Capital BlueCross Open/Closed Formulary Update (1 st Quarter 2017)

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1 Capital BlueCross Open/Closed Formulary Update (1 st Quarter 2017) The Capital BlueCross formulary is a reference list of prescription drugs that contains a wide range of generic and brand drugs that have been approved by the U.S. Food and Drug Administration (FDA). The formulary is updated on a quarterly basis or when new generic or brand-name medications become available and as discontinued drugs are removed from the marketplace. Several new drugs have come to market and are now included in our formulary. KEY: Capital BlueCross Formulary Update lowercase print = generic; UPPERCASE PRINT = BRAND; (PAR) = Prior Authorization Required; (EPA) = Enhanced Prior Authorization Required; (QLL) = Quantity Level Limits Apply Brand Name CINRYZE* (PAR) VEMLIDY* Tier Status BNP BP Newly Marketed Drugs Effective Immediately Indication Prophylactic therapy for hereditary angioedema Treatment of chronic hepatitis B virus (HBV) infection in adults with compensated liver disease. KEY: Generic Preferred (GP), Generic Non-Preferred (GNP), Brand Preferred (BP), Brand Non-Preferred (BNP) Preferred Alternatives N/A entecavir, lamivudine The Capital BlueCross formulary serves as a reference for all prescription drug benefit designs ranging from an open formulary to a closed formulary. An open formulary provides access to generic preferred, generic non-preferred, brand preferred brand and brand non-preferred medications. A closed formulary provides access to generic preferred, generic non-preferred and brand preferred medications. Brand non-preferred medications are not covered under a closed formulary. You or your physician may request coverage for medically necessary brand non-preferred drugs through the Nonformulary Consideration Process. KEY: Capital BlueCross Formulary Update lowercase print = generic; UPPERCASE PRINT = BRAND; (PAR) = Prior Authorization Required; (EPA) = Enhanced Prior Authorization Required; (QLL) = Quantity Level Limits Apply Brand Name Products Changing Tier Status (Open/Closed) Current Tier (Open/Closed) New Tier Preferred Alternatives EPIPEN, EPIPEN JR. (PAR) BP BNP epinephrine pen

2 Certain medications are subject to Enhanced Prior Authorization (EPA) due to health care concerns and/or safety reasons. In order to have these medications covered under your prescription drug benefit, you may be required to try a formulary alternative first or to complete the Prior Authorization process. To obtain Prior Authorization, your physician or pharmacist should call or fax a request with supporting clinical information to the CVS/caremark TM Prior Authorization Department at (Fax: ). Members may initiate a Prior Authorization request by calling CVS/caremark at or by visiting the website at capbluecross.com. Certain medications are also subject to Quantity Level Limit (QLL) to help promote appropriate use of medications and enhance patient safety. Prescriptions written for more than the allowed quantity will only be filled up to the allowed amount. Your physician can direct quantity override requests to CVS/caremark by calling or faxing the request with supporting clinical information to (Fax: ). The following medications have been added to the Prior Authorization (PAR) program. KEY: Pharmacy Management Program Update (PAR) = Prior Authorization Required; (ST) = Step Therapy Required; (QLL) = Quantity Level Limits Apply lowercase print = generic; UPPERCASE PRINT = BRAND CINRYZE* (PAR) Prior Authorization (PAR) Program Effective Immediately Purpose/Guidelines Diagnosis of hereditary angioedema Pharmacy Management Program Update Prior Authorization (PAR) Program EPINEPHRINE AUTO INJECTORS (PAR) : ADRENACLICK, AUVI Q, EPIPEN, EPIPEN JR. Purpose/Guidelines Diagnosis of an anaphylactic reaction and trial and failure of generic epinephrine pen

