August 2017 Pharmacy Formulary Change Notice BlueChoice HealthPlan Medicaid is here to help you stay on top of your health care. We want to tell you about some upcoming changes to your Preferred Drug List (PDL) as of August 1, 2017. Your PDL is a list of preferred drugs covered by BlueChoice HealthPlan Medicaid. A group of doctors and pharmacists check the PDL to make sure the drugs you re taking are safe and effective. Medication SPIRIVA 18 MCG CP-HANDIHALER DIFFERIN 0.1% GEL (OTC PRODUCT) (BRAND ONLY) COUMADIN 1 MG TABLET COUMADIN 2 MG TABLET COUMADIN 2.5 MG TABLET COUMADIN 3 MG TABLET COUMADIN 4 MG TABLET COUMADIN 5 MG TABLET COUMADIN 6 MG TABLET COUMADIN 7.5 MG TABLET COUMADIN 10 MG TABLET EQUETRO 100 MG CAPSULE EQUETRO 200 MG CAPSULE EQUETRO 300 MG CAPSULE LITHIUM 8 MEQ/5 ML SOLUTION LITHIUM 8 MEQ/5 ML SOLUTION TOUJEO SOLOSTAR 300 UNITS/ML Effective for all members on August 1, 2017 Changes WITH STEP THERAPY WITH PRIOR AUTHORIZATION (PA) ADD QUANTITY LIMIT (QL)* 15 ML PER 30 DAYS Your doctor may change it to one of these preferred drugs: SPIRIVA RESPIMAT 2.5 MCG INHALER SPIRIVA RESPIMAT 1.25 MCG INHALER WARFARIN TABLET JANTOVEN TABLET www.bluechoicescmedicaid.com BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections. WEBMBSC-0173-17 8/17
HUMULIN R 500 UNITS/ML VIAL HUMULIN R 500 UNITS/ML KWIKPEN NOVOLOG 100 UNIT/ML VIAL NOVOLOG 100 UNITS/ML FLEXPEN NOVOLOG 100 UNIT/ML CARTRIDGE LANTUS 100 UNITS/ML VIAL BASAGLAR 100 UNIT/ML KWIKPEN LANTUS SOLOSTAR 100 UNITS/ML HUMALOG 100 UNITS/ML VIAL HUMALOG 100 UNITS/ML KWIKPEN HUMALOG 200 UNITS/ML KWIKPEN HUMALOG 100 UNITS/ML CARTRIDGE LEVEMIR 100 UNITS/ML VIAL LEVEMIR FLEXTOUCH 100 UNITS/ML HUMULIN R 100 UNITS/ML VIAL NOVOLIN R 100 UNITS/ML VIAL RELION NOVOLIN R 100 UNIT/ML HUMULIN N 100 UNITS/ML VIAL NOVOLIN N 100 UNITS/ML VIAL RELION NOVOLIN N 100 UNIT/ML HUMULIN N 100 UNITS/ML KWIKPEN NOVOLOG MIX 70-30 VIAL NOVOLOG MIX 70-30 FLEXPEN SYRN HUMALOG MIX 75-25 VIAL HUMALOG MIX 50-50 VIAL HUMALOG MIX 75-25 KWIKPEN HUMALOG MIX 50-50 KWIKPEN HUMULIN 70-30 VIAL NOVOLIN 70-30 100 UNIT/ML VIAL RELION NOVOLIN 70-30 VIAL HUMULIN 70/30 KWIKPEN AFREZZA 90-4 UNIT AFREZZA 90-8 UNIT HYDROXYPROGESTERONE 1.25 G/5ML MAKENA 1;250 MG/5 ML VIAL MAKENA 250 MG/ML VIAL NALOXONE 0.4 MG/ML VIAL NALOXONE 4 MG/10 ML VIAL BD LUER-LOK SYRINGE 1ML 20GX1' LIDOCAINE 5% LIDOCAINE HCL 4% SOLUTION LIDOCAINE 2% VISCOUS SOLN LIDOCAINE HCL 4% SOLUTION 21ML PER 30 DAYS 30ML PER 30 DAYS 6 BOXES PER 30 DAYS 4 BOXES PER 30 DAYS WITH PA 5GMS PER DAY 10ML PER DAY
METRONIDAZOLE TOPICAL 1% GEL METRONIDAZOLE TOP 1% GEL PUMP HYDROCORTISONE 0.5 % TRIAMCINOLONE ACETONIDE 0.5 % TRIAMCINOLONE ACETONIDE 0.5 % ALCLOMETASONE DIPROPIONATE 0.05 % ALCLOMETASONE DIPROPIONATE 0.05 % HYDROCORTISONE BUTYRATE 0.1 % LOCOID 0.1 % HYDROCORTISONE BUTYRATE 0.1 % LOCOID LIPO 0.1 % SOLUTION, NON-ORAL CORMAX 0.05 % SOLUTION, NON-ORAL HALOBETASOL PROPIONATE 0.05 % ULTRAVATE 0.05 % HALOBETASOL PROPIONATE 0.05 % ULTRAVATE 0.05 % AMCINONIDE 0.1 % AMCINONIDE 0.1 % DESONIDE 0.05 % DESOWEN 0.05 % TRIDESILON 0.05 % DESONIDE 0.05 % LOTION (ML) DESOWEN 0.05 % LOTION (ML) DESONIDE 0.05 % DESOXIMETASONE 0.25 % TOPICORT 0.25 % DESOXIMETASONE 0.05 % GEL TOPICORT 0.05 % GEL DESOXIMETASONE 0.25 % TOPICORT 0.25 % DIFLORASONE DIACETATE 0.05 % PSORCON 0.05 % DIFLORASONE DIACETATE 0.05 % APEXICON E 0.05 % CUTIVATE 0.05 % 30GMS PER 30 DAYS 45GMS PER 30 DAYS 50GMS PER 30 DAYS 60GMS PER 30 DAYS
