Quarterly pharmacy formulary change notice
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1 Quarterly pharmacy formulary change notice Summary of change: The Pharmacy and Therapeutics Committee (P&T) reviewed and approved the formulary changes listed in the table below on March 29, What this means to you: The changes outlined below apply to all Amerigroup patients effective April 15, June 1, August 1 and October 1, 2016, respectively. What is the impact of this change? Therapeutic class Drug Revised status NALOXONE PRODUCTS DIABETIC SUPPLIES AND TEST STRIPS ANTHELMINTICS ORAL ATYPICAL ANTI-PSYCHOTIC ORAL ATYPICAL ANTI-PSYCHOTIC HEPATITIS C 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 TRUE METRIX TEST STRIPS IVERMECTIN 3 MG TABLET ALBENZA 200 MG TABLET BILTRICIDE 600 MG TAB PALIPERIDONE (EXTENDED RELEASE) ER 1.5 MG TABLET PALIPERIDONE ER 3 MG TABLET PALIPERIDONE ER 6 MG TABLET PALIPERIDONE ER 9 MG TABLET ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE 5 MG TABLET ARIPIRAZOLE 10 MG TABLET ARIPIRAZOLE 15 MG TABLET ARIPIRAZOLE 20 MG TABLET ARIPIRAZOLE 30 MG TABLET ZEPATIER MG TABLET WITH QUANTITY LIMIT (QL) WITH PRIOR AUTHORIZATION (PA) REQUIRED NOT APPLICABLE () FLPEC June 2016
2 ANTI-FUNGAL SGLT2S ORAL ESTROGEN ORAL ESTROGEN ACNE GENERIC TOPICAL TRETINOINS ACNE GENERIC TOPICAL ANTI-INFECTIVES ACNE GENERIC TOPICAL ANTI-INFECTIVES Effective for all patients on August 1, 2016 VORICONAZOLE VIAL VORICONAZOLE SUSPENSION VORICONAZOLE TABLET JARDIANCE 10 MG TABLET JARDIANCE 25 MG TABLET SYNJARDY MG TABLET SYNJARDY MG TABLET SYNJARDY 5-1,000 MG TABLET MENEST 0.3 MG TABLET MENEST MG TABLET MENEST 1.25 MG TABLET MENEST 2.5 MG TABLET PREMARIN 0.3 MG TABLET PREMARIN MG TABLET PREMARIN 0.9 MG TABLET PREMARIN 1.25 MG TABLET PREMARIN 0.45 MG TABLET TRETINOIN GEL MICRO 0.1% TUBE TRETINOIN 0.05% EMOLLIENT WITH STEP THERAPY (ST) REQUIRED NON NON ESTRADIOL 0.5 MG, 1 MG, 2 MG TABLET ESTROPIPATE (0.75 MG), 1.25 (1.5 MG) and 2.5 (3 MG) TABLET ESTRADIOL 0.5 MG, 1 MG, 2 MG TABLET ESTROPIPATE (0.75 MG), 1.25 (1.5MG) and 2.5 (3MG) TABLET CLINDAMYCIN PH 1% GEL ERYTHROMYCIN 2% SOLUTION NON ACNE THERAPY ADAPALENE CLINDAMYCIN PH 1% GEL ERYTHROMYCIN 2% PLEDGETS ERYTHROMYCIN 2% SOLUTION TRETINOIN 0.01% GEL TRETINOIN 0.025% GEL TRETINOIN 0.05% GEL TRETINOIN 0.025% TRETINOIN 0.05% TRETINOIN 0.1% Page 2 of 6
3 GENERIC LONG- ACTING NARCOTICS FOR TUBERCULOSIS (TB) WILSON S DISEASE DIABETIC SUPPLIES AND TEST STRIPS DIABETIC SUPPLIES AND TEST STRIPS GENERIC AVINZA: MORPHINE SULFATE ER 30 MG MORPHINE SULFATE ER 45 MG MORPHINE SULFATE ER 60 MG MORPHINE SULFATE ER 75 MG MORPHINE SULFATE ER 90 MG MORPHINE SULFATE ER 120 MG GENERIC KADIAN: MORPHINE SULFATE ER 10 MG MORPHINE SULFATE ER 20 MG MORPHINE SULFATE ER 30 MG MORPHINE SULFATE ER 50 MG MORPHINE SULFATE ER 60 MG MORPHINE SULFATE ER 80 MG MORPHINE SULFATE ER 100 MG NON CURRENT UTILIZERS WILL BE GRANDFATHERED PRIFTIN 150 MG TABLET DEPEN TITRATAB SYPRINE SULES ALL OTHER DIABETIC TEST STRIPS LANCETS NON WITH QL < 18 YEARS OF AGE 200/MONTH AGE AND OLDER (NO INSULIN) 50/MONTH AGE AND OLDER (ON INSULIN) 150/MONTH < 18 YEARS OF AGE 200/MONTH AGE AND OLDER (NO INSULIN) 100/MONTH AGE AND OLDER (ON INSULIN) 200/MONTH MORPHINE SULFATE ER TABLET METHADONE SOLUTION METHADONE TABLET METHADOSE FENTANYL 25 MICROGRAM/HOUR (MCG/HR) PATCH FENTANYL 50 FENTANYL 75 FENTANYL 12 FENTANYL 100 Page 3 of 6
4 ANTI-PSYCHOTICS VRAYLAR SULE ANTI-PSYCHOTICS INVEGA SUSTENNA INJ INVEGA TRINZA INJ ADD PA AND QL ANTI-PSYCHOTICS ARISTADA PULMONARY PULMOZYME TYVASO UPTRAVI ANTI-VIRAL ZOVIRAX XERESE DENAVIR SITAVIG BUCCAL TABLET ANTI-VIRAL VIRAZOLE VIAL BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY INTERLEUKINS RHEUMATOLOGICAL RHEUMATOLOGICAL GASTROINTESTINAL CARDIOVASCULAR CARDIOVASCULAR FOR ACTINIC KERATOSIS FLUOROQUINOLONE OTIC ANTIDEPRESSANTS ANTI-PLATELET DRUGS ANTI-PLATELET DRUGS PULMONARY AVODART JALYN ARCALYST INJECTION (INJ) ILARIS VIAL ACTEMRA VIALS/SYRINGE KINERET SYRINGE ORENCIA VIAL/SYRINGE HUMIRA PEN INJECTOR KIT HUMIRA SYRINGE KIT ADD AGE LIMIT AND GENDER LIMIT QUANTITY LIMIT REVISION CIMZIA VIAL RANEXA ER AGGRENOX CARAC EFUDEX FLUOROPLEX PICATO ZYCLARA CETRAXAL 0.2% EAR SOLUTION CIPRO HC OTIC SUSPENSION APLENZIN ER FORFIVO XL ZONTIVITY DURLAZA ER BRILINTA DALIRESP Page 4 of 6
