Formulary Changes. One mission: you TABLE A. FORMULARY CHANGES 7/1/2018: Commercial 3-Tier Formulary. Commercial 4-Tier Formulary
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1 One mission: you Changes July 1, 2018 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for your care. Because the formulary is reviewed on an ongoing basis, we want to keep you informed of coming and recent changes to our covered drug lists. The following is a list of changes that have occurred. The online pharmacy tools and resources are updated with these decisions by the effective date of the change. This list applies to members of Health Plans. This list does not apply to Federal Employee Program members, Medicare Advantage members, or Qualified Health Plans. TABLE A. FORMULARY CHANGES 7/1/2018: Medication Alternatives Drug Brand Name (Drug Scientific Name) Class/Category Indication Tier = Benefit Level for Drug Under The MN-PA = Medical Necessity Prior Authorization MBC = Medical Benefit Channel PA = Prior Authorization is Required ST = Step Therapy is Required QL = Quantity Limit Cosentyx (Secukinumab) Anti-interleukin 17A Monoclonal Antibody Tier 2 with PA Tier 3 with PA Tier 5 with PA Otezla (Apremilast) Phosphodiesterase- 4 Enzyme Inhibitor Psoriasis & Psoriatic Arthritis Tier 2 with PA Tier 3 with PA Tier 5 with PA Stelara (ustekinumab) Interleukin-12 Inhibitor; Interleukin-23 Inhibitor Tier 2 with PA Tier 3 with PA Tier 5 with PA Kevzara (sarilumab) Interleukin-6 Receptor Antagonist Rheumatoid Arthritis Tier 2 with PA Tier 3 with PA Tier 5 with PA
2 Alternatives Humira (adalimumab) Tumor Necrosis Factor (TNF) Blocking Agent No Change Tier 2 with PA Tier 3 with PA Tier 5 with PA Enbrel (etanercept) Tumor Necrosis Factor (TNF) Blocking Agent No Change Tier 2 with PA Tier 3 with PA Tier 5 with PA Actemra (tocilizumab) Interleukin-6 Receptor Antagonist Enbrel, Humira, Kevzara Cimzia (Certolizumab Pegol) Tumor Necrosis Factor (TNF) Blocking Agent Humira, Enbrel, Stelara Kineret (Anakinra) Interleukin-1 Receptor Antagonist Kevzara, Humira, Enbrel Orencia (abatacept) Selective T-Cell Costimulation Blocker Kevzara, Humira, Enbrel, Stelara, Otezla, Cosentyx Simponi (Golimumab) Tumor Necrosis Factor (TNF) Blocking Agent Kevzara, Cosentyx, Otezla, Stelara, Humira, Enbrel
3 Alternatives Taltz (ixekizumab) Anti-interleukin 17A Monoclonal Antibody Plaque Psoriasis & Psoriatic Arthritis Cosentyx, Otezla, Stelara, Humira, Enbrel Xeljanz and Xeljanz XR (tofacitinib) Janus Associated Kinase Inhibitor Kevzara, Cosentyx, Otezla, Stelara, Humira, Enbrel Extavia (Interferon Beta-1b) Interferon Relapsing forms of multiple Rebif, Avonex and Betaseron Betaseron (Interferon Beta-1b) Interferon Relapsing forms of multiple Tier 2 with QL Tier 3 with QL Tier 5 with QL Aubagio (Teriflunomide) Pyrimidine Synthesis Inhibitor Relapsing forms of multiple Tier 2 with QL Tier 3 with QL Tier 5 with QL Rebif (Interferon Beta-1a) Interferon Relapsing forms of multiple Tier 2 with QL Tier 3 with QL Tier 5 with QL Avonex (Interferon Beta-1a) Interferon Relapsing forms of multiple Tier 2 with QL Tier 3 with QL Tier 5 with QL Copaxone 40mg/ml (Glatiramer) Multiple Sclerosis Tier 2 with QL Tier 3 with QL Tier 5 with QL Glatopa 20mg/ml (Glatiramer) Ampyra (Dalfampridine (4- Aminopyridine)) Multiple Sclerosis Tier 1 with QL Tier 3 with QL Tier 5 with QL Potassium Channel Blocker Used to improve walking in patients with multiple Tier Tier 3 Tier 4 Tier 6
