PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand = Sabril Pak) lanthanum chewable tab (Brand = Fosrenol ) lamotrigine starter kit (Brand = Lamictal Starter Kit) paroxetine cap (Brand = Brisdelle ) fosamprenavir calcium tab (Brand = Lexiva ) sodium phenylbutyrate tab (Brand = Buphenyl ) abacavir sulfate soln 20 mg/ml (Brand = Ziagen ) glatiramer acetate 40 mg/ml (Brand = Copaxone ) dapsone gel 5% (Brand = Aczone ) Current As of 4/1/18 G No Change Generic Addition 8/7/17 G No Change Generic Addition 8/21/17 G/SP* No Change Generic Addition 8/28/17 G No Change Generic Addition 9/4/17 G No Change Generic Addition 9/18/17 G No Change Generic Addition 9/25/17 G No Change Generic Addition 9/25/17 G/SP* No Change Generic Addition 9/25/17 G No Change Generic Addition 10/2/17 G/SP* No Change Generic Addition 10/9/17 G No Change Generic Addition 10/23/17 (continued)
Drug Name Current As of 4/1/18 sildenafil citrate G + PA + QL No Change Generic Addition 12/18/17 (Brand = Viagra ) (8 per 30 days) Epiduo Gel 0.1-2.5% PB NPD adapalene-benzoyl-peroxide Gel Brand Uptier 4/1/18 (generic = adapalenebenzoyl-peroxide Gel 0.1-2.5%) 0.1-2.5% Lexiva PB NPD fosamprenavir calcium Brand Uptier 4/1/18 (generic = fosamprenavir calcium) Viagra PB + QL + PA NPD + QL + PA sildenafil citrate 25 mg, 50 mg, Brand Uptier 4/1/18 (generic = sildenafil citrate) 100 mg tramadol ER cap 100 mg, G + QL NPD + QL tramadol IR/ER tabs Generic Uptier 4/1/18 150 mg, 200 mg, 300 mg Cotempla XR ODT NPD + PA +QL No Change 8/7/17 Duzallo NPD + PA No Change 9/4/17 Trelegy Ellipta NPD + PA No Change 10/9/17 Ximino NPD + PA No Change 10/16/17 Xhance MIS 93 mcg NPD + PA No Change 10/16/17 ArmonAir RespiClick NPD + PA No Change 8/14/17 Idhifa NPD/SP + PA No Change 8/7/17 Verzenio NPD/SP + PA No Change 10/9/17 Symproic NPD + PA No Change 10/9/17 Proctocort supp 30 mg Excluded NPD + PA Coverage Added PA Addition 4/1/18 Endari powder NPD NPD + PA PA Addition 4/1/18 Baxdela NPD NPD + PA PA Addition 4/1/18 dihydroergotamine G G + PA PA Addition 4/1/18 nasal spray Aplenzin NPD NPD + PA PA Addition 4/1/18 Focalin XR 25 mg, 35 mg NPD + QL NPD + QL + PA PA Addition 4/1/18 (continued)
Drug Name Current As of 4/1/18 Topamax Tab NPD NPD + PA PA Addition 4/1/18 Topamax Sprinkle NPD NPD + PA PA Addition 4/1/18 Avidoxy G + PA G No Change PA Removal 4/1/18 Fiasp Soln NPD + QL No Change 10/9/17 Fiasp Flex NPD + QL No Change 10/9/17 Migranal Nasal Spray NPD + PA No Change No Change Updated PA Criteria 4/1/18 Bevyxxa NPD NPD + QL No Change 42 days supply per 4/1/18 180 days acetaminophen-codeine 6 per 1 day 12 per 1 day No Change Updated QL 3/1/18 300/15 mg, 300/30 mg codeine 15 mg, 30 mg 6 per 1 day 12 per 1 day No Change Updated QL 3/1/18 dihydrocodeine-aspirincaffeine 6 per 1 day 10 per 1 day No Change Updated QL 3/1/18 356.4-30-16 caps (Brand = Synalgos ) hydrocodoneacetaminophen 6 per 1 day 12 per 1 day No Change Updated QL 3/1/18 2.5/325 mg, 5/300 mg, 7.5/300 mg, 7.5/325 mg (Brand = Vicodin, Norco, Lortab, Xodol ) morphine 10 mg/5 ml liq 34 ml per 1 day 45 ml per 1 day No Change Updated QL 3/1/18 morphine 20 mg/5 ml liq 34 ml per 1 day 23 ml per 1 day No Change Updated QL 3/1/18 morphine 5 mg Supp 6 per 1 day 18 per 1 day No Change Updated QL 3/1/18 Oxaydo 5 mg 6 per 1 day 12 per 1 day No Change Updated QL 3/1/18 Oxaydo 7.5 mg 6 per 1 day 8 per 1 day No Change Updated QL 3/1/18 oxycodone 5 mg tab/cap 6 per 1 day 12 per 1 day No Change Updated QL 3/1/18 oxycodone 5 mg/5 ml liq 90 ml per 1 day 60 ml per 1 day No Change Updated QL 3/1/18 (continued)
Drug Name oxycodone-acetaminophen 2.5/325 mg, 5/300 mg, 5/325 mg, Endocet (Brand = Percocet, Primlev ) oxycodone-acetaminophen 7.5/325mg, Endocet (Brand = Percocet, Primlev ) oxycodone-acetaminophen 5 mg/325 mg/5 ml liq oxycodone-aspirin 4.8355/325 mg oxycodone-ibuprofen 5/400 mg tramadol-acetaminophen 37.5/325 mg Current As of 4/1/18 6 per 1 day 12 per 1 day No Change Updated QL 3/1/18 6 per 1 day 8 per 1 day No Change Updated QL 3/1/18 1000 ml per 60 ml per 1 day No Change Updated QL 3/1/18 30 days 6 per 1 day 12 per 1 day No Change Updated QL 3/1/18 28 per 30 days 4 per 1 day No Change Updated QL 3/1/18 40 per 30 days 40 per 5 days No Change Updated QL 3/1/18
Abbreviation Key G PB NPD SP NF PA QL Generic Addition Generic Uptier Brand Downtier Brand Uptier Brand Addition Brand/Generic Deletion 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. Quantity limits A generic drug that recently became available in the marketplace. These generic drugs 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.amerihealthnj.com AmeriHealth HMO, Inc. AmeriHealth Insurance Company of New Jersey