December 2011 - Prime Therapeutics

Prime Perspective | November 2011MAC List UpdatesClinical format Effective Date Description of Changeacyclovir tabs, 400 mg (ZOVIRAX) 8/15/11 Additionclotrimazole crm, 1% 8/1/11 Additiondesmopressin acetate nasal spray soln (refrigerated), 0.01% (DDAVP) 7/1/11 Additiondiflorasone oint, 0.05% 8/1/11 Additionestradiol transdermal weekly patch, 0.025 mg/24 hr (CLIMARA) 7/1/11 Additionimipramin pamoate caps, 125 mg (TOFRANIL-PM) 8/1/11 Additionletrozole tabs, 2.5 mg (FEMARA) 7/1/11 Additionlevofloxacin tabs, 250 mg, 500 mg, 750 mg (LEVAQUIN) 8/1/11 Additionnisoldipine ext-release 24 hour tabs, 17 mg (SULAR) 8/1/11 Additionvancomycin for inj, 1000 mg 8/1/11 Additionvenlafaxine ext-release 24 hour caps, 37.5 mg, 75 mg, 150 mg (EFFEXOR XR) 7/1/11 Additionvenlafaxine ext-release 24 hour tabs, 37.5 mg, 75 mg, 150 mg (VENLAFAXINE ER) 7/1/11 Additionzolpidem ext-release tabs, 6.25 mg, 12.5 mg (AMBIEN CR) 7/15/11 Additionamphetamine/dextroamphetamine mixed salts tabs, 7.5 mg, 15 mg (ADDERALL) 9/1/11 Removalaugmented betamethasone dipropionate lotn, 0.05% (DIPROLENE) 7/1/11 Removalcarbamazepine susp, 100 mg/5 mL (TEGRETOL) 8/1/11 Removalchlorpropamide tabs, 100 mg, 250 mg 7/1/11 Removalclarithromycin tabs, 250 mg, 500 mg (BIAXIN) 9/15/11 Removalclotrimazole crm, 1% 7/15/11 Removalclotrimazole/betamethasone lotn, 1-0.05% (LOTRISONE) 8/1/11 Removaldesoximetasone gel, 0.05% (TOPICORT) 7/1/11 Removaldexamethasone sodium phosphate ophth soln, 0.1% 7/15/11 Removaldexmethylphenidate tabs, 5 mg (FOCALIN) 8/1/11 Removaldrospirenone/ethinyl estradiol tabs, 3-0.02 mg (YAZ) 9/15/11 Removalfentanyl transdermal patch 72 hour, 12.5 mcg/hr (DURAGESIC) 8/15/11 RemovalFLUNISOLIDE nasal soln, 0.025% 8/15/11 Removalfluocinonide oint, 0.05% 9/1/11 Removalfluocinonide soln, 0.05% 8/15/11 Removallansoprazole delayed-release orally disintegrating tabs, 15 mg (PREVACID SOLUTAB) 7/1/11 Removalmethotrexate sodium preservative-free inj, 25 mg/mL 8/1/11 RemovalNYSTATIN/TRIAMCINOLONE crm, 100000 units - 1 mg/g 8/15/11 Removaloxcarbazepine susp, 300 mg/5 mL (TRILEPTAL) 8/15/11 Removalpermethrin crm, 5% 9/15/11 Removalpolyethylene glycol 3350 oral packets 8/1/11 Removalsulfacetamide sodium/sulfur emul, 10-5% (PLEXION CLEANSER) 9/15/11 Removal12 © Prime Therapeutics LLC