Value Formulary: What s not covered and their alternatives. Non-formulary drug list as of July 1, 2018

Transcription

1 Value Formulary: What s not covered and their alternatives Non-formulary drug list as of July 1, 2018 The Value Formulary is a list of drugs that have been selected based on their clinical effectiveness, safety and value. It is a restricted formulary that does not cover certain drugs that offer no clear clinical advantage over less costly brand or generic alternatives that are covered. In the following chart, the column titled Non- Formulary Drug lists drugs that are not covered, and the column titled Formulary Alternative lists covered drug alternatives 1 that are available through the Value Formulary. To look up any drug on the Value Formulary, visit ibx.com/ffm/formulary5v. Please note that because prescription drug benefits vary by group, the inclusion of a drug as a Formulary Alternative does not imply coverage. Additionally, please call Customer Services at the number listed on the back of your ID card if you have any questions about your prescription drug benefits. This document is current as of the date prepared and is subject to change. Drugs listed are commonly prescribed; additional drugs may not be covered. New drugs are not immediately covered on the Value Formulary until they have been reviewed at which time they may or may not be covered. Please use the on line drug look-up to determine the current status of any drug. 1. Some of the formulary alternatives may be subject to quantity limits, age limits, or have prior authorization requirements.

2 Therapeutic Category Non-Formulary Drug Formulary Alternative All Categories Any brand drug that has a generic equivalent The generic equivalent of the non-formulary brand drug Antihistamines Antihistamines Ryvent carbinoxamine, clemastine, desloratadine, cyproheptadine Cough/Cold/Allergy Anti-Infectives Tuzistra XR, Tussicaps, Z-Tuss AC, Semprex-D, Clarinex-D, Obredon promethazine VC [codeine], promethazinecodeine, promethazine DM, hydrocodone polstcpm, hydrocodone-homatropine, pseudoephchlorphen-hydrocod solution Tetracyclines Acticlate, Solodyn, Doryx MPC, Oracea demeclocycline, doxycycline, minocycline, tetracycline Aminoglycosides Tobi Podhaler Bethkis nebulization solution, tobramycin nebulization solution Anti-Fungals Onmel, Vfend fluconazole, griseofulvin, itraconazole, ketoconazole, voriconazole Antineoplastics Anti-Inflammatory/Antirheumatic Rasuvo, Otrexup methotrexate tablets Autonomic Drugs Antiasthmatics & Bronchodilators Dulera Advair HFA, Symbicort, fluticasone-salmeterol Flovent, Flovent HFA, Armonair Respiclick, Pulmicort Flexhaler, Arnuity Ellipta, Aerospan Tudorza Ventolin HFA, Proventil HFA Asmanex [HFA], Qvar, budesonide ipratropium, ipratropium-albuterol, Seebri Neohaler, Sprivia [Handihaler/Respimat], Atrovent HFA, Combivent, Incruse Ellipta Proair, levalbuterol, albuterol Musculoskeletal Lorzone, Amrix, metaxalone methocarbamol, carisoprodol, carisoprodolaspirin, chlorzoxazone, cyclobenzaprine, tizanidine, orphenadrine ER, baclofen Neurological Namzaric memantine, donepezil, galantamine, rivastigmine Blood Formation, Coagulation, Thrombosis Endocrine & Metabolic Agents Stimate, Noctiva desmopressin Hematopoietic Agents Aranesp, Epogen Procrit Anticoagulants Fragmin enoxaparin Hematological Durlaza aspirin Cardiovascular Beta Blockers 2 Value Formulary non-formulary drug list as of July 1, 2018 Hemangeol, Innopran XL, Sotylize, Inderal XL, Dutoprol, Coreg CR acebutolol, atenolol, atenolol-chlorthalidone, betaxolol, bisoprolol, bisoprolol-hctz, carteolol, carvedilol [ER], labetalol, metoprolol, metoprolol-hctz, nadolol, nadololbendroflumethiazide, pindolol, propranolol [ER], sorine, sotalol, timolol Calcium Channel Blockers Cardizem LA afeditab CR, amlodipine, amlodipineatorvastatin, cartia XT, dilt-xr, diltiazem [ER/ CD], felodipine [ER], isradipine, nicardipine, nifedipine [ER], nifedical XL, nisoldipine ER, nimodipine, taztia XT, trandolapril-verapamil ER, verapamil [ER], verelan

