Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect This is an update about information in the provider manual. For access to the latest manual, go online to www.anthem.com/inmedicaiddoc. Quarterly pharmacy formulary change Effective September 1, 2016, October 1, 2016, and November 1, 2016, the preferred formulary changes detailed in the table below will apply to Anthem Blue Cross and Blue Shield (Anthem) members enrolled in Hoosier Healthwise and Healthy Indiana Plan. Additionally, effective November 1, 2016, there will be changes to the nonpreferred and prior authorization requirements of these formulary items as well. These formulary changes were reviewed and approved at the second quarter Pharmacy and Therapeutics (P&T) committee meetings held on June 27, 2016. Effective for all patients on September 1, 2016 Therapeutic class Medication Formulary status change Potential alternatives (preferred products) CORTICOSTERIOIDS COMBINATION ARNUITY ELLIPTA 100 MCG INH ARNUITY ELLIPTA 200 MCG INH PULMICORT 1 MG/2 ML RESPULE (BRAND) QVAR 40 MCG ORAL QVAR 80 MCG ORAL PULMICORT 180 MCG FLEXHALER PULMICORT 90 MCG FLEXHALER ASMANEX HFA 100 MCG ASMANEX HFA 200 MCG ASMANEX TWISTHALER 110 MCG ASMANEX TWISTHALER 220 MCG FLOVENT HFA 110 MCG FLOVENT HFA 44 MCG FLOVENT HFA 220 MCG FLOVENT 50 MCG DISKUS FLOVENT 100 MCG DISKUS FLOVENT 250 MCG DISKUS BREO ELLIPTA 200-25 MCG INH BREO ELLIPTA 100-25 MCG INH FOR MEMBERS 12 YEARS OF AGE AND OLDER FOR MEMBERS 6 YEARS OF AGE AND OLDER ST REQUIRED BUDESONIDE 1 MG/2 ML INH SUSPENSION AEROSPAN 80 MCG ARNUITY ELLIPTA 100 MCG INH ARNUITY ELLIPTA 200 MCG INH ARNUITY ELLIPTA AEROSPAN ARNUITY ELLIPTA AEROSPAN QVAR (For members up to 12 years of age) www.anthem.com/inmedicaiddoc Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, 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. Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative. AINPEC-1041-16
CORTICOSTERIOIDS COMBINATION SYMBICORT 80-4.5 MCG SYMBICORT 160-4.5 MCG Anthem Blue Cross and Blue Shield Page 2 of 6 BREO ELLIPTA DULEREA ST REQUIRED HIV DESCOVY 200-25 MG TABLET HIV INTELENCE REMOVE PRIOR AUTHORIZATION (PA) LAMA/LABA LONG ACTING NARCOTICS OVER ACTIVE BLADDER NARCOTICS NARCOTICS NARCOTIC NSAIDS PAH NARCOTIC ANTICONVULSANTS ORAL ESTROGENS ANORO ELLIPTA 62.5-25 MCG INH MORPHINE ER TABS (GENERIC MS CONTIN) METHADONE (ALL DOSAGE FORMS) FENTANYL PATCH DARIFENACIN ER 7.5 MG TABLET DARIFENACIN ER 15 MG TABLET BELBUCA FILM MORPHABOND XTAMPZA ER 9 MG CAPSULE XTAMPZA ER 13.5 MG CAPSULE XTAMPZA ER 18 MG CAPSULE VIVLODEX LETAIRIS 5 MG TABLET LETAIRIS 10 MG TABLET XTAMPZA ER 27 MG CAPSULE XTAMPZA ER 36 MG CAPSULE APTIOM TABLET BANZEL ORAL SUSPENSION BANZEL TABLET BRIVIACT ORAL SOLN BRIVIACT TABLET POTIGA TABLET VIMPAT ORAL SOLUTION VIMPAT TABLET PA REQUIRED (CURRENT UTILIZERS GRANDFATHERED) ADD QUANTITY LIMIT (QL) 2 FILMS PER DAY 2 TABS PER DAY 2 CAPS PER DAY 1 CAP PER DAY WITH PA 8 CAPS PER DAY WITH PA REQUIRED Effective for all patients on October 1, 2016 PREMARIN 0.3 MG TABLET PREMARIN 0.45 MG TABLET PREMARIN 0.625 MG TABLET PREMARIN 0.9 MG TABLET PREMARIN 1.25 MG TABLET Effective for all patients on November 1, 2016 ESTRADIOL TABLETS ESTROPIPATE TABLETS ALKYLATING CYCLOPHOSPHAMIDE CAPS ALCOHOL PREP PADS ONE PHARMACEUTICAL PHOENIX HEALTHCARE SPECIALTY MED HOME AID DIAGNOSTICS SIMPLE DIAGNOSTICS SMITH & NEPHEW, INC BOCA PHARMACAL MCKESSON DRUG TARGET CORP. RITE AID CORP. WALGREEN CO. LEADER CVS WAL-MART STORES BD DIABETES
