER TABLET EXTENDED RELEASE 12 HR Tier 4

QL (62 EA per 31 days)

PACLitaxel CONCENTRATE 300 MG/50ML INTRAVENOUS* Tier 4 B/D PA

PEG-3350/Electrolytes SOLUTION RECONSTITUTED 236 GM ORAL Tier 2

Phenadoz SUPPOSITORY 12.5 MG Tier 3

PA Applies (HRM – ANTIHISTAMINES)

Phenergan SUPPOSITORY 12.5 MG Tier 3


Phenergan SUPPOSITORY 25 MG Tier 3


Phenergan SUPPOSITORY 50 MG Tier 3 PA Applies (HRM –

ANTIHISTAMINES)




Tier Quantity


Requirement Step

Therapy

Pilocarpine HCl SOLUTION 1 % OPHTHALMIC Tier 4



Preferred Plus Insulin Syringe 28G X 1/2" 0.5 ML Tier 3


Premasol SOLUTION 10 % INTRAVENOUS* Tier 4

Premasol SOLUTION 6 % INTRAVENOUS* Tier 4

Procalamine SOLUTION 3 % INTRAVENOUS* Tier 4

Promacta TABLET 12.5mg Tier 5

QL (62 EA per 31 days)

PA Applies (PROMACTA)

Promethazine HCl SOLUTION 25 MG/ML INJECTION Tier 3


Promethazine HCl SOLUTION 50 MG/ML INJECTION Tier 3


Promethazine HCl SUPPOSITORY 12.5 MG Tier 3


Promethazine HCl SUPPOSITORY 25 MG Tier 3


Promethazine HCl SUPPOSITORY 50 MG Tier 3


Promethazine HCl SYRUP 6.25 MG/5ML ORAL Tier 2


Promethazine HCl TABLET 12.5 MG ORAL Tier 2





Tier Quantity


Requirement Step

Therapy

Promethazine HCl TABLET 25 MG ORAL Tier 2


Promethazine HCl TABLET 50 MG ORAL Tier 2


Promethazine VC Plain SYRUP 6.25-5 MG/5ML ORAL Tier 3


Promethegan SUPPOSITORY 25 MG Tier 3


Promethegan SUPPOSITORY 50 MG Tier 3


Prosol SOLUTION 20 % INTRAVENOUS* Tier 4

Quadracel SUSPENSION INTRAMUSCULAR* Tier 3

Ravicti LIQUID† 1.1 GM/ML ORAL Tier 5 PA Applies (RAVICTI)

Recombivax HB SUSPENSION 5 MCG/0.5ML INJECTION Tier 3 B/D PA

Riluzole TABLET 50 MG ORAL Tier 5

SAPHRIS 2.5 MG SUBLINGUAL TABLET [SAPHRIS] Tier 4 ST New Starts Signifor LAR SUSPENSION RECONSTITUTED 20 MG INTRAMUSCULAR* Tier 5

PA Applies (SIGNIFOR LAR)

Signifor LAR SUSPENSION RECONSTITUTED 40 MG INTRAMUSCULAR* Tier 5


Signifor LAR SUSPENSION RECONSTITUTED 60 MG INTRAMUSCULAR* Tier 5


Signifor SOLUTION 0.3 MG/ML SUBCUTANEOUS* Tier 5 PA Applies (SIGNIFOR) Signifor SOLUTION 0.6 MG/ML SUBCUTANEOUS* Tier 5 PA Applies (SIGNIFOR) Signifor SOLUTION 0.9 MG/ML SUBCUTANEOUS* Tier 5 PA Applies (SIGNIFOR)




Tier Quantity


Requirement Step

Therapy

Sirturo TABLET 100 MG ORAL Tier 5 PA Applies (SIRTURO)

Sodium Fluoride TABLET CHEWABLE 1.1 (0.5 F) MG ORAL Tier 2

Telmisartan TABLET 20 MG ORAL Tier 4

Telmisartan TABLET 40 MG ORAL Tier 4

Telmisartan TABLET 80 MG ORAL Tier 4 Tenivac INJECTABLE 5-2 LFU INTRAMUSCULAR* Tier 3 Theophylline ER TABLET EXTENDED RELEASE 24 HR* 400 MG ORAL Tier 3 Theophylline ER TABLET EXTENDED RELEASE 24 HR* 600 MG ORAL Tier 3

