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Changes in PDL for Commonwealth Care Type I, Commonwealth Care Type II & III and Commonwealth Care Bridge

Author: admin
This entry was posted on Tuesday, January 19th, 2010 and is filed under Uncategorized.

Dear CeltiCare Community,

During the year, CeltiCare will review our pharmacy program to ensure appropriate and improved services for our members.  Please note the below changes to your Preferred Drug List (PDL) that is available at www.celticarehealthplan.com under the members tab.

Commonwealth Care Type I PDL:

The following drugs have been added to list of covered drugs: 

Trade Name Dosage Form Dosage Message
APLENZIN TB24 174MG Bupropion XL preferred
CARMOL-HC CREA 1%; 10% Generics preferred~ Tier Change
GELNIQUE GEL 10%  
GRANISETRON HCL TABS 1MG  
LAMICTAL ODT KIT 0  
LAMICTAL ODT KIT 0  
LAMICTAL ODT KIT 0  
LAMICTAL ODT TBDP 25MG  
LAMICTAL ODT TBDP 50MG  
LAMICTAL ODT TBDP 100MG  
LAMICTAL ODT TBDP 200MG  
LOSEASONIQUE TABS 0; 0  
PROGRAF CAPS 0.5MG Generics preferred~ Tier Change
PROGRAF CAPS 5MG Generics preferred~ Tier Change
PROGRAF CAPS 1MG Generics preferred~ Tier Change
PROGRAF CAPS 5MG Generics preferred~ Tier Change
CELLCEPT CAPS 250MG Generics preferred~ Tier Change
CELLCEPT TABS 500MG Generics preferred~ Tier Change
RAPAFLO CAPS 4MG  
RAPAFLO CAPS 8MG  
RYZOLT TB24 100MG  
RYZOLT TB24 200MG  
RYZOLT TB24 300MG  
VIMPAT SOLN 200MG/20ML  
VIMPAT TABS 50MG  
VIMPAT TABS 100MG  
VIMPAT TABS 150MG  
VIMPAT TABS 200MG  
ADCIRCA TABS 20MG Prior authorization for review as specialty drug
AFINITOR TABS 5MG Prior authorization for review as specialty drug
AFINITOR TABS 10MG Prior authorization for review as specialty drug
ASACOL HD TBEC 800MG  
EFFIENT TABS 5MG  
EFFIENT TABS 10MG  
MULTAQ TABS 400MG  
ULESFIA LOTN 5%  

 

Commonwealth Care Type II & III and Commonwealth Care Bridge PDLs:

The following drugs have been added to list of covered drugs:

Tier 1:

Lansoprazole

Tier 2:

Aricept ODT

Exforge HCT

Prevacid SoluTab

Zenpep

Tier 3:

Prevacid Capsule

If you have additional questions regarding the copayment amounts please contact CeltiCare Member Services at 1-866-895-1786.

This entry is filed under Uncategorized.


Changes in PDL for Commonwealth Care Type I, Commonwealth Care Type II & III and Commonwealth Care Bridge