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FORMULARY DELETIONS UPDATE:
The following summary describes recent changes to the 2011 QHP MAPD Formularies.
FORMULARY DELETIONS, CHANGES IN PREFERRED OR TIERED COST-SHARING STATUS,
OR ADDITION OF UTILIZATION MANAGEMENT TO AN EXISTING FORMULARY DRUG
Effective
Alternative Drugs
Brand Name
Generic Name
Description of Change
Reason for Change
LIORESAL INTRATHECAL
INJECTION 0.05MG/1ML
MYOBLOC INJECTION
2500/0.5ML
QUTENZA KIT 8% 1-PCH,
AZMACORT AEROSOL
propoxyphene-n w/ apap
BALACET 325 TABLET
tablet 100-325mg
propoxyphene-n w/ apap
DARVOCET A500 TABLET
tablet 100-500mg
propoxyphene-n w/ apap
DARVOCET-N 100 TABLET
tablet 100-650mg
propoxyphene-n w/ apap
DARVOCET-N 50 TABLET
tablet 50-325mg
propoxyphene hcl capsule
DARVON CAPSULE 65MG
DARVON-N TABLET
propoxyphene napsylate
tablet 100mg
PROPOXACET-N TABLET
propoxyphene-n w/ apap
100-650MG
tablet 100-650mg
PROPOXYPHENE HCL W/
propoxyphene hcl w/ apap
APAP TABLET 65-650MG
tablet 65-650mg
PROPOXYPHENE
propoxyphene napsylate
NAPSYLATE POWDER
ACCOLATE TABLET 10MG,
QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B/D determination
Affected drug is indicated in bold.

RD: 08/17/2011
FORMULARY DELETIONS UPDATE:
The following summary describes recent changes to the 2011 QHP MAPD Formularies.
FORMULARY DELETIONS, CHANGES IN PREFERRED OR TIERED COST-SHARING STATUS,
OR ADDITION OF UTILIZATION MANAGEMENT TO AN EXISTING FORMULARY DRUG
Effective
Alternative Drugs
Brand Name
Generic Name
Description of Change
Reason for Change
AMBIEN CR TABLET
6.25MG, 12.5MG
AMERGE TABLET 1MG,
ARIMIDEX TABLET 1MG
COSMEGEN INJECTION
EXELON CAPSULE 1.5MG,
3MG, 4.5MG, 6MG
MERREM INJECTION
METHYLIN SOLUTION
5MG/5ML, 10MG/5ML
PEPCID SUSPENSION
40MG/5ML
QUIXIN SOLUTION 0.5%
AEROBID-M AEROSOL
ALKERAN TABLET 2MG
AVANDAMET TABLET
2-500MG, 2-1000MG,
4-500MG, 4-1000MG
QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B/D determination
Affected drug is indicated in bold.

RD: 08/17/2011
FORMULARY DELETIONS UPDATE:
The following summary describes recent changes to the 2011 QHP MAPD Formularies.
FORMULARY DELETIONS, CHANGES IN PREFERRED OR TIERED COST-SHARING STATUS,
OR ADDITION OF UTILIZATION MANAGEMENT TO AN EXISTING FORMULARY DRUG
Effective
Alternative Drugs
Brand Name
Generic Name
Description of Change
Reason for Change
AVANDARYL TABLET
4-1MG, 4-2MG, 4-4MG,
8-2MG, 8-4MG
AVANDIA TABLET 2MG,
colchicine tablet 0.6mg
UROQID #2 TABLET
UTAC TABLET 500-500MG
VISQID A/A TABLET
ALLEGRA TABLET 60MG,
ALLEGRA-D TABLET
ALLEGRA-D TABLET
ANAMANTLE HC KIT
QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B/D determination
Affected drug is indicated in bold.

RD: 08/17/2011
FORMULARY DELETIONS UPDATE:
The following summary describes recent changes to the 2011 QHP MAPD Formularies.
FORMULARY DELETIONS, CHANGES IN PREFERRED OR TIERED COST-SHARING STATUS,
OR ADDITION OF UTILIZATION MANAGEMENT TO AN EXISTING FORMULARY DRUG
Effective
Alternative Drugs
Brand Name
Generic Name
Description of Change
Reason for Change
DORYX TABLETS 75MG,
FEMHRT 1/5 TABLET
LACTIC ACID LOTION 10%
LACTINOL LOTION 10%
LIDAZONE HC KIT
LIDOCAINE/HC KIT
LOTREL CAPSULE
5-40MG, 10-40MG
MALDEMAR TABLET
NARDIL TABLET 15MG
NEURONTIN SOLUTION
250MG/5ML
ROSULA EMULSION 10-5%
RYTHMOL SR CAPSULE
225MG, 325MG, 425MG
SCOPACE TABLET 0.4MG
QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B/D determination
Affected drug is indicated in bold.

RD: 08/17/2011
FORMULARY DELETIONS UPDATE:
The following summary describes recent changes to the 2011 QHP MAPD Formularies.
FORMULARY DELETIONS, CHANGES IN PREFERRED OR TIERED COST-SHARING STATUS,
OR ADDITION OF UTILIZATION MANAGEMENT TO AN EXISTING FORMULARY DRUG
Effective
Alternative Drugs
Brand Name
Generic Name
Description of Change
Reason for Change
SULFACETAMIDE/
SULFUR EMULSION 10-5%
SULFATOL EMULSION
VAGIFEM TABLET 25MCG
XODOL TABLET 5-300MG
7.5-300MG, 10-300MG
AROMASIN TABLET 25MG
QL = Quantity Limit, PA = Prior Authorization, ST = Step Therapy, B/D = Medicare Part B/D determination
Affected drug is indicated in bold.

RD: 08/17/2011

Source: http://www.qualityhealthplansny.com/files/QHP_MAPD_Formulary_Deletions.pdf

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