MEDICAID PROVIDER BULLETIN October 2018 The formulary changes listed in the table below were reviewed and approved at the second-quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October 1, 2018, the following formulary changes will apply. This notice applies to Anthem Blue Cross and Blue Shield Medicaid (Anthem) benefits in Kentucky. Effective for all patients starting October 1, 2018 Therapeutic class Drug Revised status DIABETIC SUPPLIES DIABETIC SUPPLIES HIV THERAPY PROTON PUMP INHIBITORS (PPI) BD PEN NEEDLES BD INSULIN SYRINGES ALL OTHER PEN NEEDLES AND INSULIN SYRINGES/MANUFACTURERS CIMDUO 300-300 MG SYMFI 600-300-300 MG TROGARZO 200 MG/1.33 ML VIAL BRAND PRILOSEC OTC 20 MG BRAND PRILOSEC OTC 20.6 MG BRAND OTC NEXIUM 24HR 20 MG CAPSULE NON- WITH STEP THERAPY (ST) COVERED Potential alternatives BD PEN NEEDLES BD INSULIN SYRINGES EDITS NO CHANGES IN /NON- STATUS REVISION OR ADDITION TO UM EDIT ONLY ADHD METHYLPHENIDATE ER 72 MG TAB ADD QUANTITY LIMIT (QL) FRAGMIN 2,500 UNITS/0.2 ML SYR FRAGMIN 5,000 UNITS/0.2 ML SYR FRAGMIN 7,500 UNITS/0.3 ML SYR FRAGMIN 10,000 UNITS/ML SYR FRAGMIN 12,500 UNITS/0.5 ML 6 ML (30 SYRINGES) PER 30 9 ML (30 SYRINGES) PER 30 30 ML (30 SYRINGES) PER 30 15 ML (30 SYRINGES) PER 30 https://mediproviders.anthem.com/ky 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. AKYPEC-1838-18 September 2018
FRAGMIN 15,000 UNITS/0.6 ML FRAGMIN 18,000 UNITS/0.72 ML FRAGMIN 25,000 UNITS/3.8 ML VL ANTIHYPERTENSIVES TEKTURNA 37.5 MG ORAL PELLETS DRUGS ANTIPARASITICS ANTIPARASITICS APPETITE STIMULATOR ASTHMA BOWEL PREP CHEMOTHERAPY IMBRUVICA 140 MG CAPSULE IMBRUVICA 70 MG CAPSULE IMBRUVICA 140 MG ALBENZA 200 MG IMPAVIDO 50 MG CAPSULE MEGESTROL MEGESTROL ORAL SUSP BREO ELLIPTA 200-25 MCG INH BREO ELLIPTA 100-25 MCG INH FLUTICASONE-SALMETEROL 55-14 FLUTICASONE-SALMETEROL 113-14 FLUTICASONE-SALMETEROL 232-14 DULERA 100 MCG/5 MCG INHALER DULERA 200 MCG/5 MCG INHALER AIRDUO RESPICLICK 55-14 MCG AIRDUO RESPICLICK 113-14 MCG AIRDUO RESPICLICK 232-14 MCG ADVAIR 100-50 DISKUS ADVAIR 250-50 DISKUS ADVAIR 500-50 DISKUS ADVAIR HFA 115-21 MCG INHALER ADVAIR HFA 45-21 MCG INHALER ADVAIR HFA 230-21 MCG INHALER SYMBICORT 80-4.5 MCG INHALER SYMBICORT 160-4.5 MCG INHALER CLENPIQ SOLUTION BEXAROTENE 75 MG CAPSULE Page 2 of 5 18 ML (30 SYRINGES) PER 30 22 ML (30 SYRINGES) PER 30 22.8 ML (6 VIALS) PER 30 8 PELLETS PER DAY 4 CAPSULE PER DAY 1 CAPSULE PER DAY 4 S PER DAY 84 CAPSULES PER FILL 1 FILL EVERY 30 PA REQUIRED REMOVING REQUIREMENT FOR ICS BEFORE ICS/LABA STEP THERAPY EFFECTIVE DATE 08.01.18 STEP THERAPY FOR T/F OF ICS/LABA STILL REQUIRED 320 MLS PER 30 10 CAPSULES PER DAY