FLUTICASONE PROPIONATE 0.05 % FLUTICASONE PROPIONATE 0.005 % HALOG 0.1 % HALOG 0.1 % PANDEL 0.1 % CLOCORTOLONE PIVALATE 0.1 % CLODERM 0.1 % DERMATOP 0.1 % PREDNICARBATE 0.1 % DERMATOP 0.1 % PREDNICARBATE 0.1 % FOAM OLUX 0.05 % FOAM BETAMETHASONE DIPROPIONATE 0.05 % BETAMETHASONE DIPROPIONATE 0.05 % LOTION (ML) BETAMETHASONE DIPROPIONATE 0.05 % BETAMETHASONE VALERATE 0.1 % BETAMETHASONE VALERATE 0.1 % LOTION (ML) BETAMETHASONE VALERATE 0.1 % TEMOVATE 0.05 % TEMOVATE 0.05 % CLOBETASOL E 0.05 % FLUOCINOLONE ACETONIDE 0.01 % SOLUTION, NON-ORAL SYNALAR 0.01 % SOLUTION, NON-ORAL FLUOCINOLONE ACETONIDE 0.01 % FLUOCINOLONE ACETONIDE 0.025 % 80GMS PER 30 DAYS 90GMS PER 30 DAYS 100GMS PER 30 DAYS 120GMS PER 30 DAYS
SYNALAR 0.025 % FLUOCINOLONE ACETONIDE 0.025 % SYNALAR 0.025 % CAPEX SHAMPOO 0.01 % SHAMPOO FLUOCINONIDE 0.05 % FLUOCINONIDE 0.1 % VANOS 0.1 % HYDROCORTISONE VALERATE 0.2 % HYDROCORTISONE VALERATE 0.2 % FLUOCINONIDE 0.05 % SOLUTION, NON-ORAL FLUOCINONIDE 0.05 % GEL FLUOCINONIDE 0.05 % TRIANEX 0.05 % TRIAMCINOLONE ACETONIDE 0.025 % TRIAMCINOLONE ACETONIDE 0.1 % TRIDERM 0.1 % TRIAMCINOLONE ACETONIDE 0.025 % TRIAMCINOLONE ACETONIDE 0.1 % PREMARIN VAGINAL 180GMS PER 30 DAYS 240GMS PER 30 DAYS 430GMS PER 30 DAYS 454 GMS PER 30 DAYS WITH STEP THERAPY YUVAFEM 10 MCG VAGINAL INSERT YUVAFEM 10 MCG VAGINAL INSERT (BRAND ONLY) ELIXOPHYLLIN 80 MG/15 ML ELIX (BRAND ONLY) THEO-24 ER 100 MG CAPSULE THEO-24 ER 200 MG CAPSULE THEO-24 ER 300 MG CAPSULE THEO-24 ER 400 MG CAPSULE THEOPHYLLINE ER 400 MG TABLET THEOPHYLLINE ER 600 MG TABLET THEOPHYLLINE 80 MG/15 ML SOLN THEOPHYLLINE ER TABLETS
What does this mean for you? Some medications you take may no longer be preferred. You ll need approval from us to continue to get these medications. What should I do if I use a nonpreferred drug? Talk with your doctor to see if you can change to the new preferred drug. If your doctor says you can take the new preferred drug, ask him or her to write a new prescription for you. You and your doctor have the final say in your care. Things to remember: This doesn t change which pharmacy you go to or where you get your care. If your doctor writes a prescription for or says you need to keep using a nonpreferred drug, he or she will need to get approval from BlueChoice HealthPlan Medicaid first by calling 1-866-781-5094 (TTY 1-866-773-9634). Your health is important to us that s why we have our experienced team of doctors and pharmacists regularly review this list to keep you safe and healthy. Questions? Call us at the Customer Care Center at 1-866-781-5094 (TTY 1-866-773-9634) Monday through Friday from 8 a.m. to 6 p.m. Do you need help with your health care, talking with us, or reading what we send you? We provide our materials in other languages and formats at no cost to you. Call us toll free at 1-866-781-5094 (TTY 1-866-773-9634). Necesita ayuda con su cuidado de la salud, para hablar con nosotros o leer lo que le enviamos? Proporcionamos nuestros materiales en otros idiomas y formatos sin costo alguno para usted. Llámenos a la línea gratuita al 1-866-781-5094 (TTY 1-866-773-9634). هل تحتاج إلى مساعدة في رعايتك الصحية أو في التحد معنا أو قراءة ما نقوم بإرساله إليك نحن نقدم المواد الخاصة بنا بلغات وتنسيقات أخرى بدون تكلفة عليك. اتصل بنا على الرقم المجاني 1-866-781-5094 -1-866-773 (TTY.9634)