One mission: you Changes July 1, 2018 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for your care. Because the formulary is reviewed on an ongoing basis, we want to keep you informed of coming and recent changes to our covered drug lists. The following is a list of changes that have occurred. The online pharmacy tools and resources are updated with these decisions by the effective date of the change. This list applies to members of Health Plans. This list does not apply to Federal Employee Program members, Medicare Advantage members, or Qualified Health Plans. TABLE A. FORMULARY CHANGES 7/1/2018: Medication Alternatives Drug Brand Name (Drug Scientific Name) Class/Category Indication Tier = Benefit Level for Drug Under The MN-PA = Medical Necessity Prior Authorization MBC = Medical Benefit Channel PA = Prior Authorization is Required ST = Step Therapy is Required QL = Quantity Limit Cosentyx (Secukinumab) Anti-interleukin 17A Monoclonal Antibody Tier 2 with PA Tier 3 with PA Tier 5 with PA Otezla (Apremilast) Phosphodiesterase- 4 Enzyme Inhibitor Psoriasis & Psoriatic Arthritis Tier 2 with PA Tier 3 with PA Tier 5 with PA Stelara (ustekinumab) Interleukin-12 Inhibitor; Interleukin-23 Inhibitor Tier 2 with PA Tier 3 with PA Tier 5 with PA Kevzara (sarilumab) Interleukin-6 Receptor Antagonist Rheumatoid Arthritis Tier 2 with PA Tier 3 with PA Tier 5 with PA
Alternatives Humira (adalimumab) Tumor Necrosis Factor (TNF) Blocking Agent No Change Tier 2 with PA Tier 3 with PA Tier 5 with PA Enbrel (etanercept) Tumor Necrosis Factor (TNF) Blocking Agent No Change Tier 2 with PA Tier 3 with PA Tier 5 with PA Actemra (tocilizumab) Interleukin-6 Receptor Antagonist Enbrel, Humira, Kevzara Cimzia (Certolizumab Pegol) Tumor Necrosis Factor (TNF) Blocking Agent Humira, Enbrel, Stelara Kineret (Anakinra) Interleukin-1 Receptor Antagonist Kevzara, Humira, Enbrel Orencia (abatacept) Selective T-Cell Costimulation Blocker Kevzara, Humira, Enbrel, Stelara, Otezla, Cosentyx Simponi (Golimumab) Tumor Necrosis Factor (TNF) Blocking Agent Kevzara, Cosentyx, Otezla, Stelara, Humira, Enbrel
Alternatives Taltz (ixekizumab) Anti-interleukin 17A Monoclonal Antibody Plaque Psoriasis & Psoriatic Arthritis Cosentyx, Otezla, Stelara, Humira, Enbrel Xeljanz and Xeljanz XR (tofacitinib) Janus Associated Kinase Inhibitor Kevzara, Cosentyx, Otezla, Stelara, Humira, Enbrel Extavia (Interferon Beta-1b) Interferon Relapsing forms of multiple Rebif, Avonex and Betaseron Betaseron (Interferon Beta-1b) Interferon Relapsing forms of multiple Tier 2 with QL Tier 3 with QL Tier 5 with QL Aubagio (Teriflunomide) Pyrimidine Synthesis Inhibitor Relapsing forms of multiple Tier 2 with QL Tier 3 with QL Tier 5 with QL Rebif (Interferon Beta-1a) Interferon Relapsing forms of multiple Tier 2 with QL Tier 3 with QL Tier 5 with QL Avonex (Interferon Beta-1a) Interferon Relapsing forms of multiple Tier 2 with QL Tier 3 with QL Tier 5 with QL Copaxone 40mg/ml (Glatiramer) Multiple Sclerosis Tier 2 with QL Tier 3 with QL Tier 5 with QL Glatopa 20mg/ml (Glatiramer) Ampyra (Dalfampridine (4- Aminopyridine)) Multiple Sclerosis Tier 1 with QL Tier 3 with QL Tier 5 with QL Potassium Channel Blocker Used to improve walking in patients with multiple Tier Tier 3 Tier 4 Tier 6
Alternatives Byetta (Exenatide) Antidiabetic Agent, Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist Type 2 Diabetes Trulicity and Victoza Bydureon (Exenatide) Antidiabetic Agent, Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist Type 2 Diabetes Trulicity and Victoza Test Strips (all brands besides One Touch) Diabetes, Glucose Monitoring One Touch Pradaxa (Dabigatran Etexilate Mesylate) Anticoagulant, Direct Thrombin Inhibitor, Direct Oral Anticoagulant (DOAC) Treatment and prevention of deep venous thrombosis and pulmonary embolism and treatment of Nonvalvular atrial fibrillation Eliquis, Xarelto, Warfarin Elidel (Pimecrolimus) Calcineurin Inhibitor, Immunosuppressant Agent Atopic dermatitis Tier 2 Tier 2 Tier 3 Bystolic (Nebivolol) Restasis (Cyclosporine) Antihypertensive, Beta-1 Selective Beta-Blocker Hypertension Calcineurin Inhibitor, Immunosuppressant Agent Keratoconjunctivitis sicca Tier 2 Tier 2 Tier 3 Tier 2 Tier 2 Tier 3
