BLUE SHIELD OF CALIFORNIA JUNE 2016 PLUS 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 Plus Drug Formulary from the P&T Committee meeting are outlined below. To view a copy of the Plus 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) Descovy HIV infection Odefsey HIV infection Viagra Erectile dysfunction Prior authorization. Gender limit.. 2. FORMULARY DRUGS WITH CHANGES TO RESTRICTIONS The following drugs remain at their current formulary status but have new coverage restriction(s) as Drug FDA Indication(s) New Restriction(s) doxycycline delayed-release (generic Doryx) amlodipine-atorvastatin (generic Caduet) fluvastatin (generic Lescol, Lescol XL) quazepam (generic Doral) Proton Pump Inhibitors (PPIs) esomeprazole (generic Nexium) 40mg capsule Bacterial infection Hypertension, CAD, Hyperlipidemia triglyceride, Prevent heart attack or stroke Insomnia Gastric and Duodenal ulcer, GERD, Zollinger-Ellison syndrome Prior authorization. Prior authorization Prior authorization Prior authorization if 65 years of age or older. Prior authorization Page 1 of 5
Drug FDA Indication(s) New Restriction(s) omeprazole-sodium bicarbonate (generic Zegerid) 40mg capsule rabeprazole (generic Aciphex) Gastric and Duodenal ulcer, GERD, Esophagitis, Stress gastritis Duodenal ulcer, GERD, Esophagitis, H.pylori, Zollinger- Ellison syndrome Prior authorization Prior authorization Fenofibrates and Fibric Acid Derivatives fenofibrate 43mg, 130mg fenofibrate (generic Fenoglide) Medications and Stimulants for dexmethylphenidate extendedrelease (generic Focalin XR) dextroamphetamine tablet (generic Dexedrine) dextroamphetamine extendedrelease (generic Dexedrine Spansule) methamphetamine (generic Desoxyn) methylphenidate oral solution (generic Methylin) methylphenidate CD (generic Metadate CD) triglyceride triglyceride, Narcolepsy, Narcolepsy, Obesity, Narcolepsy methylphenidate er 10mg, 20mg, Narcolepsy The following drugs remain at their current formulary status but have coverage restriction(s) removed as Drug FDA Indication(s) Restriction removed guanfacine er (generic Intuniv) requirement lamivudine (generic Epivir HBV) tablet Hepatitis B Prior authorization requirement Epivir HBV solution Hepatitis B Prior authorization requirement 3. NON-FORMULARY DRUGS WITH CHANGES TO RESTRICTIONS Page 2 of 5
The following drugs remain at their current formulary status but have new coverage restriction(s) as Drug FDA Indication(s) New Restriction(s) Formulary Alternative(s) Antara High cholesterol and triglyceride nanocrystallized fenofibrate (generic Tricor), micronized fenofibrate (lofibra), fenofibric acid choline (generic Trilipix), fenofibric acid (generic Fibricor), gemfibrozil (generic Lopid) Seconal sodium Insomnia Triglide High cholesterol and triglyceride nanocrystallized fenofibrate (generic Tricor), micronized fenofibrate (lofibra), fenofibric acid choline (generic Trilipix), fenofibric acid (generic Fibricor), gemfibrozil (generic Lopid) Zegerid powder for suspension Gastric and Duodenal ulcer, GERD, Esophagitis, Stress gastritis Prior authorization lansoprazole, omeprazole, pantoprazole Medications and Stimulants for Aptensio XR Daytrana Dyanavel XR Evekeo, Narcolepsy dextroamphetamineamphetamine (generic Adderall), dexmethylphenidate (generic Focalin), methylphenidate (generic Methylin, Ritalin) Focalin XR 25mg, 35mg Metadate CD 20mg, 30mg, 40mg Zenzedi, Narcolepsy dextroamphetamineamphetamine (generic Adderall), dexmethylphenidate (generic Focalin), methylphenidate (generic Methylin, Ritalin) 4. DRUGS REMOVED FROM THE FORMULARY Page 3 of 5
The following drugs were moved from Formulary to Non-formulary: Drug FDA Indication(s) Restriction(s) Formulary Alternative(s) One Touch blood glucose test strips Proair HFA, Proair Respimat Sumavel Dosepro Test blood glucose Bronchospasm Migraine Prior Authorization... Accu-chek blood glucose test strips Ventolin HFA sumatriptan vial, prefilled syringe, prefilled cartridge The following brand-name drug was removed from the formulary because generic is now available and was added to the formulary: Brand-name Drug FDA Indication(s) Restriction(s) Formulary Alternative Crestor Nasonex Tegretol XR 100mg triglyceride, Reduce stroke or heart attack, Slow atherosclerosis Allergic rhinitis Seizures, Trigeminal neuralgia. rosuvastatin fluticasone nasal carbamazepine extended-release 5. DRUGS ADDED TO THE SPECIALTY TIER The following drugs were added to the Blue Shield specialty tier: Specialty Drug Cabometyx Impavido Nuplazid Taltz Venclexta Vistogard Coverage Restriction(s) Prior authorization.. Prior authorization.. Prior authorization.. Prior authorization.. Prior authorization.. Prior authorization.. The following drugs remain at their current formulary status but have new coverage restriction(s) as Drug FDA Indication(s) New Restriction(s) Preferred Alternative(s) Avonex Page 4 of 5
Drug FDA Indication(s) New Restriction(s) Preferred Alternative(s) Glatopa Rebif, Rebif Rebidose Prior authorization The following drugs remain at their current formulary status but have coverage restriction(s) removed as Drug FDA Indication(s) Restriction removed Extavia Prior authorization requirement Gilenya Prior authorization requirement 6. DRUGS REMOVED FROM COVERAGE The following drug was excluded from coverage because it is available without a prescription: Prescription Drug budesonide nasal (Rhinocort Aqua) Non-prescription Drug Rhinocort Allergy The following drugs were excluded from coverage because they are not approved by the Food and Drug Administration (FDA): Drug Animi-3 Corvite Enlyte Strovite One Drug Corvite Free Corvita Multivitamins-A, B, D, E, K, Z VC Forte, Vic Forte Page 5 of 5