Effective for all members on November 1, 2017

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1 November 2017 Pharmacy Formulary Change Notice BlueChoice HealthPlan Medicaid is here to help you stay on top of your health care. We want to tell you about some upcoming changes to your Preferred Drug List (PDL) as of November 1, Your PDL is a list of preferred drugs covered by BlueChoice HealthPlan Medicaid. A group of doctors and pharmacists check the PDL to make sure the drugs you re taking are safe and effective. Medication DEXMETHYLPHENIDATE ER CAPS CLONIDINE HCL ER 0.1 MG LET XIIDRA 5% EYE DROPS AZOPT 1% EYE DROPS REYATAZ 50 MG POWDER PACKET VIREAD POWDER RETROVIR 200 MG/20 ML VIAL VIDEX 2 GM PEDIATRIC SOLN VIDEX 4 GM PEDIATRIC SOLN TYBOST 150 MG LET INGREZZA 40 MG CAPSULE MYCOPHENOLIC ACID DR 180 MG MYCOPHENOLIC ACID DR 360 MG ISOXSUPRINE 10 MG LET ISOXSUPRINE 20 MG LET SYPRINE 250 MG CAPSULE DEPEN 250 MG TITRA Effective for all members on November 1, 2017 WITH PA NON- ADD PA AND QL* 2 CAPS PER DAY NON- WITH PA GENERIC STIMULANT MEDICATIONS (I.E., METHYLPHENIDATE, DEXTROAMPHETAMINE /AMPHETAMINE, DEXTROAMPHETAMINE) NATURAL TEARS DORZOLAMIDE OPHTHALMIC SOLUTION BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections. WEBMBSC /17

2 CUPRIMINE 250 MG CAPSULE SOMAVERT 15 MG VIAL BELVIQ XR 20 MG LET LOMAIRA 8 MG LET SUPRAX 500 MG/5 ML SUSPENSION ACETASOL HC CETRAXAL 0.2% EAR SOLUTION CIPROFLOXACIN 0.2% OTIC SOLN CIPRO HC OTIC SUSPENSION CIPRODEX OTIC SUSPENSION OTOVEL 0.3%-0.025% EAR DROPS ENOXAPARIN SODIUM FONDAPARINUX SODIUM FRAGMIN KARBINAL ER 4 MG/ 5 ML SUSP RYVENT 6 MG LET RYDAPT 25 MG CAPSULE KISQALI ZEJULA ALUNBRIG 30MG ALUNBRIG 90MG XERMELO GOLYTELY PACKET COLYTE WITH FLAVOR PACKETS GAVILYTE-C SOLUTION GAVILYTE-G SOLUTION GAVILYTE-N SOLUTION NULYTELY WITH FLAVOR PACKS SOL TRYLYTE NON- WITH PA 1 VIAL PER DAY 40ML PER FILL 1 FILL PER 30 DAYS REVISE QL* 10ML PER 30 DAYS 28 DOSES PER 30 DAYS 10ML PER 30 DAYS REVISE QL* 7.5ML PER 30 DAYS 28 VIALS PER 30 DAYS REMOVE PA* 40ML PER DAY 4 S PER DAY 8 CAPS PER DAY 6 S PER DAY 3 S PER DAY 4000 MLS PER 30 DAYS

3 PREPOPIK POWDER PACKET SUPREP BOWEL PREP KIT CEFTRIAXONE 250 MG VIAL CEFTRIAXONE 500 MG VIAL CEFTRIAXONE 1 GM VIAL CEFTRIAXONE 2 GM VIAL CEFTRIAXONE 10 GM VIAL CEFTRIAXONE 1 GM VIAL 32 S PER 30 DAYS 1 KIT PER 30 DAYS 1 INJ PER FILL 1 FILL PER 30 DAYS ORKAMBI 125MG/100MG 4 PER DAY QTERN VIBERZI VEMLIDY 25 MG LET DUTOPROL LET METOPROLOL TARTRATE 100 MG 4 S PER DAY METOPROLOL TARTRATE 50 MG VERAPAMIL 40 MG LET 4 LETS PER DAY UCERIS 2 MG RECTAL FOAM 2 KITS PER 28 DAYS NORTHERA 100 MG CAPSULE 3 S PER DAY NORTHERA 200 MG CAPSULE 6 S PER DAY NOCTIVA 1 BOTTLE PER 30 DAYS KOSHER PRENATAL PLUS IRON OBSTETRIX ONE SOFTGEL 1 CAP PER DAY PRENATAL PLUS-DHA COMBO PACK PRIMACARE SOFTGEL 1 CAP PER DAY

4 TRICARE PRENATAL CHEWABLE TRICARE PRENATAL WITH DHA PACK VITAFOL GUMMIES VITATRUE COMBO PACK PRENA1 TRUE COMBO PACK ADCIRCA 20 MG LET LETAIRIS 5 MG LET LETAIRIS 10 MG LET REVATIO 10 MG/12.5 ML VIAL REVATIO 20 MG LET REVATIO 10 MG/ML ORAL SUSP CRANBERRY 400 MG LET CRANBERRY 400MG CAPSULE CRANBERRY 500 MG CAPSULE CICLOPIROX 8% SOLUTION CICLODAN 8% SOLUTION PENLAC 8% SOLUTION NUCORT LOTION What does this mean for you? 1 CHEW PER DAY 3 VIALS PER DAY ALL QL* 3 S PER DAY 6ML PER DAY 4 PER DAY 7ML PER 30 DAYS 60GM PER 30 DAYS Some medications you take may no longer be preferred. You ll need approval from us to continue to get these medications. What should I do if I use a nonpreferred drug? Talk with your doctor to see if you can change to the new preferred drug. If your doctor says you can take the new preferred drug, ask him or her to write a new prescription for you. You and your doctor have the final say in your care.

5 Things to remember: This doesn t change which pharmacy you go to or where you get your care. If your doctor writes a prescription for or says you need to keep using a nonpreferred drug, he or she will need to get approval from BlueChoice HealthPlan Medicaid first by calling (TTY ). Your health is important to us that s why we have our experienced team of doctors and pharmacists regularly review this list to keep you safe and healthy. Questions? Call us at the Customer Care Center at (TTY ) Monday through Friday from 8 a.m. to 6 p.m. Do you need help with your health care, talking with us, or reading what we send you? We provide our materials in other languages and formats at no cost to you. Call us toll free at (TTY ). Necesita ayuda con su cuidado de la salud, para hablar con nosotros o leer lo que le enviamos? Proporcionamos nuestros materiales en otros idiomas y formatos sin costo alguno para usted. Llámenos a la línea gratuita al (TTY ). هل تحتاج إلى مساعدة في رعايتك الصحية أو في التحد معنا أو قراءة ما نقوم بإرساله إليك نحن نقدم المواد الخاصة بنا بلغات وتنسيقات أخرى بدون تكلفة عليك. اتصل بنا على الرقم المجاني (TTY.9634)

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