TOLCAPONE 100 MG ORAL TABLET Tier 5 Travasol SOLUTION 10 % INTRAVENOUS* Tier 4 TrophAmine SOLUTION 10 % INTRAVENOUS* Tier 4 Trophamine SOLUTION 6 % INTRAVENOUS* Tier 4

Trumenba INTRAMUSCULAR* Tier 4 Typhim VI SOLUTION 25 MCG/0.5ML INTRAMUSCULAR* Tier 3 ValGANciclovir HCl TABLET 450 MG ORAL Tier 5 Vaqta SUSPENSION 25 UNIT/0.5ML INTRAMUSCULAR* Tier 3 Vaqta SUSPENSION 50 UNIT/ML INTRAMUSCULAR* Tier 3 Verapamil HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 360 MG ORAL Tier 2 Voriconazole SUSPENSION RECONSTITUTED 40 MG/ML ORAL Tier 5

PA Applies (VORICONAZOLE)

Yervoy SOLUTION 50 MG/10ML INTRAVENOUS* Tier 5 PA Applies (YERVOY) Zoledronic Acid CONCENTRATE 4 MG/5ML INTRAVENOUS* Tier 4 PA Applies (ZOMETA)


MEDICATIONS WITH TIERING CHANGES Medication Name 2015 Tier 2016 Tier Acebutolol HCl CAPSULE 200 MG ORAL Tier 2 Tier 3

Acebutolol HCl CAPSULE 400 MG ORAL Tier 2 Tier 3

Albuterol Sulfate TABLET 2 MG ORAL Tier 2 Tier 4

Albuterol Sulfate TABLET 4 MG ORAL Tier 2 Tier 4

Alosetron HCl TABLET 0.5 MG ORAL Tier 3 Tier 5

Amcinonide CREAM 0.1 % EXTERNAL Tier 2 Tier 4

Amifostine SOLUTION RECONSTITUTED 500 MG INTRAVENOUS* Tier 4 Tier 5

Amitiza Tier 4 Tier 3

Atovaquone SUSPENSION 750 MG/5ML ORAL Tier 4 Tier 5 AzaCITIDine SUSPENSION RECONSTITUTED 100 MG INJECTION Tier 4 Tier 5 Azithromycin SUSPENSION RECONSTITUTED 100 MG/5ML ORAL Tier 2 Tier 3 Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL Tier 2 Tier 3 Bacitracin OINTMENT 500 UNIT/GM OPHTHALMIC Tier 2 Tier 3

Banzel TABLET 400 MG ORAL Tier 4 Tier 5 Betamethasone Dipropionate CREAM 0.05 % EXTERNAL Tier 2 Tier 4 Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL Tier 2 Tier 4 Cefaclor ER TABLET EXTENDED RELEASE 12 HR* 500 MG ORAL Tier 2 Tier 4

Cefdinir CAPSULE 300 MG ORAL Tier 2 Tier 3 Cefdinir SUSPENSION RECONSTITUTED 125 MG/5ML ORAL Tier 2 Tier 4 Cefdinir SUSPENSION RECONSTITUTED 250 MG/5ML ORAL Tier 2 Tier 4

Cefuroxime Axetil TABLET 250 MG ORAL Tier 2 Tier 3


MEDICATIONS WITH TIERING CHANGES Medication Name 2015 Tier 2016 Tier Cefuroxime Axetil TABLET 500 MG ORAL Tier 2 Tier 3

ChlorproMAZINE HCl TABLET 10 MG ORAL Tier 2 Tier 3





Ciclopirox Olamine CREAM 0.77 % EXTERNAL Tier 3 Tier 2 Ciclopirox Olamine SUSPENSION 0.77 % EXTERNAL Tier 3 Tier 2

Ciprofloxacin HCl TABLET 100 MG ORAL Tier 2 Tier 4 Citalopram Hydrobromide SOLUTION 10 MG/5ML ORAL Tier 1 Tier 2

Clarithromycin TABLET 250 MG ORAL Tier 2 Tier 3

Clarithromycin TABLET 500 MG ORAL Tier 2 Tier 3

Clindamycin Phosphate 1 % EXTERNAL Tier 2 Tier 3

Clindamycin Phosphate LOTION 1 % EXTERNAL Tier 2 Tier 3

Clobetasol Propionate E CREAM 0.05 % EXTERNAL Tier 2 Tier 4 Clobetasol Propionate OINTMENT 0.05 % EXTERNAL Tier 2 Tier 4 Clobetasol Propionate SOLUTION 0.05 % EXTERNAL Tier 2 Tier 3 Clotrimazole-Betamethasone LOTION 1-0.05 % EXTERNAL Tier 2 Tier 4 Creon CAPSULE DELAYED RELEASE PARTICLES 36000 UNIT ORAL Tier 3 Tier 5 Creon CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT ORAL Tier 3 Tier 4 Creon CAPSULE DELAYED RELEASE PARTICLES 24000 UNIT ORAL Tier 3 Tier 4 Creon CAPSULE DELAYED RELEASE PARTICLES 3000-9500 UNIT ORAL Tier 3 Tier 4 Creon CAPSULE DELAYED RELEASE PARTICLES 6000 UNIT ORAL Tier 3 Tier 4


