Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect May 2018 Quarterly pharmacy formulary change notice Effective May 1, 2018, the preferred formulary changes detailed in the table below will apply to Anthem Blue Cross and Blue Shield members enrolled in Hoosier Healthwise, Hoosier Care Connect and Healthy Indiana Plan (HIP). Additionally, effective May 1, 2018, there will be changes to the nonpreferred and prior authorization (PA) requirements of these formulary items. These formulary changes were reviewed and approved at the fourth-quarter Pharmacy and Therapeutics Committee meeting. Therapeutic class INHALED CORTICOSTEROIDS INHALED CORTICOSTEROIDS PROTON PUMP INHIBITORS PROTON PUMP INHIBITORS Effective for all patients on May 1, 2018 Medication FLOVENT HFA INHALER FLOVENT DISKUS Formulary status change FOR ALL AGES EFFECTIVE 04/15/18 Potential alternatives (preferred products) AEROSPAN 80 MCG INHALER ZEGERID 20 MG OTC ACID REDUCER DR 20 MG CAP OMEPRAZOLE DR 20 MG CAPSULE FOR MEMBERS < 6 YEARS OF AGE ANTICOAGULANTS XARELTO COVERED ANTICOAGULANTS SAVAYSA COVERED MISC ANTINEOPLASTIC BULK CHEMICALS KADCYLA ADD PA ASCORBIC ACID GRANULES PYRIDOXINE HCL CRYSTALS BULK CHEMICALS CALCIUM CARBONATE POWDER COUGH AND COLD PREPARATIONS COUGH AND COLD PREPARATIONS FOLIC ACID PREPARATION MULTISYMPTOM COLD LIQUID (OTC) MULTISYMPTOM COLD CAPLET/ SOFTGEL COLD & ALLERGY ELIXIR (OTC) HYDROXYZINE 50 MG/25 ML SYRUP CYPROHEPTADINE 4 MG/10 ML SYRP OTC GENERIC 12-HR DECONGEST 120 MG CAPLET L-METHYLFOLATE FORTE 7.5 MG CP L-METHYLFOLATE FORTE 15 MG CAP 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. 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-1770 April 2018
Page 2 of 6 GLP-1 RECEPTOR AGONIST HYPERAMMONEMIA IRON REPLACEMENT IRON REPLACEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL THERAPY POTASSIUM REPLACEMENT URINARY PH MODIFIERS OZEMPIC SODIUM PHENYLBUTYRATE POWDER SODIUM PHENYLBUTYRATE 500 MG TAB SLOW RELEASE IRON TABLET HEMOCYTE PLUS CAPSULE SIDEROL LIQUID NEPHRO-VITE TABLET DEXFERRUM 50 MG/ML VIAL DEXFERRUM 100 MG/2 ML VIAL FERRIC X-150 CAPSULE DUOFER 28 MG TABLET FOCALGIN DSS TABLET CHEWABLE IRON 30 MG TABLET METAFORM PACKET PHLEXY-VITS POWDER HCU EXPRESS POWDER MSUD POWDER/PACKET PHENYLKETONURIA (PKU) FORMULATIONS PFD TODDLER POWDER XMET ANALOG POWDER XLYS, XTRP ANALOG POWDER XPTM ANALOG POWDER XPHE, XTYR ANALOG POWDER XMTVI ANALOG POWDER OA 1 POWDER XLEU ANALOG POWDER POTASSIUM CL ER 8 MEQ CAPSULE POTASSIUM CL ER 20 MEQ TABLET K-SOL 20% (40 MEQ/15 ML) LIQ K-TAB ER 8 MEQ TABLET K-PHOS NEUTRAL TABLET PHOSPHA 250 NEUTRAL TABLET VIRT-PHOS 250 NEUTRAL TABLET WITH ST AND QL 0.25 MG DOSE; 1 PEN/28 DAYS 1 MG DOSE; 2 PENS/28 DAYS EFFECTIVE 04/01/18 WITH PA COD LIVER OIL PROTEXIN 500 MG/15 ML SYRUP CALCIFEROL 8,000 UNIT/ML DROPS BETA-CAROTENE 25,000 UNITS CAP OTC