4 Alternatives Byetta (Exenatide) Antidiabetic Agent, Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist Type 2 Diabetes Trulicity and Victoza Bydureon (Exenatide) Antidiabetic Agent, Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist Type 2 Diabetes Trulicity and Victoza Test Strips (all brands besides One Touch) Diabetes, Glucose Monitoring One Touch Pradaxa (Dabigatran Etexilate Mesylate) Anticoagulant, Direct Thrombin Inhibitor, Direct Oral Anticoagulant (DOAC) Treatment and prevention of deep venous thrombosis and pulmonary embolism and treatment of Nonvalvular atrial fibrillation Eliquis, Xarelto, Warfarin Elidel (Pimecrolimus) Calcineurin Inhibitor, Immunosuppressant Agent Atopic dermatitis Tier 2 Tier 2 Tier 3 Bystolic (Nebivolol) Restasis (Cyclosporine) Antihypertensive, Beta-1 Selective Beta-Blocker Hypertension Calcineurin Inhibitor, Immunosuppressant Agent Keratoconjunctivitis sicca Tier 2 Tier 2 Tier 3 Tier 2 Tier 2 Tier 3
5 Alternatives Xiidra (Lifitegrast) Forteo (Teriparatide) Ibrance (Palbociclib) Niaspan (Niacin) Innopran XL (Propranolol ER) Aerospan (Flunisolide Inhalation) Alvesco (Ciclesonide Inhalation) Lymphocyte Function-Associated Antigen 1 (LFA-1) Antagonist Dry eye disease Parathyroid Hormone Analog Osteoporosis in Men, Osteoporosis in postmenopausal women and treatment of glucocorticoidinduced osteoporosis Cyclin-Dependent Kinase Inhibitor, Antineoplastic Agent Advanced Breast Cancer Anti-lipemic Agent, Water Soluble Vitamin Atherosclerotic disease, Dyslipidemia, Hypertriglyceridemia, and Prevention of recurring myocardial infarction Non-Selective Beta Blockers hypertension, tremors, chest pain and atrial fibrillation., Inhalant (Oral) Maintenance treatment of asthma, Inhalant (Oral) Maintenance treatment of asthma Tier 2 with PA Tier 3 with PA Tier 5 with PA Tier 2 with PA Tier 3 with PA Tier 5 with PA Removed Not Covered Not Covered Not Covered Tier 3 Tier 3 Tier 4 products for COM: Restasis Over the Counter Niacin available products for COM: Nadolol, Pindolol, Propranolol ER, Propranolol products for COM: Asmanex, Flovent, Pulmicort, Qvar products for COM: Asmanex, Flovent, Pulmicort, Qvar
6 Alternatives Zarxio (Filgrastim) Colony Stimulating Factor, Hematopoietic Agent neutropenia associated with chemotherapy Tier 2 Tier 3 Tier 5 Neupogen (Filgrastim) Colony Stimulating Factor, Hematopoietic Agent neutropenia associated with chemotherapy Removed MN-PA MN-PA MN-PA Zarxio Leukine (Sargramostim) Colony Stimulating Factor, Hematopoietic Agent neutropenia associated with chemotherapy Removed MN-PA MN-PA MN-PA Zarxio Granix (Filgrastim) Colony Stimulating Factor, Hematopoietic Agent neutropenia associated with chemotherapy Removed MN-PA MN-PA MN-PA Zarxio Beconase AQ (Beclomethasone) Prevention of recurrence of Polyps and treatment of seasonal or perennial allergic and nonallergic rhinitis Dymista (Azelastine HCL/ Propionate), Second Generation Histamine Antagonist seasonal allergic rhinitis Brand Nasonex (Mometasone) seasonal allergic rhinitis
7 Alternatives Brand Flonase () seasonal allergic rhinitis Brand Nasacort (Triamcinolone) seasonal allergic rhinitis Omnaris (Ciclesonide) nasal symptoms associated with seasonal and perennial allergic rhinitis Qnasl (Beclomethasone) nasal symptoms associated with seasonal and perennial allergic rhinitis Brand Rhinocort (Budesonide) Management of symptoms of allergic rhinitis Veramyst ( Furoate) Management of seasonal and perennial allergic rhinitis
8 Alternatives Zetonna (Ciclesonide) nasal symptoms associated with seasonal and perennial allergic rhinitis Latuda (Lurasidone) Second Generation (Atypical) Antipsychotic Bipolar depression and Schizophrenia Tier 2 Tier 2 Tier 3 Vraylar (Cariprazine) Second Generation (Atypical) Antipsychotic Bipolar depression and Schizophrenia Tier 2 with QL Tier 2 with QL Tier 3 with QL Fanapt (Iloperidone) Second Generation (Atypical) Antipsychotic Schizophrenia Removed MN-PA MN-PA MN-PA paliperidone ER, risperidone, quetiapine ER, aripiprazole Norditropin Growth Genotropin Growth Omnitrope Growth Nutropin/Nutropin AQ Growth
9 Alternatives Saizen Growth Zomacton Growth Natazia (Estradiol + Dienogest) Estrogen & Progestin Combination Contraceptive Tier 2 Tier 2 Tier 3 Safyral ( Ethinyl Estradiol, Drospirenone, and Levomefolate ) Estrogen & Progestin Combination Contraceptive Tier 2 Tier 2 Tier 3 Lo Loestrin (Ethinyl Estradiol and Norethindrone) Estrogen & Progestin Combination Contraceptive Tier 2 Tier 2 Tier 3