Page 3 of 6 PROTON PUMP INHIBITORS PANTOPRAZOLE SOD DR 20 MG TAB PANTOPRAZOLE SOD DR 40 MG TAB NEXIUM 24HR 20 MG TABLET (OTC) NEXIUM 24HR 22.3 MG CAPSULE (OTC) OMEPRAZOLE MAG DR 20.6 MG CAP (OTC) OMEPRAZOLE DR 20 MG TABLET (OTC) PREVACID 24HR DR 15 MG CAPSULE (OTC) HEARTBURN TREATMNT 24 HR 15 MG (OTC) OSTEOPOROSIS THERAPY ANTICONVULSANTS ANTIDIURETIC AND VASOPRESSOR HORMONES ANTIFUNGAL ANTIHYPERTENSIVE ANTIMETABOLITES ANTIMIGRAINE PREPARATIONS ALENDRONATE SOD 70 MG/75 ML BRIVIACT TABLETS BRIVIACT 10 MG/ML ORAL SOLN BRIVIACT 50 MG/5 ML VIAL ADD PA AND QL DDAVP 0.2 MG TABLET MYCELEX TROCHE NOXAFIL 40 MG/ML SUSPENSION TARKA ER 2-180 MG TABLET NICARDIPINE 30 MG CAPSULE PRINIVIL 5 MG TABLET PRINIVIL 10 MG TABLET PRINIVIL 20 MG TABLET ZESTORETIC 10-12.5 MG TABLOID TABLET TREXALL TABLET ZEMBRACE SYMTOUCH ONZETRA XSAIL NASAL SPRAY PREFFERED STEP THERAPY (ST) REQUIRED ANTIMIGRAINE PREPARATIONS IMITREX 6 MG/0.5 ML VIAL ANTINEOPLASTIC INJECTIONS LEUPROLIDE 2WK 1 MG/0.2 ML KIT ANTINEOPLASTIC DRUGS ANTINEOPLASTIC DRUGS ANTIPSORIATIC/ ANTISEBORRHEIC ANTIVERTIGO AND ANTIEMETIC BARBITURATE COMBINATION SIGNIFOR LAR VIAL SOMATULINE DEPOT FIRMAGON KIT SANDOSTATIN AMPULS/VIALS SANDOSTATIN LAR DEPOT VIALS TALTZ 80 MG/ML AUTOINJECTOR TALTZ 80 MG/ML SYRINGE EMEND CAPSULE EMEND TRIPACK EMEND 150 MG VIAL ACETAMINOPHEN 25-325 MG ACETAMINOPHEN 50 MG-300 MG TABLET ACETAMINOPHEN 50 MG-325 MG TABLET ADD PA AND QL ADD PA AND QL
Page 4 of 6 CHEMOTHERAPY RESCUE/ANTIDOTE DERMATOLOGICAL GNRH GROWTH HORMONE RECEPTOR ANTAGONISTS ACETAMINOPHEN 50 MG-650 MG MG-325 MG-40 MG/15 ML SOLUTION MG-300 MG-40 MG CAPSULE MG-325 MG-40 MG CAPSULE MG-325 MG-40 MG TABLET ASPIRIN- CAFFEINE 50 MG-325 MG-40 MG CAPSULE ASPIRIN- CAFFEINE-CODEINE 50 MG-325 MG-40 MG-30 MG CAPSULE VISTOGARD 10 GRAM PACKET CARAC 0.5% CREAM EFUDEX 5% CREAM TOLAK 4% CREAM FLUOROURACIL 5% TOP SOLUTION FLUOROURACIL 2% TOPICAL SOLN FLUOROPLEX 1% CREAM ALDARA 5% CREAM PICATO 0.015% GEL PICATO 0.05% GEL SOLARAZE 3% GEL LUPANETA PACK 3.75/5 MG LUPANETA PACK 11.25/5 MG LUPRON DEPOT PED 30 MG LUPRON DEPOT PED 11.25 OR 15 MG LUPRON DEPOT 7.5 MG LUPRON DEPOT 11.25 MG, 22.5 MG LUPRON DEPOT 30 MG SUPPRELIN LA SYNAREL SOMAVERT 10MG, 15MG, 20MG, 25MG, 30MG PA REQUIRED LAXATIVES AND CATHARTICS MIRALAX CHEMET DESFERAL PA REQUIRED NASAL STEROIDS RHINOCORT ALLERGY (OTC) NASONEX/ MOMETASONE NSAIDS VIVLODEX CAPSULE
Page 5 of 6 OPIOID DEPENDENCE EVZIO OPIOID DEPENDENCE NARCAN NASAL SPRAY NALOXONE INJECTION OSTEOPOROSIS THERAPY ALENDRONATE SOD 70 MG/75 ML SKELETAL MUSCLE RELAXANTS AMRIX 30MG METHOCARBAMOL 750 MG TOPICAL ANTI- INFLAMMATORY- NSAIDS FLECTOR PATCH PENNSAID 1.5% PENNSAID 2% VOLTAREN GEL PAH ATROVENT HFA ATROVENT SOLUTION PAH PRENATAL VITAMINS PROTON PUMP INHIBITORS RHEUMATOLOGICAL UTI PROPHYLAXIS UTI PROPHYLAXIS TYVASO VENTAVIS ENBRACE HR FOCALGIN 90 DHA COMBO PACK; FOCALGIN CA COMBO PACK NIVA-PLUS OB COMPLETE GOLD PREFERA-OB PLUS DHA COMBO PACK PROVIDA DHA TRISTART DHA VITAFOL FE + DOCUSATE COMBO PACK DEXILANT SOLUTAB XELJANZ XR TABLET ADD PA AND QL NITROFURANTOIN MCR 25 MG CAP NITROFURANTOIN 25 MG/5 ML SUSP NITROFURANTOIN MCR 25 MG, 50 MG AND 100 MG CAP NITROFURANTOIN MONO-MCR 100 MG What action do I need to take? Please review these changes and work with your 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 patient cannot be converted to a formulary alternative, call our Pharmacy department at 1-866-398-1922 and follow the voice prompts for pharmacy prior authorization. You can find the preferred drug list
Page 6 of 6 on our provider website at www.anthem.com/inmedicaiddoc > Member Eligibility & Benefits > Pharmacy Benefits > Preferred Dug List. If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-866-408-6132 for Hoosier Healthwise or 1-800-345-4344 for Healthy Indiana Plan.