Blue Shield 65 Plus Choice Plan (HMO) Formulary Updates: The enclosed table lists the changes made to your formulary such as removing or adding: a drug, prior authorization, quantity limits or step therapy as well as any changes to a cost sharing tier. The table also includes the reasons for the changes and alternative drug(s) if. Abbreviation Key: AG: coverage limits based on age; BvD: requires prior authorization review to determine whether coverage is under Part B or Part D of the Medicare benefit; LA: prescription may be available only at certain pharmacies; PA: Prior Authorization; QL: Quantity Limit; ST: Step Therapy Key 1/PG: Preferred Generic s 2/G: Generic s 3/PB: Preferred Brand s 4/NPB: Non-Preferred Brand s 5/Inj: Injectable s 6/Spec: Specialty s Y0118_17_469B NM 10232017 Blue Shield of California 50 Beale Street, San Francisco, CA 94105 blueshieldca.com Blue Shield of California is an independent member of the Blue Shield Association
Name Alternative (If EPCLUSA 400-100MG TABLET Formulary Addition 01/01/18 6 PA, QL HARVONI 90MG-400MG TABLET Formulary Addition 01/01/18 6 PA, QL LYRICA 100MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 150MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 200MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 20MG/ML SOLUTION Formulary Addition 01/01/18 3 QL LYRICA 225MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 25MG CAPSULE Formulary Addition 01/01/18 3 QL
Name Alternative (If LYRICA 300MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 50MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 75MG CAPSULE Formulary Addition 01/01/18 3 QL MAVYRET 100MG-40MG TABLET Formulary Addition 01/01/18 6 PA, QL methadone 10mg tablet Formulary Addition 01/01/18 4 PA, QL methadone 10mg/5ml solution Formulary Addition 01/01/18 4 PA, QL methadone 10mg/ml solution Formulary Addition 01/01/18 5 BvD, QL methadone 5mg tablet Formulary Addition 01/01/18 4 PA, QL
Name Alternative (If methadone 5mg/5ml solution Formulary Addition 01/01/18 4 PA, QL methadose 10mg tablet Formulary Addition 01/01/18 4 PA, QL MIACALCIN 200/ML VIAL 01/01/18 5 olopatadine 2mg/ml ophthalmic solution Formulary Addition 01/01/18 3 QL sevelamer carbonate 2400mg powder pack Formulary Addition 01/01/18 3 sevelamer carbonate 800mg powder pack Formulary Addition 01/01/18 3 sevelamer carbonate 800mg tablet Formulary Addition 01/01/18 3 VOSEVI 400-100MG TABLET Formulary Addition 01/01/18 6 PA, QL
Name Alternative (If XARELTO 10MG TABLET Formulary Addition 01/01/18 3 QL XARELTO 15MG TABLET Formulary Addition 01/01/18 3 QL XARELTO 20MG TABLET Formulary Addition 01/01/18 3 QL XARELTO KIT 15MG-20MG TABLET DS PK Formulary Addition 01/01/18 3 QL ZEPATIER 50MG-100MG TABLET Formulary Addition 01/01/18 6 PA, QL ADACEL 2-2.5-5/.5 INTRAMUSCULAR SYRINGE Formulary Addition 03/01/18 5 ALIQOPA 60MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD ALUNBRIG 180MG TABLET Formulary Addition 03/01/18 6 PA, QL
Name Alternative (If ALUNBRIG 90MG TABLET Formulary Addition 03/01/18 6 PA, QL ALUNBRIG 90MG-180MG TABLET Formulary Addition 03/01/18 6 PA, QL amlodipine besylate/valsartan 5 mg-160mg tablet amlodipine besylate-valsartan 10 mg-160mg tablet amlodipine besylate-valsartan 10 mg-320mg tablet amlodipine besylate-valsartan 5 mg-320mg tablet amlodipine-olmesartan 10mg/20mg tablet amlodipine-olmesartan 10mg/40mg tablet 03/01/18 2 QL 03/01/18 2 QL 03/01/18 2 QL 03/01/18 2 QL 03/01/18 4 QL 03/01/18 4 QL