3 Therapeutic Category Non-Formulary Drug Formulary Alternative Cardiovascular (continued) Ace Inhibitors (ACE-I) Qbrelis, Epaned benazepril, captopril, enalapril, lisinopril, fosinopril, moexipril, perindopril, quinapril, ramipril, trandolapril Angiotensin II Receptor Antagonists (ARB) Edarbyclor candesartan, candesartan-hctz, eprosartan, irbesartan, irbesartan-hctz, losartan, olmesartan, olmesartan-hctz, telmisartan, telmisartan-hctz, valsartan, valsartanhydrochlorothiazide Antihyperlipidemics Altoprev atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin Erectile Dysfunction Levitra, Staxyn, Stendra, Viagra Cialis, sildenafil Pulmonary Hypertension Revatio Adcirca, sildenafil Central Nervous System Antidepressants Fetzima, Khedezla, Forfivo XL desvenlafaxine [ER], duloxetine, venlafaxine [ER], mirtazapine, bupropion [SR/XL] Antipsychotics Fanapt, Vraylar aripiprazole, clozapine, olanzapine, olanzapinefluoxetine, paliperidone ER, quetiapine [ER], risperidone, ziprasidone Anticonvulsants, Misc. Equetro, Horizant, Gralise, Spritam, Briviact, Lyrica CR carbamazepine [ER], divalproex sodium DR/ER, Epitol, felbamate, gabapentin, lamotrigine [ER], levetiracetam [ER], oxcarbazepine, primidone, tiagabine, topiramate [ER], valproate, valproic acid, zonisamide, Lyrica, gabapentin Antiparkinson Agents Rytary, Xadago carbidopa-levodopa [ER], carbidopa-levodopaentacapone, rasagiline, selegiline Hypnotics/Sleep Agents Zolpimist, Belsomra, Edluar eszopiclone, zaleplon, zolpidem [ER] ADHD Weight Loss Agents * Please note that these drugs require a rider based on benefit Aptensio XR, Adzenys XR, Mydayis, Zenzedi, Dyanavel XR, Evekeo, Quillichew ER, Quillivant XR, Ritalin LA, Cotempla, Belviq [XR], Contrave, Adipex-P, Qsymia, Xenical, Evekeo, Saxenda amphetamine-dextroamphetamine [ER], dextroamphetamine [ER], methylphenidate [ER/ CD/LA], dexmethylphenidate [ER], Metadate ER phentermine, phendimetrazine [ER], diethylpropion [ER], benzphetamine Analgesics, Anti-Inflammatory, and Misc. Allzital, Vanatol S butalbital-acetaminophen, butalbital-apapcaffeine, butalbital-asa-caffeine Sprix, Naprelan, Tivorbex, Vivlodex, Zipsor, Zorvolex, Flector patch, Cambia, Pennsaid 2% Solution, naproxen CR/ ER diclofenac 1.5% solution celecoxib, ibuprofen, naproxen, meloxicam, diclofenac, ketorolac Migraine Agents Zomig Nasal Spray, Treximet, DHE 45 dihydroergotamine, almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, zolmatriptan Antidotes/Opioid Antagonist Evzio Auto-Injector Naloxone prefilled syringe injection, Narcan nasal spray Eye, Ear, Nose, & Throat (EENT) Ophthalmic Agents Rescula, Zioptan, Istalol, Vyzulta bimatoprost, latanoprost, brimonidine, apraclonidine Pazeo azelastine, epinastine, olopatadine, cromolyn Otic Agents Otovel neomycin-polymyxin-hc solution/suspension, ofloxacin, ciprofloxacin Nasal Agents Qnasl [Children s], Beconase AQ, Dymista, flunisolide, fluticasone, mometasone Value Formulary non-formulary drug list as of July 1,

