NOTIFICATION OF FORMULARY CHANGES The following summary describes changes to the Presbyterian Commercial Large Group Plans (Non-Metal Plans) Formularies effective 2018. For the most recent list of drugs, information on obtaining a coverage determination or exception, or other questions, please contact the Presbyterian Customer Service Center. You can reach them Monday through Friday from 7:00 a.m. to 6:00 p.m. Phone: (505) 923-5678 or 1-855-356-2219 TTY: 711 Online: www.phs.org Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 01/15/2018 Aliqopa (copanlisib HCL for IV solution) 60 mg vial 01/15/2018 Alphagan P (brimonidine tartrate) 0.1% ophthalmic solution 01/15/2018 Aristada (aripiprazole lauroxil) 441 mg, 662 mg, 882 mg, and 1064 mg extended release suspension for IM injection Formulary addition MB, PA ST requirement added Tier 2, ST brimonidine tartrate 0.2% ophthalmic solution PA requirement removed Tier 4, SP 01/15/2018 Austedo (deutetrabenazine) 6 mg, 9 mg, 12 mg tablets MPC011710 Page 1 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 01/15/2018 Benlysta (belimumab) for injection for subcutaneous use 200 mg/ml single-dose prefilled autoinjector and single-dose prefilled syringe 01/15/2018 Besponsa (inotuzumab ozogamicin) injection for IV infusion, 0.9 mg singledose vial 01/15/2018 fenofibrate (generic for Tricor ) 48 mg and 145 mg tablets 01/15/2018 guanfacine ER tablets (generic for Intuniv ) 1 mg, 2 mg, 3 mg, 4 mg, SP Formulary addition MB, PA Formulary addition Tier 1 Formulary addition Tier 1, QL 01/15/2018 Humulin R U-500 (insulin human injection) Tier change Moved from Tier 3 to Tier 4 Tier 4, ST, QL 01/15/2018 Kisqali Femara Co-Pack (ribociclib; letrozole) 200/2.5 mg tablets MPC011710 Page 2 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 01/15/2018 Lynparza (olaparib) 100 mg and 150 mg tablets 01/15/2018 Restasis MultiDose (cyclosporine ophthalmic emulsion) 0.05% 5.5 ml multidose bottle 01/15/2018 tetrabenazine (generic for Xenazine ) 12.5 mg and 25 mg tablets 03/01/2018 Alecensa (alectinib) 150 mg capsules Formulary addition Tier 3, PA, QL, SP 03/01/2018 alfuzosin extended-release (generic for Uroxatral) 10 mg tablets 03/01/2018 armodafinil (generic for Nuvigil) 50 mg, 200 mg, and 250 mg tablets Tier change (moved from Tier 3 to Tier 1) Tier change (moved from Tier 3 to Tier 1) 150 mg tablets removed from formulary Tier 1, QL Tier 1, PA, QL (50 mg, 200 mg, and 250 mg tablets only) 03/01/2018 Bydureon BCISE (exenatide extended-release) injectable suspension 2 mg/0.85 ml auto-injector Formulary addition Tier 2, ST, QL MPC011710 Page 3 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 03/01/2018 Calquence (acalabrutinib) 100 mg capsules 03/01/2018 Fiasp (insulin aspart injection) 100 units/ml, 10 ml vial and 3 ml FlexTouch pen 03/01/2018 glatiramer acetate 40 mg/ml (generic for Copaxone 40 mg/ml) 03/01/2018 Heplisav-B [Hepatitis B Vaccine (Recombinant), Adjuvanted] Solution for intramuscular injection 03/01/2018 Jeluca (dolutegravir and rilpivirine) 50-25 mg tablets 03/01/2018 KedRAB Rabies Immune Globulin (Human) Solution for intramuscular injection Formulary addition Tier 2, QL Formulary addition Tier 4, ST, QL, SP Glatopa 20 mg/ml (glatiramer acetate) Tier 4, QL, SP Formulary addition $0, QL, AL Formulary addition Tier 4, QL Formulary addition MB 03/01/2018 modafinil (generic for Provigil) 100 mg and 200 mg talets Tier change (moved from Tier 4 to Tier 1) Tier 1, PA, QL 03/01/2018 Ocrevus (ocrelizumab) 30 mg/ml intravenous solution Specialty Pharmacy mandated MB, PA, SP MPC011710 Page 4 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 03/01/2018 QVAR RediHaler (beclomethasone dipropionate HFA) 40 mcg/actuation and 80 mcg/actuation breath activated inhalation aerosol Formulary addition Tier 3, PA Asmanex HFA (mometason furoate) 100 mcg/act or 200 mcg/act metered dose inhaler - Tier 2 Flovent Diskus(fluticasone propionate) 50 mcg/inhalation, 100 mcg/inhalation, or 250 mcg/inhalation dry powder inhaler - Tier 2 Flovent HFA (fluticasone propionate) 44 mcg/act, 110 mcg/act, or 220 mcg/act metered dose inhaler Tier 2 Pulmicort Flexhaler (budesonide) 90 