Name Alternative (If amlodipine-olmesartan 5mg/20mg tablet 03/01/18 4 QL amlodipine-olmesartan 5mg/40mg tablet 03/01/18 4 QL amlodipine-valsartan-hctz 10-160-12.5mg tablet 03/01/18 3 QL amlodipine-valsartan-hctz 10-160-25mg tablet 03/01/18 3 QL amlodipine-valsartan-hctz 10-325-25mg tablet 03/01/18 3 QL amlodipine-valsartan-hctz 5-160-12.5mg tablet 03/01/18 3 QL amlodipine-valsartan-hctz 5-160-25mg tablet 03/01/18 3 QL amnesteem 10mg capsule Formulary Addition 03/01/18 4
Name Alternative (If amnesteem 20mg capsule Formulary Addition 03/01/18 4 amnesteem 40mg capsule Formulary Addition 03/01/18 4 atazanavir sulfate 150mg capsule Formulary Addition 03/01/18 6 QL atazanavir sulfate 200mg capsule Formulary Addition 03/01/18 6 QL atazanavir sulfate 300mg capsule Formulary Addition 03/01/18 6 QL BAXDELA 300MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 BvD, QL BAXDELA 450MG TABLET Formulary Addition 03/01/18 6 PA, QL BENLYSTA 200MG/ML SQ AUTO INJCT Formulary Addition 03/01/18 6 PA, QL
Name Alternative (If BENLYSTA 200MG/ML SQ SYRINGE Formulary Addition 03/01/18 6 PA, QL BENZNIDAZOLE 100MG TABLET Formulary Addition 03/01/18 4 QL BENZNIDAZOLE 12.5MG TABLET Formulary Addition 03/01/18 4 QL BESPONSA 0.9MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD bortezomib 3.5mg intravenous vial Formulary Addition 03/01/18 6 BvD BOSULIF 400MG TABLET Formulary Addition 03/01/18 6 PA, QL buprenorphine 7.5mcg/hour patch tdwk Formulary Addition 03/01/18 4 PA, QL butalbital-aspirin-caffeine 50mg-325mg-40mg tablet Formulary Addition 03/01/18 2 QL
Name Alternative (If CALQUENCE 100MG CAPSULE Formulary Addition 03/01/18 6 PA, LA, QL carvedilol phosphate er 10mg cpmp 24hr Formulary Addition 03/01/18 4 ST carvedilol phosphate er 20mg cpmp 24hr Formulary Addition 03/01/18 4 ST carvedilol phosphate er 30mg cpmp 24hr Formulary Addition 03/01/18 4 ST carvedilol phosphate er 40mg cpmp 24hr Formulary Addition 03/01/18 4 ST caspofungin acetate 50mg vial Formulary Addition 03/01/18 6 PA, BvD caspofungin acetate 70mg vial Formulary Addition 03/01/18 6 PA, BvD clindamycin in 0.9 % sod chlor 300mg/50ml piggyback Formulary Addition 03/01/18 5
Name Alternative (If clindamycin in 0.9 % sod chlor 600mg/50ml piggyback Formulary Addition 03/01/18 5 clindamycin in 0.9 % sod chlor 600mg/50ml piggyback Formulary Addition 03/01/18 5 clobetasol 0.05% topical cream Formulary Addition 03/01/18 2 dactinomycin 0.5mg vial Formulary Addition 03/01/18 6 BvD desogestrel-ethinyl estradiol 0.15mg-0.03mg tablet Formulary Addition 03/01/18 2 digitek 125mcg tablet Formulary Addition 03/01/18 1 PA digitek 250mcg tablet Formulary Addition 03/01/18 1 PA digox 125mcg tablet Formulary Addition 03/01/18 1 PA
Name Alternative (If digox 250mcg tablet Formulary Addition 03/01/18 1 PA efavirenz 200mg capsule Formulary Addition 03/01/18 3 QL efavirenz 50mg capsule Formulary Addition 03/01/18 3 QL elite-ob 50mg iron-1.25mg tablet Formulary Addition 03/01/18 2 ESBRIET 267MG TABLET Quantity Limit Update 03/01/18 6 PA, QL ethynodiol-ethinyl estradiol tablet 1mg-35mcg tablet Formulary Addition 03/01/18 2 fosamprenavir 700mg tablet Formulary Addition 03/01/18 6 QL gemcitabine hcl 100mg/ml intravenous vial Formulary Addition 03/01/18 5 BvD
