Quarterly Pharmacy Formulary Change Notice
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1 MEDICAID PROVIDER BULLETIN February 26, 2015 Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our September 24, 2014, Value Assessment Committee (VAC) meeting. What this means to you: Effective March 1, 2015, the changes outlined below apply to all Anthem Blue Cross and Blue Shield Medicaid (Anthem) patients. Don t forget to read the footnotes at the bottom of the tables. What is the impact of this change? Effective for all patients on March 1, 2015 Therapeutic Class Medication Revised Status Potential Alternatives ADHD ZENZEDI QUANTITY LIMIT () RITIN LA ANTI- CONVULSANTS QUDEXY XR ANTIFUNGS TOPIC LOTRIMIN 1% ANTIDOTE EVZIO PRIOR AUTHORIZATION (PA) REQUIRED ANTI-INFECTIVE AGENTS SIVEXTRO DIFICID VANCOCIN ZITHROMAX ANTI-VIR AGENTS TAMIFLU Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., 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. AKYPEC
2 Page 2 of 13 ANTILIPEMICS EPANOVA GENERIC FENOFIBRATE JUXTAPID SIMCOR ANTI- NEOPLASTIC BELEODAQ ZYDELIG ANTIPSYCHOTICS OR ABILIFY CHLORPROMAZINE HCL TAB CLOZAPINE AND GEODON EQUETRO WITH ON 300MG FANAPT FAZACLO ODT AND FLUPHENAZINE HOPERIDOL TABLETS INVEGA LATUDA LOXAPINE ORAP OLANZAPINE OLANZAPINE ODT OLANZAPINE
3 Page 3 of 13 TABLETS PERPHENAZINE RISPERIDONE ODT RISPERIDONE TABLETS OR RISPERD TABS AND S AND TRIFLUOPERAZINE SAPHRIS SYMBYAX SEROQUEL AND SEROQUEL XR THIOTHIXENE VERSACLOZ ANTIPSYCHOTICS INJECTABLES ABILIFY MAINTENA FLUPHENAZINE DECONOATE INJ GEODON INJECTION HDOL DECONATE 100MG/ML INJ INVEGA SUSTENNA RISPERD CONSTA or ZYPREXA RELPREVV RISPERD CONSTA or ZYPREXA RELPREVV RISPERD CONSTA or ZYPREXA RELPREVV RISPERD CONSTA ZYPREXA RELPREVV ANTIPLATELET AGENT ZONTIVITY BIOLOGIC RESPONSE MODIFIERS ENTYVIO ENBREL OR HUMIRA
4 Page 4 of 13 DIABETIC OR INVOKANA JANUVIA, JANUMET, JANUMET XR OR BYETTA INVOKAMET JARDIANCE FARXIGA JANUVIA, JANUMET, JANUMET XR OR BYETTA JANUVIA, JANUMET, JANUMET XR OR BYETTA JANUVIA, JANUMET, JANUMET XR OR BYETTA JANUVIA STEP THERAPY REQUIRED METFORMIN OR METFORMIN ER JANUMET AND JANUMET XR STEP THERAPY REQUIRED METFORMIN OR METFORMIN ER ONGLYZA STEP THERAPY REQUIRED METFORMIN OR METFORMIN ER KOMBIGLYZE XR STEP THERAPY REQUIRED METFORMIN OR METFORMIN ER JEANTADUETO JANUMET, JANUMET XR, ONGLYZA OR KOMBIGLYZE XR * STEP THERAPY REQUIRED NESINA JANUMET, JANUMET XR, ONGLYZA OR KOMBIGLYZE XR * STEP THERAPY REQUIRED OSENI JANUMET, JANUMET XR, ONGLYZA OR KOMBIGLYZE XR * STEP THERAPY REQUIRED TRADJENTA JANUMET, JANUMET XR, ONGLYZA OR KOMBIGLYZE XR * STEP THERAPY REQUIRED KAZANO JANUMET, JANUMET XR, ONGLYZA OR KOMBIGLYZE XR * STEP THERAPY REQUIRED