3 Pharmacy Management Program Update Prior Authorization (PAR) Program Purpose/Guidelines OPIOID/EXTENDED RELEASE PRODUCTS (PAR,QLL) : ARYMO ER TABLET 15MG,30MG,60MG, AVINZA CAPSULE 30MG,45MG,60MG,75MG,90MG,120MG, BELBUCA FILM 75MCG,150MCG,300MCG,450MCG,600MCG,750MCG,900M CG, BUTRANS PATCH 5MCG,HR,7.5MCG/HR,10MCG/HR,20MCG/HR,15MCG/HR, CONZIP CAPSULE 100MG,200MG,300MG, DURAGESIC PATCH 12MCG/HR,25MCG/HR,50MCG/HR,75MCG/HR,100MCG/H, EMBEDA CAPSULE MG, MG,50-2MG,60-2.4MG,80-3.2MG,100-4MG,EXALGO TABLET 8MG,12MG,16MG,32MG, fentanyl patch 12mcg/hr,25mcg/hr,50mcg,75mcg/hr,100mcg/hr, FENTANYL PATCH 37.5MCG,62.5MCG,87.5MCG, hydromorphone tablet 8mg er,12mg er,16mg er,32mg er, HYSINGLA ER TABLET 20 MG,30 MG,40 MG,60 MG,80 MG,100 MG,120 MG,KADIAN CAPSULE 10MG ER,20MG ER,30MG ER,40MG ER,50MG ER,60MG ER,80MG ER,100MG ER,200MG ER, morphine sulfate beads capsule 24hr 30 mg sr,45 mg sr,60 mg sr,75 mg sr,90 mg sr,120 mg sr, morphine sulfate capsule 24hr 10 mg sr,20 mg sr, 30 mg sr, 50 mg sr,60 mg sr,80 mg sr,100 mg sr, morphine sulfate tablet 15mg er,30mg er,60mg er, 100mg er,200mg er, MS CONTIN TABLET 15MG ER,30MG ER,60MG ER,100MG ER,200MG ER, NUCYNTA ER TABLET 50MG,100MG,150MG,200MG,250MG, OPANA ER TABLET 5MG,7.5MG,10MG,15MG,20MG,30MG,40MG, oxycodone tablet 10mg er,20mg er,40mg er,60mg er,80mg er, OXYCONTIN ER TABLET 10MG,15MG,20MG,30MG,40MG,60MG,80MG, oxymorphone tablet 7.5mg er,5mg er,10mg er,15mg er,20mg er,30mg er,40mg er, tramadol biphasic tablet 100mg er,200mg er,300mg er, tramadol capsule 200mg er, 300mg er, TRAMADOL HCL CAPSULE 150MG ER, tramadol tablet 100mg er,200mg er,300mg er, ULTRAM ER TABLET 100MG, 200MG, 300MG, XTAMPZA ER CAPSULE 9MG,13.5MG,18MG,27MG,36MG, ZOHYDRO ER CAPSULE 10MG,15MG,20MG,30MG,40MG,50MG Diagnosis of pain related to a terminal diagnosis AND The requested doses do not exceed FDA or accepted clinical dosing guidelines AND Member does not have a contraindication to opioid therapy OR Diagnosis of severe chronic pain AND The requested doses do not exceed FDA or accepted clinical dosing guidelines AND Member does NOT have a contraindication to opioid therapy Member has a history of opioid use AND Member has been evaluated and will be monitored regularly for the development of opioid use disorder (abuse or dependence) AND Member s pain will be reassessed each month after the initial prescription

4 Pharmacy Management Program Update OPIOID ORAL/NASAL FENTANYL PRODUCTS (PAR,QLL) : ABSTRAL SUBLINGUAL 100 MCG,200 MCG,300 MCG,400 MCG,600 MCG,800 MCG, ACTIQ LOZENGE 200MCG,400MCG,600MCG,800MCG,1200MCG,1600MCG, fentanyl lozenge 200MCG,400MCG,600MCG,800MCG,1200MCG,1600MCG, FENTORA TABLET 100 MCG,200 MCG,400 MCG,600 MCG,800 MCG, LAZANDA SPRAY 100MCG,400MCG, SUBSYS SPRAY 100MCG,200MCG,400MCG,600MCG,800MCG, 1200MCG,1600MCG Prior Authorization (PAR) Program Purpose/Guidelines The patient does NOT have a contraindication to opioid therapy AND Member has Member has chronic pain related to cancer AND Fentanyl oral or intranasal is being used for breakthrough pain AND Member has a history of appropriate long acting opioids utilization OPIOID/METHADONE PRODUCTS (PAR,QLL) : DOLOPHINE TABLET 5MG,10MG,methadone tablet 5mg,10mg,methadone solution 5mg/5ml,10mg/5ml Diagnosis of chronic severe pain associated with a terminal diagnosis AND Member does not have a contraindication to opioid therapy AND OR Methadone is being prescribed for severe, persistent chronic pain AND Member does NOT have a contraindication to opioid therapy such as: Patient has been evaluated for at least TWO nonpharmacologic therapies Member s pain will be reassessed in the first month after the initial prescription or any dose increase AND every 3 months thereafter to ensure that clinically meaningful improvement in pain and function outweigh risks to patient safety