MEDICATIONS WITH TIERING CHANGES Medication Name 2015 Tier 2016 Tier Cyclophosphamide CAPSULE 25 MG ORAL Tier 4 Tier 2

Cyclophosphamide CAPSULE 50 MG ORAL Tier 4 Tier 2

Desonide CREAM 0.05 % EXTERNAL Tier 2 Tier 4

Desonide LOTION 0.05 % EXTERNAL Tier 2 Tier 4

Desonide OINTMENT 0.05 % EXTERNAL Tier 2 Tier 4

Diclofenac Sodium 3 % TRANSDERMAL Tier 4 Tier 5

Dipyridamole TABLET 25 MG ORAL Tier 2 Tier 3



Doxycycline Hyclate TABLET 100 MG ORAL Tier 2 Tier 4

Doxycycline Hyclate TABLET 100 MG ORAL Tier 2 Tier 4

Doxycycline Monohydrate TABLET 50 MG ORAL Tier 2 Tier 3

Doxycycline Monohydrate TABLET 50 MG ORAL Tier 2 Tier 3

Edurant TABLET 25 MG ORAL Tier 4 Tier 5 Emsam PATCH 24 HR 12 MG/24HR TRANSDERMAL Tier 4 Tier 5 Emsam PATCH 24 HR 6 MG/24HR TRANSDERMAL Tier 4 Tier 5 Emsam PATCH 24 HR 9 MG/24HR TRANSDERMAL Tier 4 Tier 5

Epogen SOLUTION 20000 UNIT/ML INJECTION Tier 4 Tier 5

Ery PAD 2 % EXTERNAL Tier 2 Tier 3

Erythromycin Base TABLET 250 MG ORAL Tier 2 Tier 4

Erythromycin Base TABLET 500 MG ORAL Tier 2 Tier 4

Fanapt TABLET 10 MG ORAL Tier 4 Tier 5



Fanapt TABLET 8 MG ORAL Tier 4 Tier 5 Faslodex SOLUTION 250 MG/5ML INTRAMUSCULAR* Tier 4 Tier 5


MEDICATIONS WITH TIERING CHANGES Medication Name 2015 Tier 2016 Tier FentaNYL PATCH 72 HR 100 MCG/HR TRANSDERMAL Tier 2 Tier 3 FentaNYL PATCH 72 HR 12 MCG/HR TRANSDERMAL Tier 2 Tier 3 FentaNYL PATCH 72 HR 25 MCG/HR TRANSDERMAL Tier 2 Tier 3 FentaNYL PATCH 72 HR 50 MCG/HR TRANSDERMAL Tier 2 Tier 3 FentaNYL PATCH 72 HR 75 MCG/HR TRANSDERMAL Tier 2 Tier 3

Fluocinolone Acetonide CREAM 0.01 % EXTERNAL Tier 2 Tier 4 FluPHENAZine Decanoate SOLUTION 25 MG/ML INJECTION Tier 2 Tier 4

Hydrochlorothiazide TABLET 12.5 MG ORAL Tier 3 Tier 2 Hydrocodone-Acetaminophen SOLUTION 7.5-325 MG/15ML ORAL Tier 2 Tier 4 Invega Sustenna SUSPENSION 78 MG/0.5ML INTRAMUSCULAR* Tier 4 Tier 5 Invega TABLET EXTENDED RELEASE 24 HR* 1.5 MG ORAL Tier 4 Tier 5 Invega TABLET EXTENDED RELEASE 24 HR* 3 MG ORAL Tier 4 Tier 5 Invega TABLET EXTENDED RELEASE 24 HR* 6 MG ORAL Tier 4 Tier 5 Invega TABLET EXTENDED RELEASE 24 HR* 9 MG ORAL Tier 4 Tier 5

