Future Formulary Changes
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1 Future Formulary Changes Upd 05/16/2018 Applies to: Employer group plan 2018 open formularies with specialty tiers KEY: PA=prior authorization; ST=step therapy; QL=quantity limit Generic name Brand name Change Effective Bexarotene Targretin Ancillary charge applies Testosterone cypionate IM Depo-Testosterone Ancillary charge applies Pegvisomant Somavert Limited to Kaiser Guselkumab Tremfya Add QL of 1 syringe per 56 Brodalumab Siliq Add QL of 2 syringes per 28 Empagliflozin/metformin ER Synjardy XR Add QL of 30 Codeine sulfate; hydromorphone; levorphanol; morphine sulfate; oxycodone IR; oxycodone/acetaminophen; oxycodone/aspirin; tramadol; tramadol/acetaminophen; buprenorphine sublingual; acetaminophen/codeine; hydrocodone/acetaminophen; hydrocodone/ibuprofen; meperidine; oxymorphone; tapentadol; oxycodone/ibuprofen; butalbital/acetaminophen/caffeine/codeine; butalbital/aspirin/caffeine/codeine; acetaminophen/caffeine/dihydrocodeine Endocet; Lorcet; Lorcet Plus; Lortab; Dilaudid; Demerol; Roxicodone; Opana; Nucynta; Ultram; Percocet; Primlev; Tylenol #3; Tylenol #4; Capital/codeine; Fioricet; Fiorinal; Panlor; Synalgos- DC; Trezix; Norco; Vicodin; Vicodin ES; Vicodin HP; Verdrocet; Xodol; Hycet; Zamicet; Ibudone; Reprexain; Vicoprofen; Xylon; Ultracet; Oxaydo Up short acting opioid QL for 7 history of use. Maximum quantity now: 42 units or 210mLs for age >21 years; 18 units or 90mLs for age <21 years Atazanavir sulfate Sustiva Move to Tier 3 Efavirenz Reyataz capsules Move to Tier 5 Tenofovir disoproxil fumarate Viread Move to Tier 3 Upd 05/16/2018
2 Codeine/chlorpheniramine Tuzistra XR Add PA Dapagliflozin/saxagliptin Qtern Add QL of 30 Doxylamine/pyridoxine Diclegis Add PA Diclofenac Cambia; Zorvolex Add PA Dextromethorphan/quinidine Nuedexta Add PA Icatibant acetate Firazyr Limited to Kaiser Immune globulin Hizentra Limited to Kaiser Fluticasone propionate Flonase Move to Tier 3, add PA Beclomethasone dipropionate Beconase AQ; Qnasl Add PA Ciclesonide Omnaris; Zetonna Add PA Budesonide Rhinocort Aqua Add PA Mometasone furoate Nasonex Add PA Promethazine/codeine Phenergan with codeine Move to Tier 3; add PA Promethazine/phenylephrine/codeine Phenergan VC with codeine Move to Tier 3; add PA Enoxaparin sodium Lovenox Ancillary charge applies Tofacitinib citrate ER Xeljanz XR Limited to Kaiser Prasugrel Effient Move to Tier 3 Moxifloxacin Vigamox Move to Tier 3 Fosamprenavir Lexiva Move to Tier 5 01/01/ /13/2017 Upd 05/16/2018
