Future Formulary Changes Applies to: Employer group plan 2019 open formularies with specialty tiers KEY: PA=prior authorization; ST=step therapy; QL=quantity limit Obeticholic acid Ocaliva Limited to Kaiser Dulaglutide Trulicity Add PA Triamcinolone acetonide nasal spray Nasacort Add PA Ivacaftor packet Kalydeco Add QL of 60 units Dichlorphenamide Keveyis Add QL of 120 tablets Adapalene cream 0.1% Differin Move to Tier 3 Clobetasol spray Clobex Ancillary charge Clobetasol shampoo Clobex Ancillary charge Clobetasol lotion Clobex Ancillary charge Tretinoin gel Retin-A, Retin-A Micro Move to Tier 3 Tretinoin cream Retin-A Move to Tier 3 Parathyroid hormone Natpara Add PA 01/07/2019 11/21/2018 Adapalene/benzoyl peroxide gel Epiduo Ancillary charge
Estradiol vaginal cream Estrace Move to Tier 3 Desonide cream Desowen Move to Tier 3 Desonide lotion Desowen Move to Tier 3 Dalfampridine ER Ampyra Limited to Kaiser Cabozantinib Cabometyx Limited to Kaiser Liraglutide Victoza Add QL of 3 Dulaglutide Trulicity Add QL of 4 Semaglutide Ozempic Add QL of 2 Exenatide Bydureon Add QL of 4 Exenatide Byetta Add QL of 1 dispensing unit per Lofexidine Lucemyra Add QL of 224 tablets Sapropterin Kuvan Add PA Budesonide Pulmicort Flexhaler Add PA Fluticasone furoate Arnuity Ellipta Add PA Interferon beta-1a Rebif Add PA Beclomethasone dipropionate Qvar; Qvar Redihaler Add PA 12/01/2018 10/12/2018
Hydroxyprogesterone caproate Makena Move to Tier 5 Filgrastim Granix Limited to Kaiser Tenofovir alafenamide Vemlidy Limited to Kaiser Toremifene Fareston Limited to Kaiser Ferric citrate Auryxia Add QL of 360 tablets Tezacaftor/ivacaftor plus ivacaftor Symdeko Add QL of 60 tablets 10/01/2018 08/13/2018 Metformin hcl ER 1,000 mg Fortamet 1,000 mg Add PA Lansoprazole ODT Prevacid SoluTab Add PA Febuxostat 40 mg Uloric 40 mg Add QL of 30 tablets Brigatinib 30 mg Alunbrig 30 mg Add QL of 60 tablets Hydrocodone w/ homatropine; belladonna alakaloids & opium; codeine sulfate; fentanyl; hydrocodone bitartrate; hydromorphone hcl; levorphanol tartrate; meperidine hcl; methadone hcl; morphine sulfate; morphine/naltrexone; oxycodone hcl; oxycodone hcl ER; oxymorphone hcl ER; oxymorphone hcl; tapentadol hcl; tramadol hcl; tramadol hcl ER; buprenorphine; butorphanol tartrate; pentazocine/naloxone; oxycodone/acetaminophen; oxycodone/aspirin; oxycodone/ibuprofen; acetaminophen/codeine; butalbital/acetaminophen/caffeine/codeine; butalbital/aspirin/caffeine/codeine; acetaminophen/caffeine/dihydrocodeine; aspirin/caffeine/dihydrocodeine; hydrocodone/acetaminophen; hydrocodone/ibuprofen; meperidine/promethazine; tramadol/acetaminophen; carisoprodol/aspirin/codeine High Dose Pain Medicine Prescriber Review: Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy. Sofosbuvir Sovaldi Move to Tier 5 Ivacaftor 150 mg Kalydeco 150 mg Move to Tier 5 Praziquantel Biltricide Move to Tier 3
Ritonavir 100 mg Norvir 100 mg Move to Tier 3 Dihydroergotamine mesylate nasal spray Migranal Move to Tier 5 Testosterone cypionate IM Depo-Testosterone Move to Tier 3 Bexarotene Targretin Ancillary charge Pegvisomant Somavert Limited to Kaiser Guselkumab Tremfya Add QL of 1 syringe per 56 days Brodalumab Siliq Add QL of 2 syringes per 28 days Empagliflozin/metformin ER Synjardy XR Add QL of 30 tablets Codeine sulfate; hydromorphone; levorphanol; morphine sulfate; oxycodone IR; oxycodone/acetaminophen; oxycodone/aspirin; tramadol; tramadol/acetaminophen; buprenorphine