Invirase CAPSULE 200 MG ORAL Tier 4 Tier 5

Invirase TABLET 500 MG ORAL Tier 4 Tier 5

Kaletra TABLET 200-50 MG ORAL Tier 4 Tier 5 Ketorolac Tromethamine SOLUTION 0.4 % OPHTHALMIC Tier 3 Tier 2 Ketorolac Tromethamine SOLUTION 0.5 % OPHTHALMIC Tier 3 Tier 2 Levofloxacin SOLUTION 25 MG/ML INTRAVENOUS* Tier 2 Tier 4

Levofloxacin SOLUTION 25 MG/ML ORAL Tier 2 Tier 4

Lexiva TABLET 700 MG ORAL Tier 4 Tier 5

Lidocaine OINTMENT 5 % EXTERNAL Tier 2 Tier 4

Lomustine CAPSULE 10 MG ORAL Tier 4 Tier 2


MEDICATIONS WITH TIERING CHANGES Medication Name 2015 Tier 2016 Tier Lomustine CAPSULE 100 MG ORAL Tier 4 Tier 2

Lomustine CAPSULE 40 MG ORAL Tier 4 Tier 2

Lotronex TABLET 0.5 MG ORAL Tier 3 Tier 5

Mesnex TABLET 400 MG ORAL Tier 4 Tier 5

Methenamine Hippurate TABLET 1 GM ORAL Tier 2 Tier 3

Midodrine HCl TABLET 10 MG ORAL Tier 2 Tier 3

Midodrine HCl TABLET 2.5 MG ORAL Tier 2 Tier 3

Midodrine HCl TABLET 5 MG ORAL Tier 2 Tier 3

Nilandron TABLET 150 MG ORAL Tier 4 Tier 5

Ondansetron TABLET DISPERSIBLE 4 MG ORAL Tier 2 Tier 3

Ondansetron TABLET DISPERSIBLE 8 MG ORAL Tier 2 Tier 3

Permethrin CREAM 5 % EXTERNAL Tier 2 Tier 4

Perphenazine TABLET 16 MG ORAL Tier 2 Tier 4








Pioglitazone HCl TABLET 15 MG ORAL Tier 2 Tier 3



Potiga TABLET 300 MG ORAL Tier 4 Tier 5

Potiga TABLET 400 MG ORAL Tier 4 Tier 5

Progesterone Micronized CAPSULE 200 MG ORAL Tier 2 Tier 3 Propranolol HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL Tier 2 Tier 3


MEDICATIONS WITH TIERING CHANGES Medication Name 2015 Tier 2016 Tier Propranolol HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 160 MG ORAL Tier 2 Tier 3 Propranolol HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 60 MG ORAL Tier 2 Tier 3 Propranolol HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL Tier 2 Tier 3

Propylthiouracil TABLET 50 MG ORAL Tier 2 Tier 3

QUEtiapine Fumarate TABLET 100 MG ORAL Tier 2 Tier 3






Rapamune SOLUTION 1 MG/ML ORAL Tier 4 Tier 5

Reyataz CAPSULE 150 MG ORAL Tier 3 Tier 5



Reyataz PACKET 50 MG ORAL Tier 3 Tier 5 Ridaura CAPSULE 3 MG ORAL Tier 3 Tier 5 Riluzole TABLET 50 MG ORAL Tier 5 Tier 4 Sulfamethoxazole-Trimethoprim SUSPENSION 200-40 MG/5ML ORAL Tier 2 Tier 3

Syprine CAPSULE 250 MG ORAL Tier 4 Tier 5

Targretin 1 % EXTERNAL Tier 3 Tier 5

Targretin CAPSULE 75 MG ORAL Tier 3 Tier 5

Tekturna Tier 4 Tier 3 Testosterone Cypionate SOLUTION 100 MG/ML INTRAMUSCULAR* Tier 2 Tier 3 Testosterone Cypionate SOLUTION 200 MG/ML INTRAMUSCULAR* Tier 2 Tier 3 Testosterone Enanthate SOLUTION 200 MG/ML INTRAMUSCULAR* Tier 2 Tier 3

Thiothixene CAPSULE 1 MG ORAL Tier 2 Tier 3 Thiothixene CAPSULE 10 MG ORAL Tier 2 Tier 3


MEDICATIONS WITH TIERING CHANGES Medication Name 2015 Tier 2016 Tier Thiothixene CAPSULE 2 MG ORAL Tier 2 Tier 3 Thiothixene CAPSULE 5 MG ORAL Tier 2 Tier 3