5 Pharmacy Management Program Update Prior Authorization (PAR) Program Purpose/Guidelines MEDICATION ASSISTED TREATMENTS (PAR,QLL) : BUNAVAIL FILM MG, MG,6.3-1MG, buprenorphine sublingual tab 2mg, 8mg, buprenorphine/naloxone sublingual tab 2-0.5mg,8-2mg, SUBOXONE FILM SUBLINGUAL 2-0.5MG,4-1MG,8-2MG,12-3MG, SUBOXONE SUBLINGUAL 2-0.5MG,8-2MG, ZUBSOLV SUBLINGUAL TAB MG, MG, MG, MG, MG, MG Member has a diagnosis of opioid dependence in patients 16 years of age or older; Prescriber has received a Drug Addiction Treatment Act (DATA) 2000 waiver The drug is being used as part of a complete program for the treatment of opioid dependence Prescriber has reviewed the Pennsylvania Prescription Drug Monitoring Program The following medications have been added to the Quantity Level Limit (QLL) program. Pharmacy Management Program Update Quantity Level Limit (QLL) Program OPIOID IMMEDIATE RELEASE COMBINATION PRODUCTS acetaminophen/codeine solution mg/5ml (QLL) acetaminophen/codeine tablet 2 (300-15mg),3 (300mg- 30mg), 4 (300mg-60mg) (QLL) acetaminophen-caffeine-dihydrocodeine capsule mg (QLL) ACETAMINOPHEN-CAFFEINE-DIHYDROCODEINE TABLET MG (QLL) aspirin-caffeine-dihydrocodeine capsule mg (QLL) CAPITAL/CODEINE SUSPENSION MG/5ML (QLL) endocet tablet mg (QLL) endocet tablet mg,5-325mg (QLL) 630 ml 70 cap 70 tab 70 cap 630 ml

6 Pharmacy Management Program Update Quantity Level Limit (QLL) Program OPIOID IMMEDIATE RELEASE COMBINATION PRODUCTS endocet tablet mg (QLL) endodan tablet (QLL) HYCET SOLUTION MG,15 ml (QLL) hydrocodone/ibuprofen tablet mg,5-200mg, mg,10-200mg (QLL) hydrocodone-acetaminophen solution , mg/15ml (QLL) hydrocodone-acetaminophen tablet mg, mg, mg,10-325mg (QLL) hydrocodone-acetaminophen tablet mg (QLL) hydrocodone-acetaminophen tablet 5-300mg,5-325mg (QLL) ibudone tablet 5-200mg,10-200mg (QLL) lorcet hd tablet mg (QLL) lorcet plus tablet mg (QLL) lorcet tablet 5-325mg (QLL) LORTAB ELIXIR MG/15 ml (QLL) lortab tablet mg, mg (QLL) lortab tablet 5-325mg (QLL) NORCO TABLET MG, MG (QLL) NORCO TABLET 5-325MG (QLL) oxycodone w/ acetaminophen soln mg/5ml (QLL) 630 ml 35 tab 630 ml 35 tab 473 ml 140 ml oxycodone/acetaminophen tablet mg (QLL) oxycodone/acetaminophen tablet mg, 5-325mg (QLL)

7 Pharmacy Management Program Update Quantity Level Limit (QLL) Program OPIOID IMMEDIATE RELEASE COMBINATION PRODUCTS oxycodone/acetaminophen tablet mg (QLL) oxycodone/aspirin tablet mg (QLL) oxycodone/ibuprofen tablet 5-400mg (QLL) PERCOCET TABLET MG (QLL) PERCOCET TABLET MG, 5-325MG (QLL) PERCOCET TABLET MG (QLL) PERCODAN TABLET MG (QLL) PRIMLEV TABLET MG (QLL) PRIMLEV TABLET 5-300MG (QLL) PRIMLEV TABLET MG (QLL) reprexain tablet mg (QLL) REPREXAIN TABLET MG, 5-200MG (QLL) ROXICET SOLUTION 5-325MG/5ML (QLL) roxicet tablet 5-325mg (QLL) SYNALGOS-DC CAPSULE MG (QLL) tramadol-acetaminophen tablet mg (QLL) TREZIX CAPSULE MG (QLL) TYLENOL/CODEINE TABLET 3, 4 (QLL) ULTRACET TABLET MG (QLL) verdrocet tablet mg (QLL) vicodin es tablet mg (QLL) 35 tab 35 tab 140 ml 70 cap 70 cap

