Future Formulary Changes
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1 Future Formulary Changes Upd 09/11/2018 Applies to: Employer group plan 2018 open formularies KEY: =prior authorization; ST=step therapy; QL=quantity limit Generic name Brand name Change Effective Hydroxyprogesterone caproate Makena Move to Tier 3 Filgrastim Granix Limited to Kaiser Tenofovir alafenamide Vemlidy Limited to Kaiser Toremifene Fareston Limited to Kaiser Ferric citrate Auryxia Add QL of 360 tablets Tezacaftor/ivacaftor plus ivacaftor Symdeko Add QL of 60 tablets 10/01/ /13/2018 Metformin hcl ER 1,000 mg Fortamet 1,000 mg Add Lansoprazole ODT Prevacid SoluTab Add Febuxostat 40 mg Uloric 40 mg Add QL of 30 tablets Brigatinib 30 mg Alunbrig 30 mg Add QL of 60 tablets Hydrocodone w/ homatropine; belladonna alakaloids & opium; codeine sulfate; fentanyl; hydrocodone bitartrate; hydromorphone hcl; levorphanol tartrate; meperidine hcl; methadone hcl; morphine sulfate; morphine/naltrexone; oxycodone hcl; oxycodone hcl ER; oxymorphone hcl ER; oxymorphone hcl; tapentadol hcl; tramadol hcl; tramadol hcl ER; buprenorphine; butorphanol tartrate; pentazocine/naloxone; oxycodone/acetaminophen; oxycodone/aspirin; oxycodone/ibuprofen; acetaminophen/codeine; butalbital/acetaminophen/caffeine/codeine; butalbital/aspirin/caffeine/codeine; acetaminophen/caffeine/dihydrocodeine; aspirin/caffeine/dihydrocodeine; hydrocodone/acetaminophen; hydrocodone/ibuprofen; meperidine/promethazine; tramadol/acetaminophen; carisoprodol/aspirin/codeine High Dose Pain Medicine Prescriber Review: Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy. Sofosbuvir Sovaldi Move to Tier 3 Ivacaftor 150 mg Kalydeco 150 mg Move to Tier 3 Upd 09/11/2018
2 Praziquantel Biltricide Move to Tier 3 Ritonavir 100 mg Norvir 100 mg Move to Tier 3 Interferon beta-1b Extavia Move to Tier 2 Dihydroergotamine mesylate nasal spray Migranal Move to Tier 3 Testosterone cypionate IM Depo-Testosterone Move to Tier 3 Bexarotene Targretin Ancillary charge Pegvisomant Somavert Limited to Kaiser Guselkumab Tremfya Add QL of 1 syringe per 56 days Brodalumab Siliq Add QL of 2 syringes per 28 days Empagliflozin/metformin ER Synjardy XR Add QL of 30 tablets 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/codein e; 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 days 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 Move to Tier 3 Tenofovir disoproxil fumarate Viread Move to Tier 3 Codeine/chlorpheniramine Tuzistra XR Add Dapagliflozin/saxagliptin Qtern Add QL of 30 tablets Upd 09/11/2018
3 Doxylamine/pyridoxine Diclegis Add Diclofenac Cambia; Zorvolex Add Dextromethorphan/quinidine Nuedexta Add Icatibant acetate Firazyr Limited to Kaiser Immune globulin Hizentra Limited to Kaiser Fluticasone propionate Flonase Move to Tier 3, add Beclomethasone dipropionate Beconase AQ; Qnasl Add Ciclesonide Omnaris; Zetonna Add Budesonide Rhinocort Aqua Add Mometasone furoate Nasonex Add Promethazine/codeine Phenergan with codeine Move to Tier 3; add Promethazine/phenylephrine/codeine Phenergan VC with codeine Move to Tier 3; add Enoxaparin sodium Lovenox Ancillary charge 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 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 01/01/ /13/2017 Scopolamine Transderm Scop Ancillary charge Upd 09/11/2018
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 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 ; add QL of 21 capsules per 180 days Methylpheni ER Cotempla Add QL of 30 tablets Amphetamine/dextroamphetamine Mydayis Add QL of 30 capsules per 30 days Fentanyl Actiq; Subsys; Abstral; Fentora; Lazanda Add Add QL of 4 dosing units per day Daclizumab Zinbryta Add QL of 1 syringe per 28 days Mometasone/formoterol Dulera Move to Tier 3 Ethacrynic acid Edecrin Add Ethacrynic acid Edecrin Move to Tier 3 Dupilumab Dupixent Add QL of 2 syringes (600mg) (exception for initial loading dose) Crisaborole Eucrisa Add QL of 120 grams Droxidopa Northera Limited to Kaiser Morphine sulfate ER Morphabond ER Add QL of 60 tablets 01/01/ /11/2017 Upd 09/11/2018
5 Morphine sulfate ER Arymo ER Add QL of 90 tablets Sacrosidase Sucraid Add Carisoprodol Soma Add QL of 45 tablets Chlorzoxazone Lorzone, Parafon Forte Add QL of 60 tablets Metaxalone Skelaxin, Metaxall Add QL of 60 tablets Orphenadrine Norflex Add QL of 30 tablets Methocarbamol Robaxin Add QL of 60 tablets Cyclobenzaprine Flexeril, Fexmid Add QL of 45 tablets Olorol Striverdi Add Quetiapine fumarate ER Seroquel XR Ancillary charge Melphalan Alkeran Move to Tier 3 Upd 09/11/2018
Future Formulary Changes
Future Formulary Changes Upd 11/21/2018 Applies to: Employer group plan 2018 2019 open formularies KEY: PA=prior authorization; ST=step therapy; QL=quantity limit Generic name Brand name Change Effective
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