Page 3 of 6 BETA CAROTENE 10,000 UNITS CAP OTC BRAND OTC PREPARATIONS VITAMIN A VITAMIN B VITAMIN C VITAMIN D VITAMIN D COMBO VITAMIN E MISCELLANEOUS VITAMINS GENERIC OTC PREPARATIONS VITAMIN A VITAMIN B VITAMIN C VITAMIN D VITAMIN D COMBO VITAMIN E MISCELLANEOUS VITAMINS EDITS NO CHANGES IN / STATUS REVISION OR ADDITION TO UM EDIT ONLY ACNE AND ROSACEA MINOLIRA, AKTIPAK ADD ST AGENTS ACNE AND ROSACEA DIFFERIN GEL 0.1% GEL, OTC AGENTS 45 GMS PER DAY QL REVISED ACNE THERAPY ADAPALENE 0.1% LOTION 59 ML PER 30 DAYS ALZHEIMER'S THERAPY; NMDA RECEPTOR ANTAGONISTS ANTICONVULSANTS ANTICONVULSANTS ANTIEMETICS AND ANTIVERTIGO ANTIEMETICS AND ANTIVERTIGO ANTIMIGRAINE PREPARATIONS ANTIPARASITICS CANCER CANCER MEMANTINE HCL 10 MG TABLET APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG CINVANTI INFUSION VARUBI INJECTION IMITREX 6 MG/0.5 ML VIAL (ML) SOLOSEC COMETRIQ 80 MG VENCLEXTA STARTING PACK 1 TABLET PER DAY 5 VIALS PER 30 DAYS 2 VIALS PER 28 DAYS QL REVISION 4 SYRINGES PER 30 DAYS 2 G PER FILL; 1 FILL PER 30 DAYS 1 CAPSULE PER DAY 1 PACK PER 365 DAYS
CANCER DIABETES EPINEPHRINE ERYTHROPOIESIS STIMULATING AGENTS ESTROGENS TRANSDERMAL ESTROGENS TRANSDERMAL GNRH ANALOG HIV ANTIRETROVIRALS VERZENIO BYDUREON BCISE SYMJEPI MIRCERA 30 MCG/0.3 ML 150 MCG/0.3 ML ESTRADIOL TDS PATCH ESTRADIOL PATCH MENOSTAR PATCH VIVELLE-DOT PATCH MINIVELLE PATCH CLIMARA PATCH ALORA PATCH MENOSTAR PATCH VIVELLE-DOT PATCH MINIVELLE PATCH CLIMARA PATCH ALORA PATCH TRIPTODUR ISENTRESS HD Anthem Blue Cross and Blue Shield Page 4 of 6 4 AUTOINJECTORS PER 28 DAYS 2 BOXES (2 PREFILLED SYRINGES) PER FILL 2 SYRINGES (0.6 ML) PER 28 DAYS REMOVE ST FOR T/F OF AN ORAL AGENT ADD ST FOR A TD ESTROGEN 1 KIT EVERY 24 WEEKS HYPERAMMONEMIA RAVICTI ADD STEP THERAPY IDIOPATHIC PULMONARY FIBROSIS IDIOPATHIC PULMONARY FIBROSIS INHERITED DISORDERS OF METABOLISM MOVEMENT DISORDER ESBRIET 267 MG TABLET ESBRIET 801 MG BUPHENYL 250 GM POWDER AFREZZA 90 CARTRIDGES (12 UNIT) AFREZZA 180 CARTRIDGES (60X4 UNIT AND 60X8 UNIT AND 60X12 UNIT) FIASP, FIASP FLEXTOUCH HUMALOG JUNIOR KWIKPEN GOCOVRI ER 68.5 MG 9 TABLETS PER DAY 3 TABLETS PER DAY QL REVISED 750 GM PER 30 DAYS 3 BOXES PER 30 DAYS 2 BOXES PER 30 DAYS 2 BOXES PER 30 DAYS 2 BOXES PER 30 DAYS 1 PER DAY
