Quarterly pharmacy formulary change notice
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- Christal Banks
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1 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, What this means to you Effective April 15, June 1, August 1 and September 1, 2016, formulary changes apply. Effective August 1, 2016, and September 1, 2016, nonformulary changes and prior authorization (PA) requirements will apply. This notice applies to HealthKeepers, Inc. benefits for members. Therapeutic class Drug Revised status NALOXONE PRODUCTS ANTHELMINTICS HEPATITIS C ORAL ATYPICAL ANTIPSYCHOTIC ORAL ATYPICAL ANTIPSYCHOTIC Effective for all patients on April 15, 2016 NALOXONE 0.4 MILLIGRAM (MG)/MILLILITER (ML) SYRINGE NALOXONE 2 MG/2 ML SYRINGE NALOXONE 0.4 MG/ML VIAL NALOXONE 4 MG/10 ML VIAL NARCAN 4 MG NASAL SPRAY Effective for all patients on June 1, 2016 IVERMECTIN 3 MG ALBENZA 200 MG BILTRICIDE 600 MG NOT APPLICABLE () ZEPATIER MG WITH PA PALIPERIDONE EXTENDED RELEASE (ER) 1.5 MG PALIPERIDONE ER 3 MG PALIPERIDONE ER 6 MG PALIPERIDONE ER 9 MG ARIPIPRAZOLE 2 MG ARIPIPRAZOLE 5 MG ARIPIRAZOLE 10 MG ARIPIRAZOLE 15 MG ARIPIRAZOLE 20 MG ARIPIRAZOLE 30 MG HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AVAPEC
2 DIABETIC SUPPLIES AND TEST STRIPS ANTI-FUNGAL SGLT2S ORAL ESTROGEN ORAL ESTROGEN ACNE GENERIC TOPICAL TRETINOINS ACNE GENERIC TOPICAL ANTI-INFECTIVES ACNE GENERIC TOPICAL ANTI-INFECTIVES TRUE METRIX TEST STRIPS Effective for all patients on August 1, 2016 Page 2 of 7 WITH QUANTITY LIMIT (QL) VORICONAZOLE VIAL VORICONAZOLE SUSPENSION VORICONAZOLE JARDIANCE 10 MG JARDIANCE 25 MG SYNJARDY MG SYNJARDY MG WITH STEP THERAPY (ST) SYNJARDY 5-1,000 MG MENEST 0.3 MG MENEST MG MENEST 1.25 MG MENEST 2.5 MG PREMARIN 0.3 MG PREMARIN MG PREMARIN 0.9 MG PREMARIN 1.25 MG PREMARIN 0.45 MG NON NON TRETINOIN GEL MICRO 0.1% TUBE TRETINOIN 0.05% EMOLLIENT CLINDAMYCIN PH 1% GEL ERYTHROMYCIN 2% NON ESTRADIOL 0.5 MG, 1 MG, 2 MG ESTROPIPATE (0.75 MG), 1.25 (1.5 MG) and 2.5 (3 MG) ESTRADIOL 0.5 MG, 1 MG, 2 MG ESTROPIPATE (0.75 MG), 1.25 (1.5 MG) and 2.5 (3 MG) CLINDAMYCIN PH 1% GEL ERYTHROMYCIN 2% PLEDGETS ERYTHROMYCIN 2% TRETINOIN 0.01% GEL TRETINOIN 0.025% GEL TRETINOIN 0.05% GEL TRETINOIN 0.025% TRETINOIN 0.05% TRETINOIN 0.1%
3 GENERIC LONG-ACTING NARCOTICS FOR TUBERCULOSIS (TB) WILSON S DISEASE DIABETIC SUPPLIES AND TEST STRIPS GENERIC AVINZA: MORPHINE SULFATE ER 30 SULE (CAP) MORPHINE SULFATE ER 45 MORPHINE SULFATE ER 60 MORPHINE SULFATE ER 75 MORPHINE SULFATE ER 90 MORPHINE SULFATE ER 120 GENERIC KADIAN: MORPHINE SULFATE ER 10 MORPHINE SULFATE ER 20 MORPHINE SULFATE ER 30 MORPHINE SULFATE ER 50 MORPHINE SULFATE ER 60 MORPHINE SULFATE ER 80 MORPHINE SULFATE ER 100 Page 3 of 7 NON CURRENT UTILIZERS WILL BE GRANDFATHERED PRIFTIN 150 MG DEPEN TITRATAB SYPRINE CAPSULES ALL OTHER DIABETIC TEST STRIPS MORPHINE SULFATE ER METHADONE METHADONE METHADOSE FENTANYL 25 MICROGRAM/HOUR (MCG/HR) PATCH FENTANYL 50 MCG/HR PATCH FENTANYL 75 MCG/HR PATCH FENTANYL 12 MCG/HR PATCH FENTANYL 100 MCG/HR PATCH NON WITH QL UNDER 18 YEARS OF AGE 200/MONTH AGE AND OLDER (NO INSULIN) 50/MONTH AGE AND OLDER (ON INSULIN) 150/MONTH
