BLUE SHIELD OF CALIFORNIA MARCH 2016 STANDARD DRUG FORMULARY CHANGES Blue Shield is committed to covering safe, effective and affordable medications, so we regularly review and update our drug formularies. Our Pharmacy and Therapeutics (P&T) Committee is made up of a group of practicing physicians and pharmacists who meet quarterly to recommend changes to our formulary based on the latest medical literature, new clinical guidelines, new information from key physician experts, and new information from the Food and Drug Administration. Changes to the Standard Drug Formulary from the P&T Committee meeting are outlined below. To view a copy of the Standard Drug Formulary, please download a copy. The drugs listed below are to be used for FDA-approved indications but may also be used for other conditions. 1. DRUGS ADDED TO FORMULARY The following drugs were added to the formulary: Drug FDA Indication(s) Coverage Restriction(s) Tier Status cyclopentolate 2% drops (generic Cyclogyl) fluticasone propionate (generic Flonase) metformin extendedrelease tablet (generic Glumetza) naftifine 2% cream (generic Naftin) naloxone 0.4mg/ml vial and syringe, 2mg/2ml syringe norgestimate-ethinyl estradiol, tri-lo-sprintec, tri-lo-estarylla, trinessa lo, tri-lo-marzia (generic Ortho Tri-Cyclen Lo) olopatadine 0.1% drops (generic Patanol) Otezla Praluent pramipexole 2.25mg extended-release (generic Mirapex ER) Tanzeum Mydriasis, Cycloplegia Allergic and non-allergic rhinitis Tinea pedis, Tinea cruris, Tinea corporis Prior authorization required. Step therapy required Opioid overdose Add quantity limit Prevent pregnancy Allergic conjunctivitis Psoriatic arthritis, Plaque psoriasis Hypercholesterolemia Prior authorization required, Prior authorization required, Tier 4 # Tier 4 # Parkinson s disease Step therapy required, Page 1 of 6
Drug FDA Indication(s) Coverage Restriction(s) Tier Status Toujeo Solostar Diabetes # must be obtained through a network specialty pharmacy Tier 2 (effective 1/1/2017) 2. FORMULARY DRUGS WITH CHANGES TO TIER AND/OR COVERAGE RESTRICTION The following drugs have coverage restriction(s) added or removed, and/or change of tier status as noted: DRUG FDA Indication(s) Coverage Restriction(s) Tier Status aripiprazole (generic Abilify) tablet, solution mania, Depression, Autistic, Tourette s Add quantity limit Azilect Parkinson s disease budesonide (generic Entocort EC) clobetasol (generic Clobex) lotion clobetasol (generic Clobex) shampoo Crohn s disease Corticosteroid responsive, Plaque psoriasis, quantity limit (effective 2017) Step therapy required Tier 2 Scalp psoriasis Step therapy required clozapine odt (generic Fazaclo) Schizophrenia dihydroergotamine mesylate (generic D.H.E. 45) dihydroergotamine (generic Migranal) nasal Epivir HBV solution exemestane (generic Aromasin) fluocinolone (generic Synalar) solution lamivudine (generic Epivir HBV) tablet metformin extended-release (generic Fortamet) phenoxybenzamine (generic Dibenzyline) Migraine, Cluster headache Migraine Hepatitis B Breast cancer Corticosteroid responsive Hepatitis B Pheochromocytoma Prior authorization required. Add step therapy.. Remove prior authorization. Remove age and gender edit Add step therapy. Remove prior authorization Tier 4 Tier 4 Tier 2 Page 2 of 6
risperidone odt (generic Risperdal M-Tab) ziprasidone (generic Geodon) Anti-retrovirals abacavir (generic Ziagen) tablet abacavir/lamivudine/zidovudine (generic Trizivir), Autistic HIV infection Add quantity limit HIV infection Add quantity limit Atripla HIV infection Add quantity limit Complera HIV infection Add quantity limit Crixivan HIV infection Add quantity limit Tier 2 didanosine (generic Videx EC) HIV infection Add quantity limit Edurant HIV infection Add quantity limit Tier 2 Emtriva HIV infection Add quantity limit Tier 2 Epzicom HIV infection Add quantity limit Tier 2 Intelence HIV infection Step therapy required. Add quantity limit Tier 2 Invirase HIV infection Add quantity limit Tier 2 Isentress HIV infection Add quantity limit Tier 2 Kaletra HIV infection Add quantity limit Tier 2 lamivudine (generic Epivir) HIV infection Add quantity limit lamivudine/zidovudine (generic Combivir) HIV infection Add quantity limit Lexiva HIV infection Add quantity limit Tier 2 nevirapine (generic Viramune) HIV infection Add quantity limit nevirapine extende-release (generic Viramune R) HIV infection Add quantity limit Norvir HIV infection Add quantity limit Tier 2 Prezista HIV infection Add quantity limit Tier 2 Rescriptor HIV infection Add quantity limit Tier 2 Reyataz capsule HIV infection Add quantity limit Tier 2 Selzentry HIV infection Prior authorization required. Add quantity limit Tier 2 stavudine (generic Zerit) HIV infection Add quantity limit Sustiva HIV infection Add quantity limit Tier 2 Truvada HIV infection Add quantity limit Tier 2 Page 3 of 6