mcg/act and 180 mcg/act Tier 3 03/01/2018 Sensipar (cinacalcet) 30 mg, 60 mg, 90 mg tablets Tier change (moved from Tier 3 to Tier 4) Tier 4, PA 03/01/2018 Shingrix (zoster vaccine recombinant, adjuvanted) Formulary addition $0, QL, AL 03/01/2018 timolol maleate (generic for Istalol) 0.5% ophthalmic solution (once daily) Tier change (moved from Tier 2 to Tier 3) Tier 3 timolol maleate 0.25% and 0.5% ophthalmic solution (generic for Timoptic) - Tier 1 03/01/2018 Vyxeos (daunorubicin and cytarabine) 44 mg/100 mg for intravenous use Formulary addition MB, PA, QL 03/01/2018 Xeljanz XR (tofacitinib) 11 mg extended-release tablets, SP MPC011710 Page 5 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 03/01/2018 Zostavax (varicella virus vaccine) PA requirement added $0, PA, QL, AL 06/01/2018 acitretin (generic for Soriatane ) 10 mg, 17.5 mg, and 25 mg capsules 06/01/2018 Afstyla [antihemophilic factor (recombinant), single chain] 250, 500, 1000, 1500, 2000, 2500, or 3000 IU 06/01/2018 alogliptin/pioglitazone (generic for Oseni) 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg tablets 06/01/2018 alprazolam extended- release (generic for Xanax XR) 0.5 mg, 1 mg, 2 mg, and 3 mg tablets 06/01/2018 Alunbrig (brigatinib) 90 mg and 180 mg tablets, 90 & 180 mg therapy pack QL updated Tier 4, PA, QL, SP Formulary addition MB, SP Formulary addition Tier 2, ST, QL Formulary addition Tier 3, QL 06/01/2018 aripiprazole (generic for Abilify ) 5 mg, 10 mg, 15 mg, 20 mg, and 30 mg tablets PA requirement removed Tier change (moved from Tier 4 to Tier 1) Tier 1, QL 06/01/2018 Biktarvy (bictegravir, emtricitabine, and tenofovir alafenamide) 50-200-25 mg tablets Formulary addition Tier 4, QL MPC011710 Page 6 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 06/01/2018 Bosulif (bosutinib) 100 mg, 400 mg, 500 mg tablets Formulary addition (400 mg tablet) PA requirements updated Tier 4, PA, QL, SP 06/01/2018 Cabometyx (cabozantinib) 20 mg, 40 mg, and 20 mg tablets 06/01/2018 celecoxib (generic for Celebrex ) 50 mg, 100 mg, 200 mg, and 400 mg capsules 06/01/2018 Cimetidine oral solution 300 mg/5 ml 06/01/2018 Cinvanti (aprepitant) 130 mg/18 ml injectable emulsion 06/01/2018 clindamycin 1% topical gel and lotion (generic for Cleocin T ) PA requirements updated Tier 4, PA, QL, SP Tier change (moved from Tier 3 to Tier 1) Tier 1, QL Tier change (moved from Tier 1 to Tier 2) Tier 2 cimetidine 200 mg, 300 mg, 400 mg and 800 mg oral tablets Tier 1 famotidine 20 mg and 40 mg oral tablets Tier 1 ranitidine 15 mg/ml, 75 mg/5 ml and 150 mg/10 ml oral syrup Tier 1 randitidine 150 mg and 300 mg oral tablets Tier 1 Formulary addition MB, PA QL added Tier 1, QL 06/01/2018 Cough and cold medications containing codeine or hydrocodone AL added Cough and cold medications containing codeine or hydrocodone will not be covered for members < 18 years of age. See formulary listing for complete formulary coverage information for cough and cold medications containing codeine or hydrocodone. MPC011710 Page 7 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 06/01/2018 Codeine containing medications used for the treatment of pain PA requirement added for members 12 to 18 years of age Codeine containing medications are not covered for members < 12 years of age. PA required for patients 12 to 18 years of age. See formulary for complete formulary coverage information for codeine containing medications. 06/01/2018 duloxetine (generic for Cymbalta ) 60 mg capsules 06/01/2018 Eloctate [antihemophilic factor (recombinant), Fc fusion protein] 250, 500, 750, 1000, 1500, 2000, 3000, 4000, 5000, and 6000 IU 06/01/2018 Enbrel Mini (etanercept) for injection 50 mg/ml single-dose prefilled cartridge for use with the AutoTouch reusable auto injector only QL updated Tier 1, QL Formulary removal Non-formulary Nuwiq [antihemophilic factor (recombinant)], 250, 500, 1000, 2000, 2500, 3000 and 4000 IU - MB, SP, SP 06/01/2018 enoxaparin (generic for Lovenox ) 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml, 100 mg/1 ml, 120 mg/0.8 ml, and 150 mg/1 ml prefilled syringes PA requirement added for quantities exceeding plan quantity limits Tier 