4 DIABETIC SUPPLIES AND TEST STRIPS LANCETS Page 4 of 7 UNDER 18 YEARS OF AGE 200/MONTH AGE AND OLDER (NO INSULIN) 100/MONTH AGE AND OLDER (ON INSULIN) 200/MONTH ANTIPSYCHOTICS VRAYLAR CAPSULE ADD PA AND QL ANTIPSYCHOTICS INVEGA SUSTENNA INJECTION (INJ) ADD PA AND QL INVEGA TRINZA INJ ANTIPSYCHOTICS ARISTADA PULMONARY ANTI-VIRAL PULMOZYME TYVASO UPTRAVI ZOVIRAX XERESE DENAVIR LIDOVIR SITAVIG BUCCAL ANTI-VIRAL VIRAZOLE VIAL BENIGN PROSTATIC AVODART ADD AGE LIMIT AND HYPERPLASIA (BPH) JALYN GENDER LIMIT THERAPY INTERLEUKINS ARCALYST INJ ILARIS VIAL ACTEMRA VIALS/SYRINGE RHEUMATOLOGICAL KINERET SYRINGE ORENCIA VIAL/SYRINGE HUMIRA PEN INJECTOR KIT RHEUMATOLOGICAL HUMIRA SYRINGE KIT GASTROINTESTINAL CARDIOVASCULAR CARDIOVASCULAR QUANTITY LIMIT REVISION CIMZIA VIAL RANEXA ER AGGRENOX
5 FOR ACTINIC KERATOSIS FLUOROQUINOLONE OTIC CARAC EFUDEX FLUOROPLEX PICATO ZYCLARA CETRAXAL 0.2% EAR CIPRO HC OTIC SUSPENSION APLENZIN ER FORFIVO XL ZONTIVITY DURLAZA ER Page 5 of 7 ANTIDEPRESSANTS ANTI-PLATELET DRUGS ANTI-PLATELET DRUGS BRILINT PULMONARY DALIRESP UTIBRON NEOHALER PULMONARY SEEBRI NEOHALER QL ADDED ALZHEIMER S THERAPY NAMZARIC RESTASIS EYE EMULSION OPHTHALMOLOGICS ORFADIN STRENSIQ XURIDEN GRANULE HEPATITIS B TYZEKA TREATMENT NEUROLOGICAL HORIZANT ER THERAPY NSAIDS ANTI-NEOPLASTIC DRUGS TREATMENT (TX) FOR ADHD/NARCOLEPSY TOPICAL CORTICOSTEROIDS ANTI-PSORIATIC/ ANTI-SEBORRHEIC DUEXIS VIMOVO COTELLIC TAGRISSO NINLARO ALECENSA QUILLICHEW DYANAVEL SUSP DERMACIN RX SILAZONE PA REQURED STELARA COSENTYX QL REVISION ANTI-CONVULSANTS SPRITAM
6 Page 6 of 7 Therapeutic class Drug Revised status ORAL ALED () CORTICOSTERIODS ORAL ALED CORTICOSTERIODS ORAL ALED CORTICOSTERIOIDS COMBINATION Effective for all patients on September 1, 2016 ARNUITY ELLIPTA 100 MCG ARNUITY ELLIPTA 200 MCG ASMANEX TWISTHALER 110 MCG ASMANEX TWISTHALER 220 MCG ASMANEX HFA 100 MCG ASMANEX HFA 200 MCG PULMICORT 180 MCG FLEXHALER PULMICORT 90 MCG NON FLEXHALER FLOVENT HFA 110 MCG FLOVENT HFA 44 MCG FLOVENT HFA 220 MCG FLOVENT 50 MCG DISKUS FLOVENT 100 MCG DISKUS FLOVENT 250 MCG DISKUS QVAR 40 MCG ORAL QVAR 80 MCG ORAL BREO ELLIPTA MCG BREO ELLIPTA MCG ARNUITY ELLIPTA AEROSPAN ORAL ALED CORTICOSTERIOIDS COMBINATION SYMBICORT MCG SYMBICORT MCG NON BREO ELLIPTA DULEREA What action do I need to take? Please review these changes and work with your 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.
7 Page 7 of 7 What if I need assistance? We recognize the unique aspects of patients cases. If your patient cannot be converted to a formulary alternative, call our Pharmacy department at 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
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