5 PULMONARY ALZHEIMER S THERAPY OPHTHALMOLOGICS HEPATITIS B TREATMENT NEUROLOGICAL THERAPY NSAIDS ANTI-NEOPLASTIC DRUGS TREATMENT (TX) FOR ADHD/NARCOLEPSY TOPICAL CORTICOSTEROIDS ANTI-PSORIATIC/ ANTI-SEBORRHEIC UTIBRON NEOHALER SEEBRI NEOHALER QL ADDED NAMZARIC RESTASIS EYE EMULSION ORFADIN STRENSIQ XURIDEN GRANULE TYZEKA HORIZANT ER DUEXIS VIMOVO COTELLIC TAGRISSO NINLARO ALECENSA QUILLICHEW DYANAVEL SUSP DERMACIN RX SILAZONE STELARA COSENTYX QL REVISION ANTI-CONVULSANTS SPRITAM Effective for all patients on October 1, 2016 ORAL INHALED (INH) CORTICOSTERIODS ARNUITY ELLIPTA 100 MCG INH ARNUITY ELLIPTA 200 MCG INH ORAL INHALED CORTICOSTERIODS ASMANEX TWISTHALER 110 MCG ASMANEX TWISTHALER 220 MCG ASMANEX HFA 100 MCG INHALER ASMANEX HFA 200 MCG INHALER PULMICORT 180 MCG FLEXHALER PULMICORT 90 MCG FLEXHALER FLOVENT HFA 110 MCG INHALER FLOVENT HFA 44 MCG INHALER FLOVENT HFA 220 MCG INHALER FLOVENT 50 MCG DISKUS FLOVENT 100 MCG DISKUS FLOVENT 250 MCG DISKUS QVAR 40 MCG ORAL INHALER QVAR 80 MCG ORAL INHALER NON AERSOSPAN ARNUITY ELLIPTA Page 5 of 6
6 ORAL INHALED CORTICOSTERIOIDS COMBINATION ORAL INHALED CORTICOSTERIOIDS COMBINATION BREO ELLIPTA MCG INH BREO ELLIPTA MCG INH ADVAIR DISKUS ADVAIR DISKUS ADVAIR DISKUS ADVAIR HFA MCG INHALER ADVAIR HFA MCG INHALER ADVAIR HFA MCG INHALER SYMBICORT MCG INHALER SYMBICORT MCG INHALER NON BREO ELLIPTA DULERA What action do I need to take? Please review these changes and work with your Amerigroup patients to transition them to formulary. If you determine preferred formulary 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 for medical reasons your Amerigroup 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 on our provider website at If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at Page 6 of 6
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IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT MAY 29, 2012
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Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
A Visual Approach to Simplifying Respiratory Drug Regimens
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TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Buckeye Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
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THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
ELEVATE. Formulary Updates to Elevate Plans (Bronze HDHP/Standard, Silver Select/Standard & Gold Select/Standard)
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TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Fasenra) Reference Number: CP.PHAR.## Effective Date: 01.16.18 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy
Quarterly pharmacy formulary change notice
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Quarterly pharmacy formulary change notice
Provider update This is an update about information in the provider manual. For access to the latest provider manual, go online to https://providers.amerigroup.com/ga. Quarterly pharmacy formulary change
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SelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA
Quarterly pharmacy formulary change notice
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Quarterly pharmacy formulary change notice
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These formulary changes,
Inhaled bronchodilators relax constricted airways and treat the noisy part of asthma: coughing, wheezing, choking and shortness of breath.
Inhaled bronchodilators relax constricted airways and treat the noisy part of asthma: coughing, wheezing, choking and shortness of breath. AccuNeb inhalation 0.021% solution: 0.63mg/3mL 3-4 times solution
These programs and quantity limitations may not apply. Check your certificate or other plan information for benefit details.
FlexRx Standard Utilization Management (PA, QL,) Updates January 1, 2018 How to use this drug list This drug list includes updates to Utilization Management (UM) programs. UM may include a prior authorization
2016 Step Therapy (ST) Criteria
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