Page 5 of 6 MOVEMENT DISORDER GOCOVRI ER 137 MG APAP/CAF/DIHYDROCODEINE 320.5/30/16 APAP/CAF/DIHYDROCODEINE 325/30/16 MG APAP/CAF/DIHYDROCODEINE 325/30/16 MG APAP/CODEINE 300/15 MG (TYLENOL WITH CODEINE) APAP/CODEINE 300/30 MG (TYLENOL WITH CODEINE) DIHYDROCODEINE/ASA/CAF 16/356/30 MG (SYNALGOS-DC) HYDROCODONE/APAP 10/500 MG, 7.5/500 MG HYDROCODONE/APAP 2.5/325 MG, 5/325 MG, 7.5/325 MG, 10/325 MG HYDROCODONE/APAP 5/300 MG, 7.5/300 MG, 10/300 MG HYDROCODONE/APAP 5/400 MG, 7.5/400 MG, 10/400 MG HYDROCODONE/APAP 5/500 MG TABLETS OXYCODONE 7.5/500 MG (PERCOCET) OXYCODONE/APAP 10/500 MG TABLET OXYCODONE/APAP 2.5/325 MG, 5/325 MG, 7.5/325 MG, 10/325 MG OXYCODONE/APAP 5/300 MG, 7.5/300 MG, 10/300 MG OXYCODONE/APAP 5/500 MG CAPSULE OXYCODONE/ASPIRIN 5/325 MG PENTAZOCINE/NALOXONE 50 MG/0.5 MG CODEINE SULFATE 15 MG CODEINE SULFATE 30 MG DILAUDID 2 MG DILAUDID 4 MG DEMEROL 50 MG MS IR 15 MG OXYCODONE 10 MG OXAYDO 7.5 MG OXYIR 5 MG ROXICODONE 5 MG OXAYDO 5 MG OPANA 5 MG DOLOPHINE 5 MG APAP/CODEINE SUSP OR ELIXIR 120 MG-12 MG/5 ML; 300 MG-30 MG/12.5 ML (CAPITAL WITH CODEINE) HYDROCODONE/APAP 2.5-108 MG/5 ML 2 PER DAY 6 CAPSULES OR TABLETS PER DAY 30 ML PER DAY
Page 6 of 6 SUBLINGUAL IMMUNTHERAPY TARGETED IMMUNE MODIFIERS HYDROCODONE/APAP 2.5-167 MG/5 ML OXYCODONE/APAP 5-325 MG/5 ML DEMEROL 50 MG/5 ML (ORAL) MORPHINE SULFATE 10 MG/5 ML MORPHINE SULFATE 20 MG/5 ML OXYCODONE 5 MG/5 ML METHADONE 5 MG/5 ML HYDROCODONE/APAP 5-163 MG/7.5 ML HYDROCODONE/APAP 5-215 MG/10 ML HYDROCODONE/APAP 5-217 MG/10 ML HYDROCODONE/APAP 5-334 MG/10 ML MORPHINE SULFATE 20 MG/ML ORAL SYRINGE, 100 MG/5 ML NUCYNTA 50 MG HYSINGLA ER 80 MG, 100 MG EXALGO 12 MG, 16 MG, 32 MG ZOHYDRO ER 30 MG, 40 MG, 50 MG XTAMPZA ER 27 MG, 36 MG AVINZA 75 MG, 90 MG, 120 MG OXYCONTIN 60 MG, 80 MG OPANA ER 30 MG ODACTRA ENBREL MINI WITH AUTOTOUCH 45 ML PER DAY 60 ML PER DAY 6 ML PER DAY 181 PER 30 DAYS 1 TABLET PER DAY 2 CAPSULES PER DAY 1 CAPSULE PER DAY ADD PA AND QL 1 TABLET PER DAY 4 CARTRIDGES PER 28 DAYS 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 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 patient cannot be converted to a formulary alternative, call our Pharmacy department at 1-866-398-1922 and follow the voice prompts for pharmacy PA. You can find the preferred drug lists on our provider website at www.anthem.com/inmedicaiddoc > Member Eligibility & Benefits > Pharmacy Benefits. 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, 1-844-533-1995 for Healthy Indiana Plan or 1-844-284-1798 for Hoosier Care Connect.