Triamcinolone Acetonide LOTION 0.1 % EXTERNAL Tier 2 Tier 4 Triamcinolone Acetonide PASTE 0.1 % MOUTH/THROAT Tier 2 Tier 3

Tybost TABLET 150 MG ORAL Tier 4 Tier 3 Tyzeka TABLET 600 MG ORAL Tier 4 Tier 5

Ursodiol CAPSULE 300 MG ORAL Tier 2 Tier 4

Venlafaxine HCl TABLET 100 MG ORAL Tier 3 Tier 2


Venlafaxine HCl TABLET 37.5 MG ORAL Tier 3 Tier 2



Xarelto TABLET Tier 3 Tier 4

Xifaxan TABLET 550 MG ORAL Tier 4 Tier 5 Zortress TABLET 0.5 MG ORAL Tier 4 Tier 5

Zortress TABLET 0.75 MG ORAL Tier 4 Tier 5

MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description 2016 Quantity Limit Acamprosate Calcium TABLET DELAYED RELEASE 333 MG ORAL QL Removed

Alinia TABLET 500 MG ORAL QL Removed

AmLODIPine Besylate TABLET 2.5 MG ORAL Added QL 31 EA per 31 days

Asmanex Aerosol Powder Changed QL 1.00 EA per 30 days Atrovent HFA AEROSOL, SOLUTION 17 MCG/ACT INHALATION Changed QL 25.8 GM per 30 days Calcitonin (Salmon) SOLUTION 200 UNIT/ACT NASAL Changed QL to 3.7 ML per 30 days Dexilant CAPSULE DELAYED RELEASE 30 MG ORAL Changed QL 62 EA per 31 days Dexilant CAPSULE DELAYED RELEASE 60 MG ORAL Changed QL 31 EA per 31 days

Emend caps QL Removed

Emend titration QL Removed


MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description 2016 Quantity Limit

Enbrel SureClick 50 MG/ML SUBCUTANEOUS* Changed QL 8 ML per 31 days

Famciclovir Tab 250 MG QL Removed

Flovent Diskus AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST INHALATION Changed QL 60 per 30 days Flovent Diskus AEROSOL POWDER, BREATH ACTIVATED 250 MCG/BLIST INHALATION Changed QL 240 EA per 30 days Flovent Diskus AEROSOL POWDER, BREATH ACTIVATED 50 MCG/BLIST INHALATION Changed QL 60 EA per 30 days Flovent HFA AEROSOL 110 MCG/ACT INHALATION Changed QL 12 GM per 30 days Flovent HFA AEROSOL 220 MCG/ACT INHALATION Changed QL 24 GM per 30 days Flovent HFA AEROSOL 44 MCG/ACT INHALATION Changed QL 10.6 GM per 30 days GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR* 2.5 MG ORAL Changed QL 62 EA per 31 days GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR* 5 MG ORAL Changed QL 62 EA per 31 days

Humira 20 MG/0.4ML SUBCUTANEOUS* Changed QL to 2 EA per 28 days

Humira 40 MG/0.8ML SUBCUTANEOUS* Changed QL to 6 EA per 28 days

Leflunomide TABLET 10 MG ORAL QL Removed

Leflunomide TABLET 20 MG ORAL QL Removed

Lenvima 14 MG Daily Dose 10 & 4 MG ORAL QL Removed

Lenvima 24 MG Daily Dose 10 (2) & 4 MG ORAL QL Removed

LevETIRAcetam TABLET 1000 MG ORAL QL Removed




Losartan Potassium TABLET 100 MG ORAL Added QL 31 EA per 31 days

Losartan Potassium TABLET 25 MG ORAL Added QL 62 EA per 31 days

Losartan Potassium TABLET 50 MG ORAL Added QL 62 EA per 31 days Losartan Potassium-HCTZ TABLET 100-12.5 MG ORAL Added QL 31 EA per 31 days Losartan Potassium-HCTZ TABLET 100-25 MG ORAL Added QL 31 EA per 31 days


MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description 2016 Quantity Limit Losartan Potassium-HCTZ TABLET 50-12.5 MG ORAL Added QL 62 EA per 31 days

Naratriptan HCl TABLET 1 MG ORAL Changed QL 9 EA per 31 days

Naratriptan HCl TABLET 2.5 MG ORAL Changed QL 9 EA per 31 days

Nitrofurantoin Macrocrystal CAPSULE 50 MG ORAL Added QL 90 EA per 365 days Nitrofurantoin Monohyd Macro CAPSULE 100 MG ORAL Added QL 90 EA per 365 days

