Quarterly pharmacy formulary change notice Provider update Summary: The formulary changes listed in the table below were reviewed and approved at our second quarter 2018, Pharmacy and Therapeutics Committee meeting. Effective October 1, 2018, the changes outlined below apply to all Amerigroup Washington, Inc. members. Effective for all patients on October 1, 2018 Therapeutic class Drug Revised status Potential alternatives DIABETIC SUPPLIES DIABETIC SUPPLIES ANTIARRHYTHMIC ANTIPARKINSONISM ANXIOLYTICS BETA BLOCKERS CALCIUM CHANNEL BLOCKING BD PEN NEEDLES BD INSULIN SYRINGES ALL OTHER PEN NEEDLES AND INSULIN SYRINGES/MANUFACTURERS QUINIDINE SULFATE BROMOCRIPTINE MESYLATE CAPSULE AND TABLET CARBIDOPA/LEVODOPA ODT CARBIDOPA/LEVODOPA/ENTACAPONE ALPRAZOLAM ODT 0.25 MG TAB ALPRAZOLAM ODT 0.5 MG TAB CLONAZEPAM ODT CLORAZEPATE 3.75 MG TABLET CLORAZEPATE 7.5 MG TABLET OXAZEPAM 30 MG CAPSULE NADOLOL 20 MG TABLET NADOLOL 40 MG TABLET NADOLOL 80 MG TABLET PINDOLOL 5 MG TABLET CARTIA XT 120 MG CAPSULE CARTIA XT 180 MG CAPSULE CARTIA XT 240 MG CAPSULE CARTIA XT 300 MG CAPSULE DILTIAZEM 24HR ER 180 MG TAB DILTIAZEM 24HR ER 240 MG TAB DILTIAZEM 24HR ER 360 MG TAB DILTIAZEM 24HR ER 420 MG TAB MATZIM LA 240 MG TABLET TAZTIA XT 360 MG CAPSULE PREFERRED WITH STEP THERAPY (ST) N/A BD PEN NEEDLES BD INSULIN SYRINGES QUINIDINE GLUCONATE ER 324 MG TABELTS CARBIDOPA & LEVODOPA PRAMIPEXOLE BENZTROPINE MESYLATE ALPRAZOLAM TABLET DIAZEPAM TABLET LORAZEPAM TABLET ATENOLOL TABLET CARVEDILOL TABLET LABETALOL HCL TABLET METOPROLOL TARTRATE TABLET DILTIAZEM HCL CAP ER 24HR 120 MG DILTIAZEM HCL CAP ER 24HR 180 MG DILTIAZEM HCL CAP ER 24HR 240 MG 24HR 120 MG 24HR 180 MG 24HR 240 MG 24HR 300 MG 24HR 360 MG 24HR 420 MG https://providers.amerigroup.com WAPEC-1639-18 September 2018
CALCIUM CHANNEL BLOCKING LIPID/CHOLESTEROL LOWERING LIPID/CHOLESTEROL LOWERING ANTIVIRALS OPHTHALMOLOGICS ORAL HYPOGLYCEMIC ORAL HYPOGLYCEMIC TETRACYCLINE ANTIBIOTICS TETRACYCLINE ANTIBIOTICS ADHD ANTIHYPERTENSIVES DRUGS ANTIPARASITICS VERAPAMIL 360 MG CAP PELLET VERAPAMIL ER 120 MG CAPSULE VERAPAMIL ER 180 MG CAPSULE VERAPAMIL ER 240 MG CAPSULE VERAPAMIL SR 120 MG CAPSULE VERAPAMIL SR 180 MG CAPSULE VERAPAMIL SR 240 MG CAPSULE VERAPAMIL ER PM 100 MG CAPSULE VERAPAMIL ER PM 200 MG CAPSULE VERAPAMIL ER PM 300 MG CAPSULE COLESTIPOL HCL GRANULES PACKET FENOFIBRATE 43 MG CAPSULE FENOFIBRATE 67 MG CAPSULE FENOFIBRATE 130 MG CAPSULE FENOFIBRATE 134 MG CAPSULE FENOFIBRIC ACID DR 135 MG CAP FENOFIBRATE 200 MG CAPSULE 24HR 360 MG VERAPAMIL HCL TAB ER 120 MG VERAPAMIL HCL TAB ER 180 MG VERAPAMIL HCL TAB ER 240 MG CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE FENOFIBRATE TAB 40 MG FENOFIBRATE TAB 48 MG FENOFIBRATE TAB 54 MG FENOFIBRATE TAB 120 MG FENOFIBRATE TAB 145 MG FENOFIBRATE TAB 160 MG AMANTADINE 100 MG TABLET AMANTADINE HCL CAP 100 MG XIIDRA 5% EYE DROPS RESTASIS 0.05% EMULSION PIOGLITAZONE-METFORMIN 15-500 PIOGLITAZONE-METFORMIN 15-850 SYNJARDY 12.5-1,000 MG TABLET SYNJARDY XR 25-1,000 MG TABLET DOXYCYCLINE 25 MG/5 ML SUSP DOXYCYCLINE MONO 75 MG CAPSULE DOXYCYCLINE MONO 150 MG CAP MINOCYCLINE HCL 50 MG TABLET MINOCYCLINE HCL 75 MG TABLET MINOCYCLINE