Name Alternative (If HAEGARDA 2,000 UNITS SUB-Q VIAL Formulary Addition 03/01/18 6 PA, LA HAEGARDA 3,000 UNITS SUB-Q VIAL Formulary Addition 03/01/18 6 PA, LA haloperidol decanoate 100mg/ml intramuscular vial Formulary Addition 03/01/18 5 HERCEPTIN 150MG VIAL Formulary Addition 03/01/18 6 BvD HUMALOG JUNIOR KWIKPEN 100UNIT/ML SQ INS PEN HF Formulary Addition 03/01/18 3 IDHIFA 100MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL IDHIFA 50MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL indomethacin er 75mg xr capsule Formulary Addition 03/01/18 2 PA
Name Alternative (If ISENTRESS HD 600MG TABLET Formulary Addition 03/01/18 6 QL isibloom 28 day 0.15-0.03mg tablet Formulary Addition 03/01/18 2 JULUCA 50MG-25MG TABLET Formulary Addition 03/01/18 6 QL lanoxin 125mcg tablet lanoxin 187.5mcg tablet lanoxin 250mcg tablet lanoxin 62.5mcg tablet 03/01/18 4 PA 03/01/18 4 PA 03/01/18 4 PA 03/01/18 4 PA lanthanum carbonate 500mg tablet chew Formulary Addition 03/01/18 6
Name Alternative (If lanthanum carbonate 1,000mg tablet chew Formulary Addition 03/01/18 6 lanthanum carbonate 750mg tablet chew Formulary Addition 03/01/18 6 LARTRUVO 10MG/ML INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD LEVO-T 0.025MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.05MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.075MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.088MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.112MG TABLET Formulary Addition 03/01/18 2
Name Alternative (If LEVO-T 0.125MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.137MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.15MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.175MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.1MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.2MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.3MG TABLET Formulary Addition 03/01/18 2 lidocaine 5% patch Formulary Addition 03/01/18 3 PA, QL
Name Alternative (If lidocaine hydrochloride 10mg/ml injectable solution Formulary Addition 03/01/18 5 lidocaine hydrochloride 5mg/ml injectable solution Formulary Addition 03/01/18 5 LYNPARZA 100MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL LYNPARZA 150MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL meropenem 1000mg intravenous vial Formulary Addition 03/01/18 5 mesalamine 1.2gm tablet Formulary Addition 03/01/18 3 QL mesalamine 4g/60ml rectal enema Formulary Addition 03/01/18 4 methotrexate 25 mg/ml 10ml vial Formulary Addition 03/01/18 5 BvD
Name Alternative (If moxifloxacin hcl 0.5% eye drops Formulary Addition 03/01/18 2 MYLOTARG 4.5MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD NERLYNX 40MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL NOVAREL 5,000UNIT VIAL Formulary Addition 03/01/18 5 BvD OPDIVO 240MG/24ML INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD oseltamivir phosphate 6mg/ml oral suspension Formulary Addition 03/01/18 3 QL oxaliplatin 100mg intravenous vial Formulary Addition 03/01/18 5 BvD piperacillin-tazobactam 2000mg-250mg intravenous vial Formulary Addition 03/01/18 5
Name Alternative (If prasugrel hcl 10mg tablet Formulary Addition 03/01/18 2 QL prasugrel hcl 5mg tablet Formulary Addition 03/01/18 2 QL PROLASTIN-C 2GRAM INTRAVENOUS VIAL Formulary Addition 03/01/18 6 BvD RITUXAN 10 MG/ML INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD RITUXAN HYCELA 1,400MG/11.7ML SUB-Q VIAL Formulary Addition 03/01/18 6 PA, BvD RITUXAN HYCELA 1,600MG/13.4ML SUB-Q VIAL Formulary Addition 03/01/18 6 PA, BvD romidepsin 10mg/2ml intravenous vial Formulary Addition 03/01/18 6 BvD RUBRACA 250MG TABLET Formulary Addition 03/01/18 6 PA, QL
