Quarterly pharmacy formulary change notice

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1 Provider Bulletin October 2018 Quarterly pharmacy formulary change notice The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. The changes listed in the table below marked with an * also apply to all Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) patients. These changes were reviewed and approved at the second quarter Pharmacy and Therapeutics Committee meeting. Effective October 1, 2018, formulary changes, nonformulary changes and prior authorization requirements will apply. Therapeutic class DIABETIC SUPPLIES* DIABETIC SUPPLIES* HIV THERAPY * PROTON PUMP INHIBITORS (PPI) Effective for all Anthem HealthKeepers Plus patients on October 1, 2018 Medication BD PEN NEEDLES BD INSULIN SYRINGES ALL OTHER PEN NEEDLES AND INSULIN SYRINGES/MANUFACTURERS CIMDUO MG TABLET SYMFI MG TABLET TROGARZO 200 MG/1.33 ML VIAL BRAND PRILOSEC OTC 20 MG TABLET BRAND PRILOSEC OTC 20.6 MG TABLET BRAND OTC NEXIUM 24HR 20 MG CAPSULE EDITS Formulary status change NON- WITH STEP THERAPY (ST) COVERED Potential alternatives (preferred products) BD PEN NEEDLES BD INSULIN SYRINGES NO CHANGES IN /NON- STATUS REVISION OR ADDITION TO UM EDIT ONLY ADHD AGENTS METHYLPHENIDATE ER 72 MG TAB ADD QUANTITY LIMIT (QL) FRAGMIN 2,500 UNITS/0.2 ML SYR FRAGMIN 5,000 UNITS/0.2 ML SYR FRAGMIN 7,500 UNITS/0.3 ML SYR FRAGMIN 10,000 UNITS/ML SYR 6 ML (30 SYRINGES) PER 30 9 ML (30 SYRINGES) PER ML (30 SYRINGES) PER 30 HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Commonwealth Coordinated Care Plus (CCC Plus) benefits to enrollees. AVAPEC September 2018

2 Page 2 of 5 ANTIHYPERTENSIVES DRUGS* ANTIPARASITICS* ANTIPARASITICS* APPETITE STIMULATOR ASTHMA BOWEL PREP FRAGMIN 12,500 UNITS/0.5 ML FRAGMIN 15,000 UNITS/0.6 ML FRAGMIN 18,000 UNITS/0.72 ML FRAGMIN 25,000 UNITS/3.8 ML VL TEKTURNA 37.5MG ORAL PELLETS IMBRUVICA 140 MG CAPSULE IMBRUVICA 70 MG CAPSULE IMBRUVICA 140 MG TABLET ALBENZA 200 MG TABLET IMPAVIDO 50 MG CAPSULE MEGESTROL TABLET MEGESTROL ORAL SUSP BREO ELLIPTA MCG INH BREO ELLIPTA MCG INH FLUTICASONE-SALMETEROL FLUTICASONE-SALMETEROL FLUTICASONE-SALMETEROL DULERA 100 MCG/5 MCG INHALER DULERA 200 MCG/5 MCG INHALER AIRDUO RESPICLICK MCG AIRDUO RESPICLICK MCG AIRDUO RESPICLICK MCG ADVAIR DISKUS ADVAIR DISKUS ADVAIR DISKUS ADVAIR HFA MCG INHALER ADVAIR HFA MCG INHALER ADVAIR HFA MCG INHALER SYMBICORT MCG INHALER SYMBICORT MCG INHALER CLENPIQ SOLUTION BEXAROTENE 75 MG CAPSULE CABOMETYX 20 MG TABLET ZYKADIA 150 MG CAPSULE 15 ML (30 SYRINGES) PER ML (30 SYRINGES) PER 30 22ML (30 SYRINGES) PER ML (6 VIALS) PER 30 8 PELLETS PER DAY 4 CAPSULE PER DAY 84 CAPSULES PER FILL 1 FILL EVERY 30 PA REQUIRED REMOVING REQUIREMENT FOR ICS BEFORE ICS/LABA STEP THERAPY EFFECTIVE DATE STEP THERAPY FOR T/F OF ICS/LABA STILL REQUIRED 320 MLS PER CAPSULES PER DAY 3 CAPSULES PER DAY