3 Abacavir Ziagen Move to Tier 3 Sevelamer Renvela Move to Tier 3 Estradiol Climara Move to Tier 3 Enoxaparin Lovenox Move to Tier 3 Clidinium/chlordiazepoxide Librax Move to Tier 3 Scopolamine Transderm Scop Ancillary charge applies (generic available) Zileuton ER Zyflo CR Move to Tier 5 Becaplermin Regranex gel Move to Tier 5 Lurasidone Latuda Move to Tier 5 Dichlorphenamide Keveyis Move to Tier 5 Lanthanum carbonate Fosrenol Move to Tier 5 Felbamate Felbatol Move to Tier 5 Rufinamide Banzel Move to Tier 5 Alosetron Lotronex Move to Tier 5 Adefovir dipivoxil Hepsera Move brand to Tier 5; Move generic to Tier 4 Vancomycin Vancocin Move brand to Tier 5; Move generic to Tier 4 Erythromycin ethylsuccinate suspension Eryped; E.E.S. Move to Tier 3 Calcitriol Vectical ointment Move to Tier 2 Oxycodone Oxycontin CR Move to Tier 2 Mesalamine Asacol HD Move to Tier 2 Upd 05/16/2018
4 Fluorouracil Carac cream Move to Tier 2 Colchicine Mitigare Move to Tier 2 Lenvatinib Lenvima Limited to Kaiser Codeine sulfate; acetaminophen/codeine; promethazine/codeine; promethazine/phenylephrine/codeine; chlorpheniramine/codeine Tylenol with codeine; Phenergan with codeine; Lexuss; Tuzistra XR; Codar AR Cyclobenzaprine ER Amrix Add PA; add QL of 21 capsules per 180 Methylpheni ER Cotempla Add QL of 30 Amphetamine/dextroamphetamine Mydayis Add QL of 30 capsules per 30 Fentanyl Actiq; Subsys; Abstral; Fentora; Lazanda Add PA Add QL of 4 dosing units per day Daclizumab Zinbryta Add QL of 1 syringe per 28 Mometasone/formoterol Dulera Move to Tier 3 Ethacrynic acid Edecrin Add PA Ethacrynic acid Edecrin Move to Tier 3 Dupilumab Dupixent Add QL of 2 syringes (600mg) per 30 (exception for initial loading dose) Crisaborole Eucrisa Add QL of 120 grams per 30 Droxidopa Northera Limited to Kaiser 01/01/ /11/2017 Upd 05/16/2018
5 Morphine sulfate ER Morphabond ER Add QL of 60 Morphine sulfate ER Arymo ER Add QL of 90 Sacrosidase Sucraid Add PA Carisoprodol Soma Add QL of 45 Chlorzoxazone Lorzone, Parafon Forte Add QL of 60 Metaxalone Skelaxin, Metaxall Add QL of 60 Orphenadrine Norflex Add QL of 30 Methocarbamol Robaxin Add QL of 60 Cyclobenzaprine Flexeril, Fexmid Add QL of 45 Olorol Striverdi Add PA Quetiapine fumarate ER Seroquel XR Ancillary charge applies Melphalan Alkeran Move to Tier 3 Penicillamine Cuprimine; Depen Add PA; Limited to Kaiser Upd 05/16/2018
6 Ixekizumab Taltz Add QL of 2 syringes/pens (160 mg) at week 0 and 1 syringe/pen (80 mg) at week 2, 4, 6, 8, 10 and 12. Maintenance phase: QL of 1 syringe/pen (80 mg) per 28. Ibuprofen/famotidine Duexis Add coverage restriction; Move to Tier 5 Diclofenac potassium Zipsor Add coverage restriction Prednisone Rayos Add coverage restriction Adapalene Differin gel Move to Tier 3 Atomoxetine Strattera Move to Tier 3 Ezetimibe Zetia Move to Tier 3 Acyclovir Zovirax Move to Tier 3 Norethindrone/ethinyl estradiol Norinyl; Ortho-Novum Remove brand from ACA list Gabapentin oral capsules and lidocaine/menthol gel; diclofenac oral tablets, ranitidine oral tablets, lidocaine topical cream; diclofenac oral tablets, ranitidine oral tablets, lidocaine/prilocaine topical cream; cyclobenzaprine oral tablet, capsaicin/menthol topical patch Active-PAC with Gabapentin; Flexizol Pak Combipak; Inflammation Pak Reduction; Cyclobenzaprine Pak, Flexpax Remove from formulary, excluded product Conjugated estrogens Premarin Add ST Idelalisib; interferon alfa-2b; entacavir