Name Alternative (If scopolamine 1.5mg patch td 3 Formulary Addition 03/01/18 4 SELZENTRY 20MG/ML SOLUTION Formulary Addition 03/01/18 4 QL SHINGRIX 50MCG/0.5ML INTRAMUSCLAR KIT Formulary Addition 03/01/18 5 QL telmisartan 20mg tablet telmisartan 40mg tablet telmisartan 80mg tablet 03/01/18 3 QL 03/01/18 3 QL 03/01/18 3 QL tenofovir disoproxil fumarate 300mg tablet Formulary Addition 03/01/18 6 QL TRACLEER BOSENTAN 32MG TABLET SUSPENSION Formulary Addition 03/01/18 6 PA, QL
Name Alternative (If TREANDA 25MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 BvD TRELEGY ELLIPTA 100MCG- 62.5MCG-25MCG ACTUATION BLST W/DEV Formulary Addition 03/01/18 3 QL TRISENOX 12MG/6ML INTRAVENOUS VIAL Formulary Addition 03/01/18 5 BvD TWINRIX 720-20/ML INTRAMUSCLUAR SYRINGE Formulary Addition 03/01/18 5 BvD TYMLOS 80MCG/DOSE SQ PEN INJECTOR Formulary Addition 03/01/18 6 PA, QL VAQTA 25/0.5ML INTRAMUSCLUAR VIAL Formulary Addition 03/01/18 5 VAQTA 50 UNIT/ML INTRAMUSCLUAR VIAL Formulary Addition 03/01/18 5 VERZENIO 100MG TABLET Formulary Addition 03/01/18 6 PA, QL
Name Alternative (If VERZENIO 150MG TABLET Formulary Addition 03/01/18 6 PA, QL VERZENIO 200MG TABLET Formulary Addition 03/01/18 6 PA, QL VERZENIO 50MG TABLET Formulary Addition 03/01/18 6 PA, QL vigabatrin 500mg powder pack Formulary Addition 03/01/18 6 PA, QL VYXEOS LIPOSOME 44MG- 100MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD XATMEP 2.5MG/ML SOLUTION Formulary Addition 03/01/18 6 PA, QL ZENPEP 20-63-84K CAPSULE DR Formulary Addition 03/01/18 4 ZENPEP 40-126-168 UNIT CAPSULE DR Formulary Addition 03/01/18 4
Name Alternative (If zoledronic acid 4mg intravenous vial 03/01/18 5 BvD zoledronic acid 4mg/5ml intravenous vial 03/01/18 5 BvD zoledronic acid 5mg/100ml piggyback 03/01/18 5 ZYTIGA 500MG TABLET Formulary Addition 03/01/18 6 PA, QL BIKTARVY 50MG-200MG-5MG TABLET Formulary Addition 04/01/18 6 QL buprenorphine-naloxone 2mg- 0.5mg sublingual tablet buprenorphine-naloxone 8mg-2 mg sublingual tablet 04/01/18 3 QL 04/01/18 3 QL efavirenz 600mg tablet Formulary Addition 04/01/18 3 QL
Name Alternative (If ELIQUIS 5MG TABLET Formulary Addition 04/01/18 3 QL ENGERIX-B ADULT 20 MCG/ML Formulary Addition 04/01/18 5 BvD FASENRA 30 MG/ML SUB-Q SYRINGE Formulary Addition 04/01/18 6 PA, BvD haloperidol lactate 5mg/ml syringe Formulary Addition 04/01/18 5 INFANRIX DTAP 25-58-10 SYRINGE Formulary Addition 04/01/18 5 medroxyprogesterone acetate 150 mg/ml oral solution Formulary Addition 04/01/18 5 BvD MENVEO MenA COMPONENT PF 10MCG/0.5ML INTRAMUSCULAR SOLUTION MENVEO MenCYW 135 COMPONENT PF INTRAMUSCULAR SOLUTION Formulary Addition 04/01/18 5 Formulary Addition 04/01/18 5
Name Alternative (If REPATHA PUSHTRONEX 420 MG/3.5 WEAR INJCT Formulary Addition 04/01/18 6 PA, QL REPATHA SURECLICK 140 MG/ML PEN INJCTR Formulary Addition 04/01/18 6 PA, QL REPATHA SYRINGE 140 MG/ML SYRINGE Formulary Addition 04/01/18 6 PA, QL roweepra xr 500mg oral tablet Formulary Addition 04/01/18 2 QL roweepra xr 500mg oral tablet er 24h Formulary Addition 04/01/18 2 QL roweepra xr 750mg oral tablet Formulary Addition 04/01/18 2 QL roweepra xr 750mg oral tablet er 24h Formulary Addition 04/01/18 2 QL TENIVAC 5-2/0.5ML VIAL Formulary Addition 04/01/18 5
Name Alternative (If trientine hcl 250mg capsule Formulary Addition 04/01/18 6 PA VIVOTIF 2B UNIT CAPSULE DR Formulary Addition 04/01/18 3 VIVOTIF BERNA 2B UNIT CAPSULE DR Formulary Addition 04/01/18 3 ZUBSOLV 0.7-0.18MG SUBLINGUAL TABLET ZUBSOLV 1.4-0.36MG SUBLINGUAL TABLET ZUBSOLV 11.4-2.9MG SUBLINGUAL TABLET ZUBSOLV 2.9-0.71MG SUBLINGUAL TABLET ZUBSOLV 5.7-1.4 MG SUBLINGUAL TABLET 04/01/18 4 QL 04/01/18 4 QL 04/01/18 4 QL 04/01/18 4 QL 04/01/18 4 QL