CHEMOTHERAPY CHEMOTHERAPY CML DERMATOLOGICAL CABOMETYX 20 MG ZYKADIA 150 MG CAPSULE TASIGNA 50 MG CAPSULE QUINJA 1.25%-1% GEL EPINEPHRINE AUVI-Q 0.1 MG AUTO-INJECTOR GLUCOSE ELEVATING PRESSURE PRESSURE PRESSURE PRESSURE GLUCAGEN 1 MG EMERGENCY KIT ADD ULORIC 40 MG ULORIC 80 MG ZURAMPIC 200 MG KRYSTEXXA 8 MG/ML VIAL DEMSER 250 MG CAPSULE DIBENZYLINE 10 MG CAPSULE KAPSPARGO SPRINKLE PREXXARTAN Page 3 of 5 3 CAPSULES PER DAY 4 CAPSULES PER DAY 60 GMS PER 30 1 BOX (2 PENS) PER FILL QL 2 KITS IN 30 2 VIALS (2ML) PER 28 16 CAPSULES PER DAY 12 CAPSULES PER DAY 1 CAPSULE PER DAY 80 MLS PER DAY IBD STEROIDS UCERIS 2 MG RECTAL FOAM GLAUCOMA GLAUCOMA GLAUCOMA GLAUCOMA GLAUCOMA GLAUCOMA INTRANASAL STEROIDS AZOPT 1% EYE DROPS BETIMOL 0.25% EYE DROPS BETIMOL 0.5% EYE DROPS RHOPRESSA 0.02% OPHTH SOLUTION TIMOPTIC-XE 0.25% AND 0.5% EYE GEL-SOLN TIMOPTIC OCUMETER PLUS 0.25% AND 0.5 % GEL FORMING SOLN TIMOPTIC 0.25% AND 0.5% OCUDOSE DROP TIMOPTIC OCUMETER PLUS 0.25% AND 0.5% SOLN VYZULTA 0.024% OPHTH SOLUTION XHANCE 93 MCG NASAL SPRAY 15 MLS PER 30 15 MLS PER 30 1 BOTTLE PER 30 5 MLS PER 30 10 MLS PER 30 1 BOTTLE PER 30 2 INHALERS PER 30
MENOPAUSAL THERAPIES MIGRAINE MIGRAINE GASTROINTESTINAL HEPATITIS B INTERFERON ANTIVIRAL THERAPY NEUROPATHIC PAIN AND FIBROMYALGIA NON-NARCOTIC ANALGESIC NSAIDS PHOSPHATE BINDERS PRENATAL VITAMINS PROGESTINS PROSTATE CANCER PROSTATE CANCER ANTIBACTERIALS IMVEXXY 10 MCG VAGINAL INSERT IMVEXXY 4 MCG VAGINAL INSERT Page 4 of 5 18 VAGINAL INSERTS PER 28 AIMOVIG 70 MG DOSE-1 AUTOINJ 1 AUTOINJECTOR/1 PACK PER 30 AIMOVIG 140 MG DOSE-2 AUTOINJ 2 AUTOINJECTORS/1 PACK PER 30 SAMSCA 15 MG SAMSCA 30 MG 2 S PER DAY RECTIV 0.4% OINTMENT PEGASYS (PEGINTERFERON ALFA 2A) INTRON A (INTERFERON ALFA 2B) ZTLIDO FIORINAL 50-325-40 MG CAPSULE BUTALBITAL-ASA-CAFFEINE CAP BUTALB-ASPIRIN-CAFFE 50-325-40 CONSENSI CALCIUM ACETATE 668 MG NESTABS ONE SOFTGEL MAKENA 275 MG/1.1 ML AUTOINJCT ERLEADA 60 MG YONSA 125 MG ALTABAX 1% OINTMENT 30 GM TUBE EVERY 30 REMOVE PA REQUIREMENTS 3 PATCHES PER DAY 6 S PER DAY 12 S PER DAY 4 AUTOINJECTORS PER 28 4 S PER DAY 4 S PER DAY 30 GMS PER FILL 1 FILL PER 30
Page 5 of 5 ANTI- INFECTIVES CORTICOSTEROIDS LOW POTENCY CORTICOSTEROIDS VERY HIGH POTENCY XEPI SYNALAR 0.025% OINTMENT KIT IMPOYZ 0.025% CREAM 45 GMS PER FILL 1 FILL PER 30 1 KIT PER 30 112 GMS PER 30 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 that 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 1-855-661-2028 and follow the voice prompts for pharmacy prior authorization. You can find the Preferred Drug List on our provider website at https://mediproviders.anthem.com/ky/pages/pharmacy.aspx. If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-855-661-2028.