Drug List exclusions for Blue Cross commercial plans
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1 Drug List exclusions for Blue Cross commercial plans The drugs shown below aren t covered on the commercial Blue Cross Blue Shield of Michigan drug lists. In most cases, if you fill a prescription for one of these drugs, you ll pay the full retail price. If you re currently using one of the excluded drugs, please ask your doctor to write you a prescription for one of the following preferred alternatives. They have similar effectiveness, quality and safety but at a fraction of the cost. Our exclusions criteria are based on current medical information and have been approved by the Blue Cross Pharmacy and Therapeutics Committee. If medical necessity coverage is approved, quantity limits may apply. The following list isn t comprehensive. If you have a question about a drug that isn t covered and doesn t appear on this list, call the Customer Service number on the back of your Blue Cross ID card. Drug List exclusions with preferred alternatives This list contains the class, subclass and preferred alternatives for the excluded drug. The trade names for the preferred alternatives are listed in parenthesis for reference. Drug Class: Anti-infectives Antivirals Viekira Pak TM Viekira XR TM Zepatier TM Cephalosporins Daxbia TM cephalexin (Keflex ) Tetracyclines Acticlate CAP Targadox TM Ximino TM doxycycline monohydrate (Monodox ) minocycline (Minocin ) tetracycline Drug Class: Cardiovascular, hypertension, cholesterol Lipid-lowering agents Updated 2/1/18 Altoprev Nikita TM Zypitamag TM rosuvastatin (Crestor ) fluvastatin (Lescol, Lescol XL) atorvastatin (Lipitor ) lovastatin (Mevacor ) pravastatin (Pravachol ) simvastatin (Zocor )
2 Drug Class: Central Nervous System CNS stimulants Cotempla XR-ODT TM Mydayis TM amphetamine/dextroamphetamine extended-release capsules (Adderall XR )* methylphenidate extended-release capsules (Metadate CD )* Migraine therapy Narcotics Allzital acetaminophen/caffeine/dihydrocodone Vanatol S, Vanatol LQ Arymo TM ER MorphaBond TM ER Troxyca ER Vantrela TM ER Xtampza TM ER methylphenidate solution and chewable tablet (Methylin ) *can be opened and sprinkled on applesauce butalbital/acetaminophen/caffeine (Esgic) butalbital/aspirin/caffeine (Fiorinal) butalbital/acetaminophen (Phrenilin) fentanyl patch (Duragesic ) hydromorphone ER (Exalgo ) methadone morphine sulfate ER (MS Contin ) Narcotic antagonists Nonsteroidal antiinflammatory drugs Parkinsons disease and related disorders Oxaydo RoxyBond TM Evzio Duexis Vimovo hydromorphone immediate-release (Dilaudid) morphine sulfate immediate-release (MSIR) oxycodone immediate-release (OxyIR) naloxone hcl injection naloxone nasal spray (Narcan ) ibuprofen (Motrin ) plus famotidine (Pepcid ) naproxen (Naprosyn ) plus a generic proton pump inhibitor (esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole) Gocovri TM amantadine hcl (Symmetrel ) Salicylates Durlaza aspirin (Ecotrin ) Yosprala TM generic aspirin plus generic omeprazole (Prilosec )