oral solution; pyrimethamine; auranofin; cobimetinib; alectinib; osimertinib; olaparib; peginterferon alfa-2b; trifluridine/tipiracil; alitretinoin; lenvatinib; aripiprazole lauroxil; cholic acid; dihydroergotamine mesylate; osalazine; ibuprofen/famotidine; atazanavir/cobicistat; alosetron; primidone; Zydelig; Intron-A; Baraclude oral solution; Daraprim; Ridaura; Cotellic; Alecensa; Targrisso; Lynparza; Sylatron; Lonsurf; Panretin; Lenvima; Aristada; Cholbam; D.H.E; Limited to a 30 day supply per fill Upd 05/16/2018
7 posaconazole; alirocumab; evolocumab; riluzole; acitretin; asfotase alfa; naproxen/esomeprazole; elvitegravir; selegeline; somatropin; lomitapide; ombitasvir/paritarevir/ritonavir; oxymetholone; paliperidone palmitate; parathyroid hormone; sapropterin; tolcapone; tolvaptan; zileuton; zileuton CR; ivacaftor packet; miltefosine Dipentum; Duexis; Evotaz; Lotronex; Mysoline; Noxafil; Praluent; Repatha; Rilutek; Soriatane; Strensiq; Vimovo; Viteka; Zelapar; Genotropin; Zomacton; Juxtapid; Technivie; Anadrol-50; Invega Trinzia; Natpara; Kuvan; Tasmar; Samsca; Zyflo, Zyflo CR; Kalydeco Packet; Impavido Lopinavir/ritonavir solution Kaletra solution Move to Tier 3 Oseltamivir Tamiflu Move to Tier 3 Rasagiline Azilect Move to Tier 3 Erythromycin ethylsuccinate suspension Eryped; E.E.S. Move to Tier 3 Glyburide Diabeta Move to Tier 3 Calcitonin nasal spray; Fortical Move to Tier 3 Pentamidine Nebupent Move to Tier 3 Estradiol valerate Desestrogen Add PA Flucytosine Ancobon Move to Tier 5 Flucytosine Generic Move to Tier 4 Aripiprazole lauroxil Aristrada Move to Tier 5 Entecavir oral solution Baraclude Move to Tier 4 Cholic acid Cholbam Move to Tier 5 Dihydroergotamine mesylate D.H.E Move to Tier 5 Pyrimethamine Daraprim Move to Tier 4 Fidaxomicin Dificid Move to Tier 5 Osalazine Dipentum Move to Tier 5 Atazanavir/cobicistat Evotaz Move to Tier 5 Felbamate Felbatol Move to Tier 5 Alosetron Lotronex Move to Tier 5 Primidone Mysoline Move to Tier 5 Alirocumab Praluent Move to Tier 5 Evolocumab Repatha Move to Tier 5 Auranofin Ridaura Move to Tier 4 Riluzole Rilutek Move to Tier 5 Upd 05/16/2018
8 Acitretin Soriatane Move to Tier 5 Asfotase alfa Strensiq Move to Tier 5 Naproxen/esomeprazole Vimovo Move to Tier 5 Elvitegravir Viteka Move to Tier 5 Selegiline Zelapar Move to Tier 5 Somatropin Genotropin; Zomacton Move to Tier 5 Entecavir Baraclude Move to Tier 5 Lomitapide Juxtapid Move to Tier 5 Ombitasvir/paritarevir/ritonavir Technivie Move to Tier 5 Oxymetholone Anadrol-50 Move to Tier 5 Paliperidone palmitate Invega Trinzia Move to Tier 5 Parathyroid hormone Natpara Move to Tier 5 Sapropterin Kuvan Move to Tier 5 Tolcapone Tasmar Move to Tier 5 Tolvaptan Samsca Move to Tier 5 Zileuton; zileuton CR Zyflo, Zyflo CR Move to Tier 5 Ivacaftor packet Kalydeco Packet Move to Tier 5 Miltefosine Impavido Move to Tier 5 Linezolid Zyvox Move to Tier 5 Upd 05/16/2018
Future Formulary Changes
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