Oxandrolone Tab 2.5 MG Changed QL to 124 EA per 31 days

Promacta TABLET 25 MG ORAL Changed QL to 62 EA per 31

Promacta TABLET 50 MG ORAL Changed QL to 62 EA per 31

Promacta TABLET 75 MG ORAL Changed QL to 62 EA per 31 Relenza Diskhaler AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER INHALATION Changed QL 60 EA per 180 days

risperidone oral tablet Changed QL 124 EA per 31 days

risperidone oral tablet dispersible Changed QL 124 EA per 31 days

Sensipar TABLET 30 MG ORAL Changed QL 62 EA per 31 days

Strattera CAPSULE 10 MG ORAL Changed QL 62 EA per 31 days

Strattera CAPSULE 18 MG ORAL Changed QL 62 EA per 31 days

Strattera CAPSULE 25 MG ORAL Changed QL 62 EA per 31 days Strattera CAPSULE 40 MG ORAL

Changed QL 62 EA per 31 days

Suboxone FILM 2-0.5 MG SUBLINGUAL Changed QL 93 EA per 31 days

Suboxone FILM 4-1 MG SUBLINGUAL Changed QL 93 EA per 31 days

Suboxone FILM 8-2 MG SUBLINGUAL Changed QL 93 EA per 31 days

Symbicort Changed QL 10.20 GM per 30 days

Tecfidera 120 & 240 MG ORAL QL Removed Tecfidera CAPSULE DELAYED RELEASE 120 MG ORAL Change QL to 62 EA per 31

ValACYclovir HCl TABLET 1 GM ORAL QL Removed

ValACYclovir HCl TABLET 500 MG ORAL QL Removed

Xifaxan TABLET 200 MG ORAL QL Removed


MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES Drug Description 2016 Quantity Limit

Zortress TABLET 0.25 MG ORAL QL Removed



MEDICATIONS WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES Medication Name Change Description Amphetamine-Dextroamphetamine TABLET 10 MG ORAL Removed PA requirement Amphetamine-Dextroamphetamine TABLET 12.5 MG ORAL Removed PA requirement Amphetamine-Dextroamphetamine TABLET 15 MG ORAL Removed PA requirement Amphetamine-Dextroamphetamine TABLET 20 MG ORAL Removed PA requirement Amphetamine-Dextroamphetamine TABLET 30 MG ORAL Removed PA requirement Amphetamine-Dextroamphetamine TABLET 5 MG ORAL Removed PA requirement Amphetamine-Dextroamphetamine TABLET 7.5 MG ORAL Removed PA requirement Butalbital-APAP-Caff-Cod CAPSULE 50-325-40-30 MG ORAL Added PA requirement Butalbital-APAP-Caffeine CAPSULE 50-300-40 MG ORAL Added PA requirement Dextroamphetamine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG ORAL Removed PA requirement Dextroamphetamine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 15 MG ORAL Removed PA requirement Dextroamphetamine Sulfate ER CAPSULE EXTENDED RELEASE 24 HOUR 5 MG ORAL Removed PA requirement Dextroamphetamine Sulfate TABLET 10 MG ORAL Removed PA requirement Dextroamphetamine Sulfate TABLET 5 MG ORAL Removed PA requirement Digoxin 0.250 mg Added PA requirement Nitrofurantoin Macrocrystal CAPSULE 50 MG ORAL Removed PA requirement Nitrofurantoin Monohyd Macro CAPSULE 100 MG ORAL Removed PA requirement ondansetron ODT Add B/D PA ondansetron tabs Add B/D PA Oxandrolone Tab 10 MG Added PA requirement Oxandrolone Tab 2.5 MG Added PA requirement Rozerem TABLET 8 MG ORAL Removed PA requirement


MEDICATIONS WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES Medication Name Change Description Testosterone Cypionate SOLUTION 100 MG/ML INTRAMUSCULAR* Added PA requirement Testosterone Cypionate SOLUTION 200 MG/ML INTRAMUSCULAR* Added PA requirement Testosterone Enanthate SOLUTION 200 MG/ML INTRAMUSCULAR* Added PA requirement Xarelto Starter Pack 15 & 20 MG ORAL Removed PA requirement Xarelto TABLET 10 MG ORAL Removed PA requirement Xarelto TABLET 15 MG ORAL Removed PA requirement Xarelto TABLET 20 MG ORAL Removed PA requirement

2016 formulary annual notice of change medicare advantage plans (mapd) · annual notice of change ....

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