4 Therapeutic Category Non-Formulary Drug Formulary Alternative Gastrointestinal Laxatives GoLytely, Clenpiq PEG 3350/electrolytes Proton Pump Inhibitors (PPIs) Dexilant, Aciphex Sprinkle capsule, omeprazolesodium bicarbonate packets omeprazole, pantoprazole, esomeprazole, lansoprazole, rabeprazole Antiemetics Zuplenz, Varubi trimethobenzamide, granisetron, ondansetron, aprepitant, scopolamine patch Digestive Aids Pancreaze, Pertzye Creon, Zenpep Gastrointestinal Agents, Misc. Relistor, Giazo, Amitiza, Apriso, Asacol HD balsalazide, mesalamine, sulfasalazine, Delzicol, Pentasa, Linzess, Movantik Hormones & Synthetic Substitutes Corticosteroids Rayos budesonide, cortisone, dexamethasone, hydrocortisone, methylprednisolone, prednisolone Androgens Androderm, Natesto danazol, methyltestosterone, testosterone, Androgel Estrogens Divigel estradiol Antidiabetics Afrezza, Basaglar, Fiasp, Humulin Lantus, Levemir, Toujeo, Tresiba, Novolin, Novolog, Humalog, Apidra, Admelog Fertility * Please note that these are considered specialty drugs and may require a rider based on benefit Soliqua, Tanzeum, Xultophy, Ozempic Jentadueto [XR], Xigduo XR, Tradjenta, Farxiga, Xigduo XR, Qtern, Steglatro, Steglujan, Segluromet Bravelle, Ovidrel, Menopur Bydureon, Trulicity, Victoza, Byetta aloglitpan, alogliptan-metformin, alogliptanpioglitazone, Janumet, Januvia, Kombiglyze, Onglyza, Glyxambi Pregnyl, Novarel Growth Hormones Genotropin, Humatrope, Zomacton, Zorbtive Norditropin, Nutropin AQ, Omnitrope Miscellaneous Therapeutic Agents Antigout Agent Mitigare, Colcrys colchicine, allopurinol Bone resorption inhibitor Binosto alendronate, etidronate, ibandronate, risedronate Multiple Sclerosis Agents Rebif [Rebidose], Extavia, Aubagio Avonex, Betaseron, Copaxone, glatiramer acetate, glatopa, Plegridy, Tecfidera, Gilenya Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association (07/18) Value Formulary non-formulary drug list as of July 1,

5 Language Assistance Services Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al (TTY: 711). Chinese: 注意 : 如果您讲中文, 您可以得到免费的语言协助服务 致电 Korean: 안내사항 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 번으로전화하십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para Gujarati: ચન : જ તમ જર ત બ લત હ, ત ન: ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલ ધ છ ક લ કર. Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Тел.: Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero Arabic: ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية متاحة لك بالمجان. اتصل برقم French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer Hindi: य न द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए उपल ध ह क ल कर German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie Japanese: 備考 : 母国語が日本語の方は 言語アシスタンスサービス ( 無料 ) をご利用いただけます へお電話ください Persian (Farsi): توجه: اگر فارسی صحبت می کنيد خدمات ترجمه به صورت رايگان برای شما فراھم می باشد. با شماره تماس بگيريد. Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti go Diné Bizaad, saad bee 1k1 1n7da 1wo d66, t 11 jiik eh. H0d77lnih koj Urdu: توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں تو آپ کے لئے مفت ميں زبان معاون خدمات دستياب ہيں کال کريں Mon-Khmer, Cambodian: ស ម ម ត ចប រមមណ របស ន ប អនកន យយភ មន- ខមរ ឬភ ខមរ ន ជ ន យ ផនកភ ន ងមនផ តល ជ នដល កអនក យឥត គ ត ថ ល ទ រសពទ ទ លខ Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016

6 Discrimination is Against the Law This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides: Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats). Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA 19103, By phone: (TTY: 711) By fax: , By civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016