PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select October 1, 2018 Updates Drug Name efavirenz 600mg (Brand = Sustiva ) trientine (Brand = Syprine ) hydrocortisone lot 0.1% (Brand = Locoid ) sumatriptan-naproxen 85-500mg (Brand = Treximet ) memantine HCL ER 7mg, 14mg, 21mg, 28mg (Brand = Namenda XR ) minocycline ER 65mg, 115mg (Brand = Solodyn ) methylphenidate cap 10mg ER (Brand = Ritalin LA ) lansoprazole tab (Brand = Prevacid solutab) tiagabine 12mg, 16mg (Brand = Gabitril ) ritonavir tab 100mg (Brand = Norvir ) miglustat 100mg (Brand = Zavesca ) G No Change Generic Addition No Change 2/5/18 G/SP* No Change Generic Addition No Change 2/19/18 G No Change Generic Addition No Change 2/19/18 + AL (18 per 30 days) No Change Generic Addition No Change 2/19/18 G + AL No Change Generic Addition No Change 2/26/18 No Change Generic Addition No Change 2/26/18 No Change Generic Addition No Change 3/5/18 + QL No Change Generic Addition No Change 3/19/18 G No Change Generic Addition No Change 3/19/18 G No Change Generic Addition No Change 3/19/18 G/SP* + PA No Change Generic Addition No Change 4/23/18
praziquantel 600mg G No Change Generic Addition No Change 4/30/18 (Brand = Biltricide ) Erleada 600mg NPD/SP* + PA No Change No Change No Change 2/19/18 Lonhala Magnair soln NPD + PA No Change No Change No Change 2/19/18 25mcg Symdeko 100-150 NPD/SP* + PA No Change No Change No Change 2/19/18 Biktarvy NPD No Change No Change No Change 2/12/18 Bonjesta 20-20mg NPD + PA No Change No Change No Change 3/12/18 Zypitamag 1mg, 2mg, 4mg NPD + PA No Change Generic statins No Change No Change 3/26/18 Rhopressa Sol 0.02% NPD + PA No Change latanoprost, bimatoprost No Change No Change 4/2/18 Jynarque Pak 45-15mg, NPD + PA No Change No Change No Change 4/30/18 60-30mg, 90-30mg Namenda XR PB + AL NPD + AL Generic equivalent drug available Brand Uptier No Change 10/1/18 7mg, 14mg, 21mg, 28mg Norvir tab 100mg PB NPD Generic equivalent drug available Brand Uptier No Change 10/1/18 Sustiva tab 600mg PB NPD Generic equivalent drug available Brand Uptier No Change 10/1/18 oxycodone ER tablet Xtampza XR Drug Uptier No Change 10/1/18 30mg, 40mg, 60mg, 80mg Eucrisa NPD + PA PB + PA Brand Downtier No Change 10/1/18 hydromorphone tab 4mg, 8mg (Brand = Dilaudid tab) morphine sulfate IR 30mg morphine sulfate IR sol 20mg/ml oxycodone IR 15mg, 20mg, 30mg (Brand = Roxicodone) (6ml per day) (6ml per day)
oxycodone IR 100mg/5ml sol (6ml per day) (6ml per day) oxymorphone IR 10mg (Brand = Opana ) Nucynta 75mg, 100mg Promacta NPD/SP* NPD/SP* + PA Vasotec NPD NPD + PA Generic equivalent drug available Zestril NPD NPD + PA Generic equivalent drug available Lovaza NPD NPD + PA Generic equivalent drug available Zetia NPD NPD + PA Generic equivalent drug available Elidel NPD NPD + PA Protopic NPD NPD + PA Generic equivalent drug available oxycodone ER tablet 10mg, 15mg, 20mg Nucynta ER 50mg, 100mg morphine sulfate ER tablet (Brand = MS Contin ) morphine sulfate ER capsule 10mg, 20mg, 30mg (Brand = Kadian ) Kadian 40mg morphine sulfate beads ER cap 30mg, 45mg, 60mg, 75mg Embeda 20-0.8mg, 30-1.2mg Drug Uptier PA Addition 10/1/18
oxymorphone ER 12HR 5mg, 7.5mg, 10mg (Brand = Opana ER) Belbuca Film 75mcg, 150mcg Zohydro ER 10mg, 15mg, 20mg, 30mg, 40mg Hysingla ER 20mg, 30mg, 40mg, 60mg, 80mg Arymo ER Morphabond ER Xtampza ER 9mg, 13.5mg, 18mg Oxycontin 10mg, 15mg, 20mg Brand name short acting opioids with generic alternatives (Percocet, Norco, Roxicodone, Demerol, Dilaudid, Tylenol/Codeine, Ultram, Ultracet, Ibudone, Fioricet/Codeine, Fiorinal/Codeine, Xodol, Opana ) methadone tablet 5mg, 10mg (Brand = Dolophine ) Varies PB + QL + PA (QL varies) + QL Brand Downtier PA Addition 10/1/18 Xtampza XR Generic equivalent drug available
methadone con + QL 10mg/ml (6ml per day) methadone sol + QL 5mg/5ml (60ml per day) methadone sol + QL 10mg/5ml (30ml per day) buprenorphine hcl sub No Change QL Update 10/1/18 8mg (4 per day) Firvanq soln NPD NPD + AL No Change AL Addition 10/1/18 tramadol-acetaminophen tab 37.5-325mg Flurazepam Triazolam 0.125mg, 0.25mg (Brand = Halcion ) Quazepam 15mg (Brand = Doral ) Estazolam 1mg, 2mg Temazepam 7.5mg, 15mg, 22.5mg, 30mg (Brand = Restoril ) Lorazepam 1mg, 2mg (Brand = Ativan ) Oxazepam 10mg, + AL (40 per 5 day) age less than 6) G+ QL + AL (8 per day) age less than 15) age less than 12) age less than 12) No Change QL Update 10/1/18
Alprazolam (Brand = Xanax ) alprazolam ER Varies No Change AL Addition 10/1/18 (Brand = Xanax XR) Dulera NPD + PA + AL NPD + PA No Change AL Removal 10/1/18 Linzess PB + AL PB No Change AL Removal 10/1/18 Opioids products containing the following active ingredients: codeine, dihydrocodeine, fentanyl, hydrocodone, hydromorphone, levorphanol, meperidine, methadone, morphine, opium, oxycodone, oxymorphone, tapentadol, and tramadol Select topical acne products Varies Varies + MME Varies MME Addition 10/1/18 age greater than 35) age greater than 25)
Abbreviation Key G LCG PB NPD SP NF PA MME D/S QL AL Generic Addition Generic Downtier Generic/Drug Uptier Brand Downtier Brand Uptier Brand Addition Brand/Generic Deletion Generic Low Cost Generic Preferred Brand Non-Preferred Drug Specialty Drug. Specialty Tier cost-share will apply for those benefits that have a prescription drug specialty tier. Non-. Non- refers to drugs not covered on the formulary. A formulary exception is available upon request. Prior Authorization is required. Morphine Milligram Equivalent Days Supply Limit Quantity Limits Age Limit A generic drug that recently became available in the marketplace This generic drug will be covered at the appropriate preferred drug level of cost-sharing. This generic drug will be covered at the appropriate non-preferred drug level of cost-sharing. These brand drugs were added to the formulary as of the date indicated and are covered at the appropriate preferred brand formulary level of cost-sharing. These brand drugs will be covered at the appropriate non-preferred drug level of cost-sharing. Coverage was added to this drug. Coverage was removed from this drug. alternatives are available. DL 01 1608 0412 www.ibx.com Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association.