3 Skeletal muscle relaxants chlorzoxazone 250mg chlorzoxazone 500mg (Parafon Forte DSC) Drug Class: Dermatology Acne Treatment Aczone 7.5% Retin-A micro pump 0.06% adapalene 0.1% cream/gel (Differin ) benzamycin/clindamycin gel (Benzaclin ) Tazorac Antipsoriatic and antiseborrheic (Treatment of Psoriasis) Corticosteroids- Medium Potency Corticosteroids- High to Very High Potency Topical Antibacterials Topical Antifungals tretinoin (Retin-A ) Siliq TM Cosentyx Cordran lotion flurandrenolide lotion Locoid lotion Sernivo TM Ultravate lotion Ultravate -X Humira Otezla Stelara betamethasone dipropionate- cream, gel, lotion, ointment (Diprosone ) betamethasone valerate- cream, lotion, ointment (Valisone ) fluticasone- cream, lotion, ointment, spray (Cutivate ) hydrocortisone butyrate- cream, ointment, topical solution (Locoid ) mometasone- cream, ointment, topical solution (Elocon ) triamcinolone- cream, lotion, ointment (Aristocort, Kenalog ) augmented betamethasone dipropionatecream, ointment, lotion (Diprolene ) clobetasol propionate- cream, gel, ointment, topical solution (Clobex ) fluocinonide- cream, gel, ointment, topical solution (Lidex, Lidex-E ) halobetasol propionate- cream, ointment (Ultravate ) Centany mupirocin cream, ointment (Bactroban ) Jublia Kerydin Onmel topical ciclopirox (Penlac ) oral itraconazole (Sporanox ) oral terbinafine (Lamisil ) griseofulvin (Gris-Peg )
4 Drug Class: Endocrinology Corticosteroids Non-insulin hypoglycemic agents LoCort Z o D e x ZonaCort Glumetza metformin ER (Glumetza ) dexamethasone metformin HCL (Glucophage ) metformin HCL ER (Glucophage XR, Fortamet ) Drug Class: Gastrointestinal Ulcer therapy glycopyrrolate 1.5mg (Glycate TM ) glycopyrrolate 1mg, 2mg (Robinul, Robinul Forte) Miscellaneous Gastrointestinal Agents Relistor injection Trulance Amitiza Lactulose Linzess polyethylene glycol 3350 (Glycolax ) Drug Class: Ophthalmology Ophthalmic Antiinflammatory Agents BromSite TM bromfenac (Bromday TM, Xibrom TM ) diclofenac (Voltaren ) ketorolac (Acular )
5 Drug Class: Otic and nasal preparations Nasal Preparations Xhance TM azelastine hcl (Astelin ) fluticasone propionate (Flonase ) Drug Class: Respiratory, cough and cold Antihistamines carbinoxamine 6mg (Ryvent TM ) Ryvent TM loratadine (Claritin ) levocetirizine (Xyzal ) cetirizine (Zyrtec ) carbinoxamine 4mg Epinephrine Auvi-Q EpiPen EpiPen Jr epinephrine 0.15 mg and 0.3 mg (Adrenaclick authorized generic) epinephrine 0.15mg and 0.3 mg (EpiPen /EpiPen Jr authorized generic) Inhaled steroid and beta-agonist combinations AirDuo TM RespiClick Advair HFA Breo Ellipta Dulera fluticasone propionate/salmeterol (AirDuo TM RespiClick authorized generic) Symbicort Drug Class: Urology Urinary antispasmodics Oxytrol oxybutynin (Ditropan, Ditropan XL ) tolterodine (Detrol, Detrol LA) trospium (Sanctura, Sanctura XR ) Drug Class: Diagnostic and other miscellaneous Chelating agents Cuprimine Depen
6 These exclusions apply to most Blue Cross commercial members; they don t apply to Medicare plans.
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WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions
WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions ANORO ELLIPTA 62.5-25MCG BLST W/DEV INHALATION ARCAPTA NEOHALER 75 MCG CAP W/DEV INHALATION CALCIPOTRIENE
Michigan Department of Community Health Co-pay and Quantity Limitations
Michigan Department of Community Health Co-pay and Quantity Limitations Benefit Plan Co-pay Information Group ID Coverage Co-pay INCARCE Incarcerated Medicaid No coverage No coverage patients SHPDUAL CSHCSCAID
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Enstilar, Sernivo, Taclonex) Reference Number: CP.CPA.255 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end
ALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %
June 2016 On 13th May, the DH announced that there would be reductions to Category M prices from June until September. http://psnc.org.uk/our-news/contractor-notice-category-m-price-reduction/ This has