8 Pharmacy Management Program Update Quantity Level Limit (QLL) Program OPIOID IMMEDIATE RELEASE COMBINATION PRODUCTS vicodin hp tablet mg(QLL) vicodin tablet 5-300mg (QLL) VICOPROFEN TABLET MG (QLL) XARTEMIS XR TABLET MG (QLL) XODOL TABLET MG, MG (QLL) XODOL TABLET 5-300MG (QLL) xylon tablet mg (QLL) zamicet solution mg/15 ml (QLL) 35 tab 35 tab 630 ml OPIOID IMMEDIATE RELEASE SINGLE PRODUCTS butorphanol nasal spray 10mg/ml (QLL) CODEINE SULFATE SOLUTION 15MG/2.5ML, 30MG/5ML (QLL) codeine sulfate tablet 15 mg,30mg, 60mg (QLL) CODEINE SULFATE TABLET 60 MG (QLL) DEMEROL TABLET 50MG,100MG (QLL) DILAUDID LIQUID 1MG/ML (QLL) DILAUDID TABLET 2MG,4MG,8MG (QLL) hydromorphone liquid 1mg/ml (QLL) hydromorphone suppository (QLL) HYDROMORPHONE SUPPOSITORY 3MG (QLL) hydromorphone tablet 2mg,4mg,8mg (QLL) levorphanol tablet 2mg (QLL) 5 ml (2 bottles) 210 ml 18 tab 140 ml 140 ml 28 supp 28 supp

9 OPIOID IMMEDIATE RELEASE SINGLE PRODUCTS meperidine solution 50mg/5ml (QLL) meperidine syrup 50mg/5ml (QLL) meperidine tablet 50mg/100mg (QLL) morphine sulfate solution 10mg/0.5ml,20mg/ml,100mg/5ml (QLL) morphine sulfate solution 10mg/5ml (QLL) morphine sulfate solution 20mg/5ml (QLL) morphine sulfate suppository 5mg,10mg (QLL) morphine sulfate suppository 20mg (QLL) MORPHINE SULFATE SUPPOSITORY 30MG (QLL) morphine sulfate suppository 30mg (QLL) morphine sulfate tablet 15mg (QLL) morphine sulfate tablet 30mg (QLL) msir solution 10mg/5ml (QLL) msir solution 20mg/5ml (QLL) NUCYNTA TABLET 100MG (QLL) NUCYNTA TABLET 50MG (QLL) NUCYNTA TABLET 75MG (QLL) OPANA TABLET 10MG (QLL) OPANA TABLET 5MG (QLL) OXAYDO TABLET 5MG,7.5MG (QLL) oxycodone capsule 5mg (QLL) oxycodone concentrate 10mg/0.5ml,20mg/ml,100mg/5ml (QLL) oxycodone solution 5mg/5ml (QLL) OXYCODONE TABLET 10MG (QLL) 90 ml 90 ml 18 tab 32 ml 210 ml 158 ml 42 supp 28 supp 21 supp 21 supp 21 tab 210 ml 158 ml 14 tab 21 tab 21 tab 42 cap 30 ml 420 ml

10 OPIOID IMMEDIATE RELEASE SINGLE PRODUCTS oxycodone tablet 5mg,10mg (QLL) oxycodone tablet 15mg (QLL) OXYCODONE TABLET 20MG (QLL) oxycodone tablet 20mg (QLL) oxycodone tablet 30mg (QLL) oxycodone tablet er 10mg,15mg,20mg,30mg,40mg,60mg,80mg (QLL) oxymorphone hcl tablet 10mg (QLL) oxymorphone hcl tablet 5mg (QLL) pentazocine/naloxone tablet mg (QLL) percolone tablet 5mg (QLL) ROXICODONE TABLET 15MG (QLL) ROXICODONE TABLET 30MG (QLL) ROXICODONE TABLET 5MG (QLL) tramadol hcl tablet 50mg (QLL) ULTRAM TABLET 50MG (QLL) 21 tab 21 tab 14 tab 21 tab 14 tab OPIOID EXTENDED RELEASE PRODUCTS ARYMO ER TABLET 15MG, 30MG, 60MG (PAR,QLL) AVINZA CAPSULE 30MG, 45MG, 60MG, 75MG,90MG, 120MG (PAR,QLL) BELBUCA FILM 75MCG, 150MCG, 300MCG, 450MCG, 600MCG, 750MCG, 900MCG (PAR,QLL) BUTRANS PATCH 5MCG/HR, 7.5MCG/HR 10MCG/HR, 15MCG/HR, 20MCG/HR (PAR,QLL) CONZIP CAPSULE 100MG, 200MG, 300MG (PAR,QLL) DURAGESIC PATCH 12MCG/HR, 25MCG/HR 100MCG/HR, 50MCG/HR, 75MCG/HR (PAR,QLL) EMBEDA CAPSULE MG, MG, 50-2MG, MG, MG, 100-4MG (PAR,QLL) EXALGO TABLET 8MG,12MG,16MG,32MG (PAR,QLL) 60 film 4 patch 10 patch