HCL 100 MG TABLET EDITS PIOGLITAZONE HCL TAB 15 MG METFORMIN HCL TAB 500 MG METFORMIN HCL TAB 850 MG INVOKAMET TAB 150-500 MG INVOKAMET TAB 50-1000 MG XIGDUO XR TAB ER 24HR 2.5-1000 MG XIGDUO XR TAB ER 24HR 5-1000 MG XIGDUO XR TAB ER 24HR 10-1000 MG DOXYCYCLINE MONOHYDRATE TAB 50 MG DOXYCYCLINE MONOHYDRATE TAB 75 MG DOXYCYCLINE MONOHYDRATE TAB 150 MG MINOCYCLINE HCL CAP 50 MG MINOCYCLINE HCL CAP 75 MG MINOCYCLINE HCL CAP 100 MG NO CHANGES IN PREFERRED/ STATUS REVISION OR ADDITION TO UM EDIT ONLY METHYLPHENIDATE ER 72 MG TAB TEKTURNA 37.5MG ORAL PELLETS IMBRUVICA 140 MG CAPSULE IMBRUVICA 70 MG CAPSULE IMBRUVICA 140 MG TABLET ALBENZA 200 MG TABLET ADD QUANTITY LIMIT (QL) FOR MEMBERS 18 YEARS OF AGE AND OLDER 8 PELLETS PER DAY 4 CAPSULE PER DAY 1 CAPSULE PER DAY 4 PER DAY Page 2 of 5
ANTIPARASITICS APPETITE STIMULATOR BOWEL PREP CML DERMATOLOGICAL EPINEPHRINE GLUCOSE ELEVATING IMPAVIDO 50 MG CAPSULE MEGESTROL TABLET MEGESTROL ORAL SUSP CLENPIQ SOLUTION BEXAROTENE 75 MG CAPSULE CABOMETYX 20 MG TABLET ZYKADIA 150 MG CAPSULE TASIGNA 50 MG CAPSULE QUINJA 1.25%-1% GEL AUVI-Q 0.1 MG AUTO-INJECTOR GLUCAGEN 1 MG EMERGENCY KIT ULORIC 40 MG TABLET ULORIC 80 MG TABLET ZURAMPIC 200 MG TABLET KRYSTEXXA 8 MG/ML VIAL DEMSER 250 MG CAPSULE DIBENZYLINE 10 MG CAPSULE KAPSPARGO PREXXARTAN 84 CAPSULES PER FILL 1 FILL EVERY 30 DAYS PA REQUIRED 320 MLS PER 30 DAYS 10 CAPSULES PER DAY 3 CAPSULES PER DAY 4 CAPSULES PER DAY 60 GMS PER 30 DAYS 1 BOX (2 PENS) PER FILL 2 KITS IN 30 DAYS 2 VIALS (2ML) PER 28 DAYS 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 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 15 MLS PER 30 DAYS 15 MLS PER 30 DAYS 5 MLS PER 30 DAYS 5 MLS PER 30 DAYS 10 MLS PER 30 DAYS 2.5 MLS PER 30 DAYS Page 3 of 5
INTRANASAL STEROIDS 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 TOPICAL ANTIBACTERIALS TOPICAL ANTI- INFECTIVES XHANCE 93 MCG NASAL SPRAY IMVEXXY 10 MCG VAGINAL INSERT IMVEXXY 4 MCG VAGINAL INSERT AIMOVIG 70 MG DOSE-1 AUTOINJ AIMOVIG 140 MG DOSE-2 AUTOINJ SAMSCA 15 MG TABLET SAMSCA 30 MG TABLET 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 BUTALBITAL-ASA-CAFFEINE CAP CONSENSI CALCIUM ACETATE 668 MG TABLET NESTABS ONE SOFTGEL MAKENA 275 MG/1.1 ML AUTOINJCT ERLEADA 60 MG TABLET YONSA 125 MG TABLET ALTABAX 1% OINTMENT XEPI 2 INHALERS PER 30 DAYS 18 VAGINAL INSERTS PER 28 DAYS 1 AUTOINJECTOR/PACK PER 30 DAYS 2 AUTOINJECTORS/1 PACK PER 30 DAYS 2 PER DAY 30 GM TUBE EVERY 30 DAYS REMOVE PA REQUIREMENTS 3 PATCHES PER DAY 6 PER DAY 12 PER DAY 4 AUTOINJECTORS PER 28 DAYS 4 PER DAY 4 PER DAY 30GM PER FILL 1 FILL PER 30 DAYS 45 GMS PER FILL 1 FILL PER 30 DAYS Page 4 of 5
TOPICAL CORTICOSTEROIDS LOW POTENCY TOPICAL CORTICOSTEROIDS- VERY HIGH POTENCY SYNALAR 0.025% OINTMENT KIT IMPOYZ 0.025% CREAM 1 KIT PER 30 DAYS 112 GM PER 30 DAYS 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 (PA) 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 1-800-454-3730 and follow the voice prompts for pharmacy PA. You can find the Preferred Drug List on our provider website at https://providers.amerigroup.com/wa. If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-454-3730. Page 5 of 5