10
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 8 Last Review Date: March 16, 2018 Orencia Description Orencia (abatacept)
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.24 Subject: Xeljanz Page: 1 of 5 Last Review Date: March 17, 2017 Xeljanz Description Xeljanz, Xeljanz
TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp
Stelara. Stelara (ustekinumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.90.04 Subject: Stelara Page: 1 of 6 Last Review Date: December 8, 2017 Stelara Description Stelara (ustekinumab)
Oral Agents. Fml Limits. Available Strengths NF NF
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Allergy Medications LAST REVIEW: 9/12/2017 THERAPEUTIC CLASS: Rheumatologic/Immunologic REVIEW HISTORY: 9/16, 5/15, 9/14
COSENTYX (secukinumab)
COSENTYX (secukinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
Fml Limits. Azathioprine (Imuran) 50mg, 75mg, 100mg - $26.85 Cyclosporine, 25mg, 100mg. $ Leflunomide (Arava) 10mg Tablet - $144.
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Rheumatoid Arthritis (RA) P&T DATE: 2/15/2017 CLASS: Rheumatology/Anti-inflammatory Disorders REVIEW HISTORY 2/16, 5/15,
ANTICONVULSANT THERAPY
Network Health Insurance Corporation NetworkCares Step Therapy Last Updated: 7/2017 ANTICONVULSANT THERAPY Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200
Added, Removed or Changed. Date of Change. No Change
One mission: you s September 7, 2017 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for your
Regulatory Status FDA-approved indication: Enbrel and Erelzi are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.27 Subject: Enbrel Page: 1 of 10 Last Review Date: June 22, 2018 Enbrel Description Enbrel (etanercept),
ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION
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Cyltezo (adalimumab-adbm) CG-DRUG-64, CG-DRUG-65
Market DC Cyltezo (adalimumab-adbm) CG-DRUG-64, CG-DRUG-65 Override(s) Prior Authorization Quantity Limit Medications Cyltezo (adalimumab-adbm) 40 mg/0.8 ml prefilled syringe #* ^ Approval Duration 1 year
Step Therapy Approval Criteria
Effective Date: 10/01/2016 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Cymbalta (duloxetine) 3. Dovonex (calcipotriene) 4. Enbrel (etanercept)
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Regulatory Status FDA-approved indication: Humira and Amjevita are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 14 Last Review Date: June 22, 2018 Humira Description Humira (adalimumab),
(tofacitinib) are met.
Xeljanz (tofacitinib) Policy Number: 5.01. 560 Origination: 3/2014 Last Review: 3/2014 Next Review: 3/2015 Policy BCBSKC will provide coverage for Xeljanz (tofacitinib) when it is determined to be medically
certolizumab pegol (Cimzia )
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
Quarterly pharmacy formulary change notice
Provider Bulletin June 24, 2016 Summary of change The Pharmacy and Therapeutics Committee reviewed and approved the formulary changes listed in the table below on March 29, 2016. What this means to you
Simponi / Simponi ARIA (golimumab)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 6 Last Review Date: September 15, 2016 Simponi / Simponi
MDwise Self-Administered Codes for Medical
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Center for Evidence-based Policy
P&T Committee Brief Targeted Immune Modulators: Comparative Drug Class Review Alison Little, MD Center for Evidence-based Policy Oregon Health & Science University 3455 SW US Veterans Hospital Road, SN-4N
The Medical Letter. on Drugs and Therapeutics. Drug Some Formulations OTC/Rx Usual Dosage Comments Class Comments Cost 1
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