Quarterly Pharmacy Formulary Change Notice
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1 Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our December 18, 2014 Value Assessment Committee (VAC) meeting. What this means to you: Effective April 1, 2015 the changes outlined below apply to all Amerigroup patients. What is the impact of this change? Effective for all patients on April 1, 2015 Therapeutic Class Medication Formulary Status Change Alternatives ANTIEMETICS ANTI-DIABETIC AGENTS ALOXI PALONOSETRON INVOKAMET XIGDUO XR JARDIANCE REQUIRES PRIOR AUTHORIZATION (PA) ADD STEP THERAPY (ST) AND QUANTITY LIMIT () N/A TRULICITY BYETTA OR VICTOZA ANTI-INFECTIVES ACTICLATE ST GENERIC IR MINOCYCLINE OR DOXYCYCLINE MONOHYDRATE (CAPSULES) ANTIEMETICS ANTI-DIABETIC AGENTS ALOXI PALONOSETRON INVOKAMET REQUIRES PRIOR AUTHORIZATION (PA) ADD STEP THERAPY (ST) AND QUANTITY LIMIT () N/A 1
2 XIGDUO XR JARDIANCE TRULICITY BYETTA OR VICTOZA GENERIC IR MINOCYCLINE OR DOXYCYCLINE MONOHYDRATE (CAPSULES) ANTI-INFECTIVES ACTICLATE ST ATOVAQUONE 750MG/5ML SUSP CEFDINIR CAPSULES AND SUSPENSION CIPROFLOXACIN ER TABS CIPROFLOXACIN ORAL SUSPUSPENSION NON- WITH PA ALL CURRENT UTILIZERS TO BE GRANDFATHERED N/A FACTIVE NOROXIN XIFAXAN XYREM QUININE SULFATE PA AND N/A ANTINEOPLASTICS THALOMID NON- WITH PA N/A REVLIMID NON- WITH PA N/A OFEV ONCAPSAR PA N/A 2
3 ERWINAZE PA N/A KEYTRUDA PA N/A ONCASPSAR PA N/A ERWINAZE PA N/A TAXOTERE (DOCETAXEL) PRIOR AUTHORIZATION PA N/A ALIMTA (PEMETREXED) PRIOR AUTHORIZATION PA N/A VELCADE (BORTEZOMIB) PRIOR AUTHORIZATION PA N/A ANTIVIRAL COMBINATIONS TRIUMEQ CENTRAL NERVOUS SYSTEM AGENTS AKYNZEO TARGINIQ CONTRACEPTIVES ELECTROLYTES BELSOMRA ALL- ORAL, INJECTABLE AND TOPICAL CERALYTE 50 LIQ/PEDIALYTE AGE LIMIT (AL) IMMUNOLOGIC AGENTS ESBRIET METABOLIC AGENTS FABRAZYME REMOVED METABOLIC AGENTS CERDELGA PA N/A MISC COAGULATION MODIFIERS FACTOR VIIA RECOMBINANT PA N/A 3
4 COAGULATION AGENTS- NOVOSEVEN RT FACTOR (FACTOR VIII) HUMAN PLASMA-DERIVED AGENTS-HEMOFIL M, KOĀTE-DVI, MONOCLATE-P PA N/A FACTOR (FACTOR VIII) RECOMBINANT AGENTS-ADVATE, HELIXATE FS, KOGENATE FS, NOVOEIGHT, RECOMBINATE, XYNTHA PA N/A FACTOR (RECOMBINANT), PORCINE SEQUENCE AGENTS -OBIZUR PA N/A FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX AGENTS- ALPHANATE, HUMATE-P, WILATE PA N/A COAGULATION FACTOR IX ALPHANINE SD, MONONINE PA N/A FACTOR IX COMPLEX, BEBULIN, PA N/A 4
5 PROFILNINE SD FACTOR XIII AGENTS- CORIFACT, TRETTEN PA N/A FIBRINOGEN CONCENTRATE RIASTAP PA N/A FIBRINOGEN CONCENTRATE RIASTAP PA N/A ELOCTATE [RECOMBINANT FACTOR, FC FUSION PROTEIN (RFVIIIFC) PA N/A FACTOR IX RECOMBINANT AGENTS-BENEFIX, RIXUBIS PA N/A NEUROLOGICAL AGENTS RILUTEK PA N/A OPHTHALMIC OVERACTIVE BLADDER AGENTS NAPHAZOLINE SOL 0.1% TRAVATAN DROPS 0.004% TOLTERODINE TARTRATE TOLTERODINE TARTRATE ER TROSPIUM CHLORIDE TROSPIUM CHLORIDE ER RESPIRATORY AGENT SPIRIVA RESPIMAT WITH 5
6 STRIVERDI RESPIMAT INCRUSE ELLIPTA ARNUITY ELLIPTA AEROSPAN 80MCG INHALER SELECT ANDROGEN AGENTS VOGELXO PA AND N/A TESTOSTERONE GEL/PUMP PA AND N/A TOPICAL ANTIFUNGALS JUBLIA PA AND KERYDIN 5% PA AND ORAL ITRACONAZOLE AND TERBINAFINE ORAL ITRACONAZOLE AND TERBINAFINE What action do I need to take? Please review these changes and work with your Amerigroup patients to transition them to formulary alternatives. If you determine preferred 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 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 site. If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at In Louisiana, Amerigroup Louisiana, Inc.; In Washington, Amerigroup Washington. PEC-ALL Issued April 2015 by Amerigroup Pharmacy dept. 6
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