Viracept HIV infection Add quantity limit Tier 2 zidovudine (generic Retrovir) capsule, syrup HIV infection Add quantity limit 3. DRUGS REMOVED FROM THE FORMULARY The following drugs will be removed from the formulary starting January 2017. Non-formulary drugs require a formulary exception based on medical necessity for coverage. Drug FDA Indication(s) Formulary Alternative(s) Bydureon, Bydureon pen, Byetta metformin, sulfonylurea, TZD, Tanzeum (steptherapy required) Glucophage metformin (generic Glucophage) Glucophage XR metformin extended release (generic Glucophage XR) Glucovance glyburide/metformin (generic Glucovance) Kasano, Nesina, Oseni Kombiglyze XR, Onglyza Latuda Januvia, Janumet (step therapy required for both) Januvia, Janumet (step therapy required for both) olanzapine, quetiapine, risperidone Levemir, Levemir Flextouch Diabetes Lantus, Toujeo metformin extended-release (generic Fortamet) metformin extended-release (generic Glucophage XR) Nasonex Allergic rhinitis fluticasone nasal Nuvigil olanzapine-fluoxetine (generic Symbyax) Saizen Saphris Seroquel XR Topical Corticosteroids Obstructive sleep apnea, Narcolepsy, Shift work Bipolar, Depression Growth hormone deficiency mania, Depression modafinil (PA required) olanzapine, quetiapine, risperidone Nutropin, Nutropin AQ (PA required) olanzapine, quetiapine, risperidone quetiapine (generic Seroquel) Page 4 of 6
Drug FDA Indication(s) Formulary Alternative(s) amcinonide cream, lotion, ApexiCon E betamethasone valerate (generic Luxiq) foam clobetasol (generic Clobex) spray Clodan clocortolone (generic Cloderm) cream desonide (generic Desowen) lotion desoximetasone (generic Topicort) 0.05% cream desoximetasone (generic Topicort) gel,, 0.25% cream diflorasone cream, fluocinolone (generic Derma- Smoothe-FS) body oil fluocinolone (generic Derma- Smoothe-FS) scalp oil fluticasone (generic Cutivate) lotion of the scalp Plaque psoriasis Scalp psoriasis Atopic dermatitis Scalp psoriasis fluocinonide 0.05% gel, cream,, solution; betamethasone augmented 0.05% cream, lotion,, gel fluocinonide 0.05% gel, cream,, solution; betamethasone augmented 0.05% cream, lotion,, gel, lotion; betamethasone valerate 0.1% cream,, lotion; TAC 0.1% cream,, lotion; fluticasone 0.05% cream, ; mometasone 0.1% cream, clobetasol cream,, solution, gel, cream emollient clobetasol cream,, solution, gel, cream emollient, lotion; betamethasone valerate 0.1% cream,, lotion; TAC 0.1% cream,, lotion; fluticasone 0.05% cream, ; mometasone 0.1% cream, hydrocortisone 2.5% cream,, lotion; alclometasone 0.05% cream,, lotion; betamethasone valerate 0.1% cream,, lotion; TAC 0.1% cream,, lotion; fluticasone 0.05% cream, ; mometasone 0.1% cream, fluocinonide 0.05% gel, cream,, solution; betamethasone augmented 0.05% cream, lotion,, gel betamethasone, augmented 0.05% lotion,, gel, cream hydrocortisone 2.5% cream,, lotion; alclometasone 0.05% cream, hydrocortisone 2.5% cream,, lotion; alclometasone 0.05% cream,, lotion; betamethasone valerate 0.1% cream,, lotion; TAC 0.1% cream,, lotion; fluticasone 0.05% cream, ; mometasone 0.1% cream, Page 5 of 6
Drug FDA Indication(s) Formulary Alternative(s) hydrocortisone butyrate/emollient (generic Locoid Lipocream) cream Scalacort triamcinolone acetonide (generic Kenalog) spray Trianex, lotion; betamethasone valerate 0.1% cream,, lotion; TAC 0.1% cream,, lotion; fluticasone 0.05% cream, ; mometasone 0.1% cream, hydrocortisone 2.5% cream,, lotion; alclometasone 0.05% cream,, lotion; betamethasone valerate 0.1% cream,, lotion; TAC 0.1% cream,, lotion; fluticasone 0.05% cream, ; mometasone 0.1% cream,, lotion; betamethasone valerate 0.1% cream,, lotion; TAC 0.1% cream,, lotion; fluticasone 0.05% cream, ; mometasone 0.1% cream, 4. DRUGS REMOVED FROM COVERAGE The following drugs were excluded from coverage because they are not approved by the Food and Drug Administration (FDA): Drug Ala-quin cream hydrocortisone-iodoquinol cream, cream pack Iodosorb gel Drug Nicomide Ultrasal ER Vytone Page 6 of 6