5 Page 5 of 13 DIABETIC - INHED INSULIN AFREZZA APIDRA DIABETIC - INSULINS APIDRA SOLOSTAR AND U-100 VI BYDUREON BYETTA VICTOZA DISEASE- MODIFYING ANTIRHEUMATIC DRUGS ELECTROLYTE MIXTURES GROWTH HORMONES OTEZLA CERYTE 50/PEDIYTE ENBREL OR HUMIRA TEV-TROPIN NORDITROPIN HEPATITIS B BARACLUDE EPIVIR HBV ² HEPSERA VIREAD ² HEREDITARY ANGIOEDEMA IMMUNO- MODULATOR TOPIC LAXATIVES MONOCLON ANTIBODIES RUCONEST ELIDEL 1% PROTOPIC 0.03% AND 0.1 % MIRAX POWDER BULK AND PACKETS SYLVANT
6 Page 6 of 13 NARCOLEPSY AGENTS SELECT NAS STEROIDS XYREM **FLONASE OTC OPHTHMIC DECONGESTANTS FLUNISOLIDE SPRAY ** (RX) SPRAY (RX) NASACORT LERGY OTC NASACORT LERGY OTC NASACORT LERGY OTC NAPHAZOLINE SOL 0.1% OPHTHMIC PROSTAGLANDINS TRAVATAN DROPS 0.004% OPIOID ADDICTION BUNAVAIL BUPRENORPHINE HCL/NOXONE HCL TABLET BUPRENORPHINE SL PROTON PUMP INHIBITORS RESPIRATORY AGENTS SELECT TOPIC STEROIDS (SUPER POTENCY) NEXIUM OTC SPIRIVA RESPIMAT DIPROPIONTE, E, GEL, AND E GEL
7 Page 7 of 13 DIFLORASONE, E, GEL, AND HOBETASOL, E, GEL, AND HOBETASOL, E, GEL, AND SELECT TOPIC STEROIDS (HIGH POTENCY) AMCINONIDE GEL,,,,
8 Page 8 of 13,,,,,, DESOXIMETASONE DESOXIMETASONE GEL DESOXIMETASONE,,,,,
9 Page 9 of 13 SELECT TOPIC STEROIDS (MEDIUM POTENCY) FLUOCINONIDE FLUOCINONIDE E FLUOCINONIDE GEL FLUOCINONIDE FLUOCINONIDE,,,,,,,,,
10 Page 10 of 13 FLUOCINOLONE FLUOCINOLONE OIL VERTAE, /OINT, /OINT/ SOL, /OINT VERTAE, /OINT, /OINT/ SOL, /OINT VERTAE, /OINT, /OINT/ SOL, /OINT FLUOCINOLONE VERTAE, /OINT, /OINT/ SOL, /OINT
11 Page 11 of 13 BUTYRATE BUTYRATE BUTYRATE VERTAE, /OINT, /OINT/ SOL, /OINT VERTAE, /OINT, /OINT/ SOL, /OINT VERTAE, /OINT, /OINT/ SOL, /OINT VERTAE, /OINT, /OINT/ SOL, /OINT
12 Page 12 of 13 VERTAE, /OINT, /OINT/ SOL, /OINT PREDNICARBATE VERTAE, /OINT, /OINT/ SOL, /OINT VERTAE, /OINT, /OINT/ SOL, /OINT SELECT TOPIC STEROIDS (LOW POTENCY) CLOMETASONE, OR CLOMETASONE DESONIDE, OR, OR
13 Page 13 of 13 SYNTHETIC ERYTHROPOIETIN PROTEIN AGENTS FOR THROM- BOCYTOPENIA DESONIDE DESONIDE GEL, OR, OR, OR, OR MIRCERA NPLATE PROMACTA **Fluticasone spray (Rx) will be preferred until the release of Flonase OTC What action do I need to take? Please review these changes and work with your Anthem 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 Anthem 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
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