Alternatives Xiidra (Lifitegrast) Forteo (Teriparatide) Ibrance (Palbociclib) Niaspan (Niacin) Innopran XL (Propranolol ER) Aerospan (Flunisolide Inhalation) Alvesco (Ciclesonide Inhalation) Lymphocyte Function-Associated Antigen 1 (LFA-1) Antagonist Dry eye disease Parathyroid Hormone Analog Osteoporosis in Men, Osteoporosis in postmenopausal women and treatment of glucocorticoidinduced osteoporosis Cyclin-Dependent Kinase Inhibitor, Antineoplastic Agent Advanced Breast Cancer Anti-lipemic Agent, Water Soluble Vitamin Atherosclerotic disease, Dyslipidemia, Hypertriglyceridemia, and Prevention of recurring myocardial infarction Non-Selective Beta Blockers hypertension, tremors, chest pain and atrial fibrillation., Inhalant (Oral) Maintenance treatment of asthma, Inhalant (Oral) Maintenance treatment of asthma Tier 2 with PA Tier 3 with PA Tier 5 with PA Tier 2 with PA Tier 3 with PA Tier 5 with PA Removed Not Covered Not Covered Not Covered Tier 3 Tier 3 Tier 4 products for COM: Restasis Over the Counter Niacin available products for COM: Nadolol, Pindolol, Propranolol ER, Propranolol products for COM: Asmanex, Flovent, Pulmicort, Qvar products for COM: Asmanex, Flovent, Pulmicort, Qvar
Alternatives Zarxio (Filgrastim) Colony Stimulating Factor, Hematopoietic Agent neutropenia associated with chemotherapy Tier 2 Tier 3 Tier 5 Neupogen (Filgrastim) Colony Stimulating Factor, Hematopoietic Agent neutropenia associated with chemotherapy Removed MN-PA MN-PA MN-PA Zarxio Leukine (Sargramostim) Colony Stimulating Factor, Hematopoietic Agent neutropenia associated with chemotherapy Removed MN-PA MN-PA MN-PA Zarxio Granix (Filgrastim) Colony Stimulating Factor, Hematopoietic Agent neutropenia associated with chemotherapy Removed MN-PA MN-PA MN-PA Zarxio Beconase AQ (Beclomethasone) Prevention of recurrence of Polyps and treatment of seasonal or perennial allergic and nonallergic rhinitis Dymista (Azelastine HCL/ Propionate), Second Generation Histamine Antagonist seasonal allergic rhinitis Brand Nasonex (Mometasone) seasonal allergic rhinitis
Alternatives Brand Flonase () seasonal allergic rhinitis Brand Nasacort (Triamcinolone) seasonal allergic rhinitis Omnaris (Ciclesonide) nasal symptoms associated with seasonal and perennial allergic rhinitis Qnasl (Beclomethasone) nasal symptoms associated with seasonal and perennial allergic rhinitis Brand Rhinocort (Budesonide) Management of symptoms of allergic rhinitis Veramyst ( Furoate) Management of seasonal and perennial allergic rhinitis
Alternatives Zetonna (Ciclesonide) nasal symptoms associated with seasonal and perennial allergic rhinitis Latuda (Lurasidone) Second Generation (Atypical) Antipsychotic Bipolar depression and Schizophrenia Tier 2 Tier 2 Tier 3 Vraylar (Cariprazine) Second Generation (Atypical) Antipsychotic Bipolar depression and Schizophrenia Tier 2 with QL Tier 2 with QL Tier 3 with QL Fanapt (Iloperidone) Second Generation (Atypical) Antipsychotic Schizophrenia Removed MN-PA MN-PA MN-PA paliperidone ER, risperidone, quetiapine ER, aripiprazole Norditropin Growth Genotropin Growth Omnitrope Growth Nutropin/Nutropin AQ Growth
Alternatives Saizen Growth Zomacton Growth Natazia (Estradiol + Dienogest) Estrogen & Progestin Combination Contraceptive Tier 2 Tier 2 Tier 3 Safyral ( Ethinyl Estradiol, Drospirenone, and Levomefolate ) Estrogen & Progestin Combination Contraceptive Tier 2 Tier 2 Tier 3 Lo Loestrin (Ethinyl Estradiol and Norethindrone) Estrogen & Progestin Combination Contraceptive Tier 2 Tier 2 Tier 3