11 OPIOID EXTENDED RELEASE PRODUCTS fentanyl patch 12mcg/hr,25mcg/hr,50mcg,75mcg/hr,100mcg/hr (PAR,QLL) FENTANYL PATCH 37.5MCG,62.5MCG,87.5MCG (PAR,QLL) hydromorphone tablet 8mg er,12mg er,16mg er,32mg er (PAR,QLL) HYSINGLA ER TABLET 20 MG,30 MG,40 MG,60 MG,80 MG,100 MG,120 MG (PAR,QLL) KADIAN CAPSULE 10MG ER,20MG ER,30MG ER,40MG ER, 50MG ER,60MG ER,80MG ER,100MG ER,200MG ER (PAR,QLL) morphine sulfate beads capsule sr 24hr 30mg,45mg,60mg,75mg,90mg,120 mg (PAR,QLL) morphine sulfate capsule sr 24hr 10 mg,20 mg,30 mg,50 mg,60 mg,80 mg,100 mg (PAR,QLL) morphine sulfate tablet 15mg er,30mg er,60mg er,100mg er,200mg er (PAR,QLL) MS CONTIN TABLET 15MG ER,30MG ER,60MG ER, 100MG ER,200MG ER (PAR,QLL) NUCYNTA ER TABLET 50MG,100MG,150MG,200MG, 250MG (PAR,QLL) OPANA ER TABLET 5MG,7.5MG,10MG,15MG,20MG,30MG,40MG (PAR,QLL) oxycodone tablet 10mg er,20mg er,40mg er,60mg er,80mg er (PAR,QLL) OXYCONTIN ER TABLET 10MG,15MG,20MG,30MG,40MG,60MG,80MG (PAR,QLL) oxymorphone tablet 5mg er,7.5mg er,10mg er,15mg er,20mg er,30mg er,40mg er (PAR,QLL) tramadol biphasic tablet 100mg er,200mg er,300mg er (PAR,QLL) tramadol capsule 200mg er,300mg er (PAR,QLL) TRAMADOL HCL CAPSULE 150MG ER (PAR,QLL) tramadol tablet 100mg er,200mg er,300mg er (PAR,QLL) 10 patch 10 patch ULTRAM ER TABLET 100MG, 200MG,300MG (PAR,QLL) XTAMPZA ER CAPSULE 9MG,13.5MG,18MG,27MG,36MG (PAR,QLL) ZOHYDRO ER CAPSULE 10MG,15MG,20MG,30MG,40MG,50MG (PAR,QLL) ABSTRAL SUBLINGUAL 100 MCG,200 MCG,300 MCG,400 MCG,600 MCG,800 MCG (PAR,QLL) FENTANYL PRODUCTS (ORAL/INTRANASAL) 60 cap 60 cap 120 subl tab

12 FENTANYL PRODUCTS (ORAL/INTRANASAL) ACTIQ LOZENGE 200MCG,400MCG,600MCG,800MCG,1200MCG,1600MCG (PAR,QLL) fentanyl lozenge 200MCG,400MCG,600MCG,800MCG,1200MCG,1600 (PAR,QLL) FENTORA TABLET 100 MCG,200 MCG,400 MCG,600 MCG,800 MCG (PAR,QLL) LAZANDA SPRAY 100MCG,400MCG (PAR,QLL) SUBSYS SPRAY 100MCG,200MCG,400MCG,600MCG,800MCG (PAR,QLL) SUBSYS SPRAY 1200MCG,1600MCG (PAR,QLL) 120 lozenge 120 lozenge 120 tab 30 sprays 120 sprays 240 sprays METHADONE PRODUCTS DOLOPHINE TABLET 5MG,10MG (PAR,QLL) methadone tablet 5mg,10mg (PAR,QLL) methadone solution 5mg/5ml,10mg/5ml (PAR,QLL) 300 ml MEDICATION ASSISTED TREATMENTS BUNAVAIL FILM MG, MG,6.3-1MG (PAR,QLL) buprenorphine sublingual 2mg (PAR,QLL) buprenorphine sublingual 8mg (PAR,QLL) buprenorphine/naloxone sublingual 2-0.5mg,8-2mg (PAR,QLL) SUBOXONE FILM SUBLINGUAL 2-0.5MG,4-1MG,8-2MG (PAR,QLL) SUBOXONE FILM SUBLINGUAL12-3MG (PAR,QLL) ZUBSOLV SUBLINGUAL MG, MG, MG, MG (PAR,QLL) ZUBSOLV SUBLINGUAL MG (PAR,QLL) ZUBSOLV SUBLINGUAL MG (PAR,QLL) 60 film 240 tab 90 tab 90 film 60 film 90 tab

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