3 CML* DERMATOLOGICAL AGENTS EPINEPHRINE AGENTS GLUCOSE ELEVATING PRESSURE PRESSURE PRESSURE AGENTS PRESSURE AGENTS TASIGNA 50 MG CAPSULE QUINJA 1.25%-1% GEL AUVI-Q 0.1 MG AUTO-INJECTOR GLUCAGEN 1 MG EMERGENCY KIT ULORIC 40 MG TABLET ULORIC 80 MG TABLET ZURAMPIC 200 MG TABLET KRYSTEXXA 8 MG/ML VIAL DEMSER 250 MG CAPSULE DIBENZYLINE 10 MG CAPSULE KAPSPARGO SPRINKLE PREXXARTAN Anthem HealthKeepers Plus Page 3 of 5 4 CAPSULES PER DAY 60 GMS PER 30 1 BOX (2 PENS) PER FILL 2 KITS IN 30 2 VIALS (2ML) PER CAPSULES PER DAY 12 CAPSULES PER DAY 1 CAPSULE PER DAY 80 MLS PER DAY IBD STEROIDS UCERIS 2 MG RECTAL FOAM INTRANASAL STEROIDS MENOPAUSAL THERAPIES* MIGRAINE* AZOPT 1% EYE DROPS BETIMOL 0.25% EYE DROPS BETIMOL 0.5% EYE DROPS RHOPRESSA 0.02% OPHTH SOLUTION TIMOPTIC-XE 0.25% AND 0.5% EYE GEL-SOLN TIMOPTIC OCUMETER PLUS 0.25% AND 0.5 %GEL FORMING SOLN TIMOPTIC 0.25% AND 0.5% OCUDOSE DROP TIMOPTIC OCUMETER PLUS 0.25% AND 0.5% SOLN VYZULTA 0.024% OPHTH SOLUTION XHANCE 93 MCG NASAL SPRAY IMVEXXY 10 MCG VAGINAL INSERT IMVEXXY 4 MCG VAGINAL INSERT AIMOVIG 70 MG DOSE-2 AUTOINJ 15 MLS PER MLS PER 30 1 BOTTLE PER 30 5 MLS PER MLS PER 30 1 BOTTLE PER 30 2 INHALERS PER VAGINAL INSERTS PER 28 1 AUTOINJECTOR/1 PACK PER 30

4 Page 4 of 5 MIGRAINE* GASTROINTESTINAL HEPATITIS B INTERFERON ANTIVIRAL THERAPY HEPATITIS B INTERFERON ANTIVIRAL THERAPY NEUROPATHIC PAIN AND FIBROMYALGIA NON-NARCOTIC ANALGESIC* NSAIDS PHOSPHATE BINDERS PRENATAL VITAMINS* PROGESTINS PROSTATE CANCER* PROSTATE CANCER* ANTIBACTERIALS ANTI- INFECTIVES* CORTICOSTEROIDS LOW POTENCY CORTICOSTEROIDS- VERY HIGH POTENCY AIMOVIG 140 MG DOSE-2 AUTOINJ SAMSCA 15 MG TABLET SAMSCA 30 MG TABLET RECTIV 0.4% OINTMENT PEGASYS (PEGINTERFERON ALFA 2A) INTRON A (INTERFERON ALFA 2B)* ZTLIDO FIORINAL MG CAPSULE BUTALBITAL-ASA-CAFFEINE CAP BUTALB-ASPIRIN-CAFFE CONSENSI CALCIUM ACETATE 668 MG TABLET NESTABS ONE SOFTGEL MAKENA 275 MG/1.1 ML AUTOINJCT ERLEADA 60 MG TABLET YONSA 125 MG TABLET ALTABAX 1% OINTMENT XEPI SYNALAR 0.025% OINTMENT KIT IMPOYZ 0.025% CREAM 2 AUTOINJECTORS/1 PACK PER 30 2 TABLETS PER DAY 30GM TUBE EVERY 30 REMOVE PA REQUIREMENTS REMOVE PA REQUIREMENTS 3 PATCHES PER DAY 6 TABLETS PER DAY 12 TABLETS PER DAY 4 AUTOINJECTORS PER 28 30GM PER FILL 1 FILL PER GMS PER FILL 1 FILL PER 30 1 KIT PER GM PER 30

5 Page 5 of 5 What action do I need to take? Please review these changes and work with your Anthem HealthKeepers Plus patients to transition them to formulary alternatives. If you determine formulary alternatives are not clinically appropriate for specific patients, you will need to obtain prior authorization to continue coverage beyond the applicable effective date. What if I need assistance? We recognize the unique aspects of patients cases. If your Anthem HealthKeepers Plus patient cannot be converted to a formulary alternative, call our Pharmacy department at (Anthem CCC Plus patients should call ) and follow the voice prompts for pharmacy prior authorization. You can find the Preferred Drug List (formulary) on our provider website at If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at (for Anthem CCC Plus assistance call ).

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