Name Alternative (If ZUBSOLV 8.6-2.1MG SUBLINGUAL TABLET 04/01/18 4 QL abacavir 20mg/ml solution Formulary Addition 05/01/18 4 QL BIKTARVY 50MG-200MG-25MG TABLET Formulary Addition 05/01/18 6 QL DALIRESP 250MCG TABLET Formulary Addition 05/01/18 4 PA, QL desmopressin acetate 10/spray pump Formulary Addition 05/01/18 4 ERLEADA 60MG TABLET Formulary Addition 05/01/18 6 PA, QL glatiramer acetate 20mg/ml syringe Formulary Addition 05/01/18 6 PA, QL IMBRUVICA 140MG TABLET Formulary Addition 05/01/18 6 PA, LA, QL
Name Alternative (If IMBRUVICA 280MG TABLET Formulary Addition 05/01/18 6 PA, LA, QL IMBRUVICA 420MG TABLET Formulary Addition 05/01/18 6 PA, LA, QL IMBRUVICA 560MG TABLET Formulary Addition 05/01/18 6 PA, LA, QL IMBRUVICA 70MG CAPSULE Formulary Addition 05/01/18 6 PA, LA, QL isotretinoin 10mg capsule Formulary Addition 05/01/18 4 isotretinoin 20mg capsule Formulary Addition 05/01/18 4 isotretinoin 30mg capsule Formulary Addition 05/01/18 4 isotretinoin 40mg capsule Formulary Addition 05/01/18 4
Name Alternative (If kelnor 1mg-50mcg tablet Formulary Addition 05/01/18 2 LUPRON DEPOT-PED 11.25MG INTRAMUSCULAR KIT Formulary Addition 05/01/18 6 LUPRON DEPOT-PED 11.25MG INTRAMUSCULAR KIT 05/01/18 6 LUPRON DEPOT-PED 15MG INTRAMUSCULAR KIT Formulary Addition 05/01/18 6 LUPRON DEPOT-PED 30MG INTRAMUSCULAR KIT Formulary Addition 05/01/18 6 LUPRON DEPOT-PED 7.5MG INTRAMUSCULAR KIT 05/01/18 6 memantine hcl 14mg capsule spr 24 Formulary Addition 05/01/18 3 QL memantine hcl 21mg capsule spr 24 Formulary Addition 05/01/18 3 QL
Name Alternative (If memantine hcl 28mg capsule spr 24 Formulary Addition 05/01/18 3 QL memantine hcl 7mg capsule spr 24 Formulary Addition 05/01/18 3 QL methotrexate 25mg/ml 10ml vial Formulary Addition 05/01/18 5 BvD naloxone hcl 0.4mg/ml syringe Formulary Addition 05/01/18 2 QL ritonavir 100mg tablet Formulary Addition 05/01/18 4 QL sodium phenylbutyrate 500mg tablet Formulary Addition 05/01/18 6 PA SYMFI LO 400-300MG TABLET Formulary Addition 05/01/18 6 QL tiagabine hcl 12mg tablet Formulary Addition 05/01/18 3 PA
Name Alternative (If tiagabine hcl 16mg tablet Formulary Addition 05/01/18 3 PA VIDEX EC 125MG CAPSULE Formulary Addition 05/01/18 3 QL ZENPEP 25,000 UNIT-79,000 UNIT-105,000 UNIT CAPSULE Formulary Addition 05/01/18 4 ZENPEP 5,000 UNIT-17,000 UNIT-24,000 UNIT CAPSULE Formulary Addition 05/01/18 4 Brand name drugs are capitalized (for example, AUGMENTIN) and generic drugs are listed in lower-case italics (for example, amoxicillin). Document Last Updated: 04/30/2018 Blue Shield of California is an HMO and PDP plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The Formulary may change at any time. You will receive notice when necessary. This is not a complete list of drugs covered by our plan. For a complete listing, please call 1-800-776-4466 or visit bluedshieldca.com/med_formulary. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-776-4466 (TTY: 711).
ATENCIÓN: Si no habla inglés, tiene a su disposición gratis el servicio de asistencia en idiomas. Llame al 1-800-776-4466 (TTY: 711). Blue Shield of California complies with Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Shield of California cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Blue Shield of California 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人