sublingual; acetaminophen/codeine; hydrocodone/acetaminophen; hydrocodone/ibuprofen; meperidine; oxymorphone; tapentadol; oxycodone/ibuprofen; butalbital/acetaminophen/caffeine/codeine; butalbital/aspirin/caffeine/codeine; acetaminophen/caffeine/dihydrocodeine Endocet; Lorcet; Lorcet Plus; Lortab; Dilaudid; Demerol; Roxicodone; Opana; Nucynta; Ultram; Percocet; Primlev; Tylenol #3; Tylenol #4; Capital/codeine; Fioricet; Fiorinal; Panlor; Synalgos-DC; Trezix; Norco; Vicodin; Vicodin ES; Vicodin HP; Verdrocet; Xodol; Hycet; Zamicet; Ibudone; Reprexain; Vicoprofen; Xylon; Ultracet; Oxaydo Up short acting opioid QL for 7 days history of use. Maximum quantity now: 42 units or 210mLs for age >21 years; 18 units or 90mLs for age <21 years Atazanavir sulfate Sustiva Move to Tier 3 Efavirenz Reyataz capsules Move to Tier 5 Tenofovir disoproxil fumarate Viread Move to Tier 3 Codeine/chlorpheniramine Tuzistra XR Add PA Dapagliflozin/saxagliptin Qtern Add QL of 30 tablets
Doxylamine/pyridoxine Diclegis Add PA Diclofenac Cambia; Zorvolex Add PA Dextromethorphan/quinidine Nuedexta Add PA Icatibant acetate Firazyr Limited to Kaiser Immune globulin Hizentra Limited to Kaiser Fluticasone propionate Flonase Move to Tier 3, add PA Beclomethasone dipropionate Beconase AQ; Qnasl Add PA Ciclesonide Omnaris; Zetonna Add PA Budesonide Rhinocort Aqua Add PA Mometasone furoate Nasonex Add PA Promethazine/codeine Promethazine/phenylephrine/codeine Phenergan with codeine Phenergan VC with codeine Move to Tier 3; add PA Move to Tier 3; add PA Enoxaparin sodium Lovenox Ancillary charge Tofacitinib citrate ER Xeljanz XR Limited to Kaiser Prasugrel Effient Move to Tier 3 Moxifloxacin Vigamox Move to Tier 3 Fosamprenavir Lexiva Move to Tier 5 Abacavir Ziagen Move to Tier 3 Sevelamer Renvela Move to Tier 3 Estradiol Climara Move to Tier 3 01/01/2018 11/13/2017
Enoxaparin Lovenox Move to Tier 3 Clidinium/chlordiazepoxide Librax Move to Tier 3 Scopolamine Transderm Scop Ancillary charge (generic available) Zileuton ER Zyflo CR Move to Tier 5 Becaplermin Regranex gel Move to Tier 5 Lurasidone Latuda Move to Tier 5 Dichlorphenamide Keveyis Move to Tier 5 Lanthanum carbonate Fosrenol Move to Tier 5 Felbamate Felbatol Move to Tier 5 Rufinamide Banzel Move to Tier 5 Alosetron Lotronex Move to Tier 5 Adefovir dipivoxil Hepsera Move brand to Tier 5; Move generic to Tier 4 Vancomycin Vancocin Move brand to Tier 5; Move generic to Tier 4 Erythromycin ethylsuccinate suspension Eryped; E.E.S. Move to Tier 3 Calcitriol Vectical ointment Move to Tier 2 Oxycodone Oxycontin CR Move to Tier 2 Mesalamine Asacol HD Move to Tier 2 Fluorouracil Carac cream Move to Tier 2 Colchicine Mitigare Move to Tier 2 Lenvatinib Lenvima Limited to Kaiser
Codeine sulfate; acetaminophen/codeine; promethazine/codeine; promethazine/phenylephrine/codeine; chlorpheniramine/codeine Tylenol with codeine; Phenergan with codeine; Lexuss; Tuzistra XR; Codar AR Cyclobenzaprine ER Amrix Add PA; add QL of 21 capsules per 180 days Methylpheni ER Cotempla Add QL of 30 tablets Amphetamine/dextroamphetamine Mydayis Add QL of 30 capsules per 30 days Fentanyl Actiq; Subsys; Abstral; Fentora; Lazanda Add PA Add QL of 4 dosing units per day Daclizumab Zinbryta Add QL of 1 syringe per 28 days Mometasone/formoterol Dulera Move to Tier 3 Ethacrynic acid Edecrin Add PA Ethacrynic acid Edecrin Move to Tier 3 01/01/2018 10/11/2017