Quarterly pharmacy formulary change

Transcription

1 Medi-Cal Managed Care L. A. Care Major Risk Medical Insurance Program Provider Bulletin The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective August 1, 2018, these changes will apply to Anthem Blue Cross members. June 2018 Effective for members new to therapy on August 1, 2018, and existing members on October 1, 2018 Therapeutic class Drug name Revised status APIDRA 100 UNITS/ML VIAL APIDRA SOLOSTAR 100 UNITS/ML EFFECTIVE FOR NEW STARTS ON 8/1/18; EFFECTIVE FOR ON 10/1/18 Effective for all members on August 1, 2018 Therapeutic class Drug Revised status (EDIT ONLY) ADMELOG 100 UNIT/ML VIAL ADMELOG SOLOSTAR 100 UNIT/ML HUMULIN R 500 UNITS/ML VIAL HUMULIN R 500 UNITS/ML KWIKPEN 30MLS PER 30 DAYS ADDING PA TO PRODUCT Potential alternatives ADMELOG 100 UNIT/ML VIAL ADMELOG SOLOSTAR 100 UNIT/ML Potential alternatives ANTIPERSPIRANTS HYPERCARE 15% SOLUTION DPP4s GLP1s GLP1s ICS/LABA JENTADUETO 2.5 MG-1000 MG TAB JENTADUETO 2.5 MG-500 MG TAB JENTADUETO 2.5 MG-850 MG TAB JENTADUETO XR 2.5 MG-1,000 MG JENTADUETO XR 5 MG-1,000 MG TB TRADJENTA 5 MG TABLET TANZEUM 30 MG PEN INJECT TANZEUM 50 MG PEN INJECT OZEMPIC MG DOSE PEN OZEMPIC 1 MG DOSE PEN (AUTHORIZED GENERIC OF AIRDUO RESPICLICK) FLUTICASONE-SALMETEROL FLUTICASONE-SALMETEROL FLUTICASONE-SALMETEROL WITH STEP EFFECTIVE 4/1/18 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. ACAPEC June 2018 JANUVIA JANUMET XR ST APPLIES OZEMPIC VICTOZA ST APPLIES

2 ICS/LABA IRON SUPPLEMENTS MISCELLANEOUS ANTINEOPLASTIC DRUGS MISCELLANEOUS OPHTHALMOLOGICS DULERA 100 MCG/5 MCG INHALER DULERA 200 MCG/5 MCG INHALER POLY-VI-SOL WITH IRON DROPS POLY-VI-SOL DROPS MITOXANTRONE 20 MG/10 ML VIAL MITOXANTRONE 25 MG/12.5 ML VIAL MITOXANTRONE 30 MG/15 ML VIAL IMMUNOMODULATORS PROLEUKIN 22 MILLION UNIT VIAL Anthem Blue Cross Page 2 of 5 COVERED * AUTHORIZED GENERIC FOR AIDUO RESPICLK FLUTICASONE- SALMETEROL BREO ELLITA VISUDYNE 15 MG VIAL COVERED ADD PA LAMA/LABA STIOLTO RESPIMAT INHAL SPRAY PHOSPHATE BINDERS PHOSPHATE BINDERS LANTHANUM CARB 500 MG TAB CHEW LANTHANUM CARB 750 MG TAB CHEW LANTHANUM CARB 1,000 MG TB CHW SEVELAMER 0.8 GM POWDER PACKET SEVELAMER 2.4 GM POWDER PACKET SEVELAMER CARBONATE 800 MG TAB VELPHORO 500 MG CHEWABLE TAB WITH PA ELIPHOS 667 MG TABLET CALCIUM ACETATE 667 MG LANTHANUM CHEW TAB SEVELAMER TAB/PACKET PRENATAL VITAMINS GENERIC OTC PRODUCTS ONLY PRENATAL VITAMINS BRAND OTC ALL RX PRODUCTS EDITS No changes in preferred/nonpreferred status revision or addition to UM edit only. ANTICONVULSANTS ZONEGRAN 100 MG CAPSULE GENERIC OTC PRENATALS