1, QL* *PA required for amounts exceeding QL 06/01/2018 Erleada (apalutamide) 60 mg tablets MPC011710 Page 8 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 06/01/2018 Granix (tbo-filgrastim) 300 mcg/0.5 ml and 480 mcg/0.8 ml prefilled syringes 06/01/2018 Iclusig (ponatinib) 15 mg and 45 mg tablets 06/01/2018 Imbruvica (ibrutinib) 140 mg, 280 mg, 420 mg and 560 mg tablets packaged as a 4-week supply 06/01/2018 Imfinzi (durvalumab) injection for intravenous use, 120/2.4 ml and 500 mg/10 ml solution in a single-dose vial 06/01/2018 Isentress (raltegravir) 100 mg chewable tablets 06/01/2018 Kalydeco (ivacaftor) 150 mg tablets; 50 mg and 75 mg oral granules 06/01/2018 Kovaltry [antihemophilic factor (recombinant)] 250, 500, 1000, 2000, and 3000 IU 06/01/2018 lidocaine 5% transdermal patch (generic for Lidoderm ) Formulary removal Non-formulary Zarxio (filgrastim-sndz), 300 mcg/0.5 ml and 480 mcg/0.8 ml prefilled syringes MB, PA PA requirements updated Tier 4, PA, QL, SP Formulary addition MB, PA QL updated Tier 2, QL, SP Formulary addition MB, SP PA requirement removed Tier 3, QL 06/01/2018 Nebupent (pentamadine isethionate) inhalation powder for solution 300 mg/ml Tier change (moved from Tier 1 to Tier 3) Tier 3, QL, SP MPC011710 Page 9 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 06/01/2018 Neupogen (filgrastim) injection 300 mcg/0.5 ml and 480 mcg/0.8 ml 06/01/2018 Nuvaring (ethinyl estradiol/etonogestrel) 11.7-2.7 mg vaginal ring 06/01/2018 Nuwiq [antihemophilic factor (recombinant)] 250, 500, 1000, 2000, 2500, 3000 and 4000 IU 06/01/2018 Orkambi (lumacaftor/ivacaftor) 200-125 mg tablets Formulary removal Non-formulary Zarxio (filgrastim-sndz), 300 mcg/0.5 ml and 480 mcg/0.8 ml prefilled syringes MB, PA AL added $0, ST, QL, AL (maximum age: 55 years) Formulary addition MB, SP, SP 06/01/2018 Paxil (paroxetine) 10 mg/5 ml oral suspension PA requirement added QL added Tier change (moved from Tier 2 to Tier 3) Tier 3, PA, QL 06/01/2018 sevelamer (generic for Renvela ) 800 mg tablet 06/01/2018 Sprycel (dasatinib) 20 mg, 50 mg, 70 mg, 80 mg, 100 mg, and 140 mg tablets 06/01/2018 Symdeko (tezacaftor/ivacaftor tablets; ivacaftor tablets) 100-150 mg and 150 mg tablets Tier change (moved from Tier 1 to Tier 4) Tier 4 PA requirements updated Tier 4, PA, QL, SP, SP 06/01/2018 Symfi Lo (efavirenz, lamivudine and tenofovir disoproxil fumarate) 400-300-300 mg tablets Formulary addition Tier 4, QL MPC011710 Page 10 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 06/01/2018 Tasigna (nilotinib) 150 mg and 200 mg capsules PA requirements updated Tier 4, PA, QL, SP 06/01/2018 Tramadol containing medications PA requirement added for members 12 to 18 years of age Tramadol containing medications are not covered for members < 12 years of age. PA required for patients 12 to 18 years of age. See formulary for complete coverage information for tramadol containing medications. 06/01/2018 Trogarzo (ibalizumab-uiyk) injection, for intravenous use 200 mg/1.33 ml in a single dose vial 06/01/2018 vancomycin (generic for Vancocin ) 125 mg capsules 06/01/2018 vancomycin (generic for Vancocin ) 250 mg capsules 06/01/2018 Verzenio (abemaciclib) 50 mg, 100 mg, 150 mg, and 200 mg tablets. 06/01/2018 Xgeva (denosumab) injection for subcutaneous use, 120 mg/1.7 ml (70 mg/ml) solution in a single-dose vial Formulary addition MB from PA to ST Tier 3, ST, QL metronidazole 500 mg tablets Tier 1 PA requirements updated Tier 3, PA, QL metronidazole 500 mg tablets Tier 1 PA requirements updated MB, PA, SP 06/01/2018 Xifaxan (rifaxamin) 200 mg and 550 mg tablets PA requirements updated Tier 4, PA, QL MPC011710 Page 11 of 12 Updated 04/30/18
Drug Name Description of Formulary Coverage Formulary Alternative(s) and Tier (if applicable 06/01/2018 Xigduo XR (dapagliflozin/metformin) 2.5-1000 mg, 5-500 mg, 5-1000 mg, 10-500 mg, and 10-1000 mg tablets Formulary addition Tier 2, ST, QL 06/01/2018 Xulane (norelgestromin/ethinyl estradiol) 150/35 mcg/day patch AL added $0, ST, QL, AL (maximum age: 55 years) Learn more about Presbyterian s Nondiscrimination Notice and Interpreter Services. MPC011710 Page 12 of 12 Updated 04/30/18