3 ANTIBIOTICS COUGH AND COLD COUGH AND COLD ANTIVIRALS ANTIVIRALS BAXDELA 450 MG TABLET COUGH AND COLD PRODUCTS CONTAINING HYDROCODONE COUGH AND COLD PRODUCTS CONTAINING CODEINE PREVYMIS 240 MG/12 ML VIAL PREVYMIS 480 MG/24 ML VIAL PREVYMIS 240 MG TABLET PREVYMIS 480 MG TABLET Anthem Blue Cross Page 3 of 5 28 TABLETS PER FILL; 1 FILL PER 30 DAYS ADD AL MEMBERS EQUAL TO OR LESS THAN 18 REQUIRE PA ADD AL MEMBERS EQUAL TO OR LESS THAN 18 REQUIRE PA 1 VIAL PER DAY 100 DAYS OF TREATMENT 100 DAYS OF TREATMENT ASTHMA XOPENEX 30 VIALS 90 VIALS PER 30 DAYS BILE ACIDS CONSTIPATION AGENTS GLP-1 RECEPTOR AGONIST GLP-1 RECEPTOR AGONIST HEPATITIS C TREATMENT AGENTS ICS ICS LIPID/CHOLESTEROL LOWERING AGENTS CHENODAL 250 MG TABLET ALUNBRIG 180 MG TABLET ALUNBRIG 90 MG-180 MG TAB PACK ALUNBRIG 90 MG TABLET SYMPROIC 0.2 MG TABLET BROVANA 15 MCG/2 ML SOLUTION PERFOROMIST 20 MCG/2 ML SOLN LONHALA MAGNAIR 25 MCG STARTER LONHALA MAGNAIR 25 MCG REFILL OZEMPIC MG DOSE PEN OZEMPIC 1 MG DOSE PEN PEGINTRON 50 MCG KIT PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS 180 MCG/ML VIAL PEGASYS PROCLICK 180 MCG/0.5 PEGASYS PROCLICK 135 MCG/0.5 QVAR REDIHALER 40 MCG QVAR REDIHALER 80 MCG FLOLIPID 7 TABLETS PER DAY 1 PACK IN 30 DAYS REVISED QL 2 TABLETS DAILY 2 VIALS (4ML) PER DAY 2 VIALS (4ML) PER DAY 1 KIT PER 30 DAYS 1 PER 30 DAYS 1 PEN PER 28 DAYS 2 PENS PER 28 DAYS REMOVE PA 1 INHALER PER 30 DAYS 2 INHALERS PER 30 DAYS 5MLS PER DAY

4 Anthem Blue Cross Page 4 of 5 NUEDEXTA MG CAPSULE INGREZZA 40 MG CAPSULE INGREZZA 80 MG CAPSULE NEUROPATHIC PAIN LYRICA 82.5 NEUROPATHIC PAIN LYRICA 165 NEUROPATHIC PAIN LYRICA 330 PANCREATIC ENZYMES PANCREATIC ENZYMES POTASSIUM SPARING DIURETICS PROGESTINS PSYCHOTHERAPEUTIC AGENTS PULMONARY ARTERIAL HYPERTENSION /DPP-4 INHIBITOR SUBSTANCE USE DISORDERS PERTZYE DR 24,000 UNIT CAPSULE VIOKASE CAROSPIR 25 MG/5 ML SUSPENSION CRINONE 4% GEL CRINONE 8% GEL ADZENYS ER 1.25 MG/ML SUSP TRACLEER 32 MG TABLET FOR SUSP XIGDUO XR 2.5 MG-1,000 MG TAB STEGLATRO 5 MG TABLET STEGLATRO 15 MG TABLET SEGLUROMET 7.5-1,000 MG TABLET SEGLUROMET MG TABLET SEGLUROMET MG TABLET SEGLUROMET 2.5-1,000 MG TABLET STEGLUJAN MG TABLET STEGLUJAN MG TABLET SUBLOCADE 300 MG/1.5 ML SYRING SUBLOCADE 100 MG/0.5 ML SYRING LOPROX 0.77% CREAM LOTRIMIN ULTRA 1% CREAM NYSTATIN 100,000 UNIT/GM CREAM NYSTATIN 100,000 UNITS/GM OINT KETOCONAZOLE 2% CREAM OXISTAT 1% CREAM 2 CAPSULES PER DAY REVISED QL 25 CAPSULES PER DAY 25 TABLETS PER DAY ADD PA AND QL 20ML PER DAY 1 APPLICATORFUL PER DAY 15ML PER DAY 32 MG TABS FOR SUSP 4 TABLETS PER DAY 2 TABLETS PER DAY 2 TABLETS PER DAY 1 SYRINGE EVERY 28 DAYS 90 GMS PER 30 DAYS 30 GMS PER 30 DAYS 120 GMS PER 30 DAYS 60 GMS PER 30 DAYS

5 Anthem Blue Cross Page 5 of 5 What action do I need to take? Please review these changes and work with your members 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 members cases. If for medical reasons your member cannot be converted to a formulary alternative, please 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 the Customer Care Center at (outside L.A. County) or (inside L.A. County).