NOTIFICATION OF FORMULARY CHANGES The following summary describes changes to the Presbyterian Centennial Care Formulary effective 2018. For the most recent list of drugs, information on asking for a prior authorization or exception, or other questions, please contact the Presbyterian Customer Service Center. You can reach them Monday through Saturday from 7:00 a.m. to 8:00 p.m. Phone: Phone: (505) 923-5200 Toll-free: 1-888-977-2333 Phone (Navajo/Diné): (505) 923-5157 Toll-free (Navajo/Diné): 1-888-806-8793 TTY: 711 Online: www.phs.org/centennialcare 01/15/2018 adapalene 0.1% gel (generic for Differin ) 01/15/2018 Advair HFA (fluticasone propionatesalmeterol) 45-21 mcg/act, 115-21 mcg/act, 230-21 mcg/act metered dose inhalers Drug Name Description of Formulary Coverage Formulary Alternative(s) Removed from the formulary NF Differin OTC (adapalene 0.1%) PA required for patients 40 years of age. Removed from the formulary NF Asmanex HFA (mometason furoate) 100 mcg/act or 200 mcg/act metered dose inhaler - Formulary Flovent Diskus(fluticasone propionate) 50 mcg/inhalation, 100 mcg/inhalation, or 250 mcg/inhalation dry powder inhaler Formulary MPC011712 Page 1 of 10 Centennial Care #2704
01/15/2018 Aliqopa (copanlisib HCL for IV solution) 60 mg vial ` 01/15/2018 Aristada (aripiprazole lauroxil) extended release suspension for intramuscular injection 441 mg, 662 mg, 882 mg, and 1064 mg 01/15/2018 atenolol/chlorthalidone (generic for Tenoretic ) 50/25 mg and 100/25 mg tablets 01/15/2018 Austedo (deutetrabenazine) 6 mg, 9 mg, 12 mg tablets Drug Name Description of Formulary Coverage Formulary Alternative(s) Formulary addition MB, PA PA requirement removed SP Formulary addition Formulary Formulary alternatives for Advair HFA continued Flovent HFA (fluticasone propionate) 44 mcg/act, 110 mcg/act, or 220 mcg/act metered dose inhaler fluticasone-salmeterol dry powder inhaler (generic for AirDuo Respiclick ) 55-14 mcg/act, 113-14 mcg/act, or 232-14 mcg/act- ST Dulera (mometasone furoate-formoterol fumarate) 100-5 mcg/act or 200-5 mcg/act metered dose in haler ST Symbicort (budesonide-formoterol fumarate) 80-4.5 mcg/act or 160-4.5 mcg/act metered dose inhaler - ST MPC011712 Page 2 of 10 Centennial Care #2704
Drug Name Description of Formulary Coverage Formulary Alternative(s) 01/15/2018 Benlysta (belimumab) for injection for, SP subcutaneous use 200 mg/ml single-dose prefilled autoinjector and single-dose prefilled syringe 01/15/2018 Besponsa (inotuzumab ozogamicin) Formulary addition MB, PA injection for IV infusion, 0.9 mg singledose vial 01/15/2018 Differin OTC (adapalene) Formulary addition PA required for patients 40 years of age 0.1% gel 01/15/2018 fenofibrate (generic for Tricor ) Formulary addition Formulary 48 mg and 145 mg tablets 01/15/2018 guanfacine ER tablets (generic for Formulary addition QL Intuniv ) 1 mg, 2 mg, 3 mg, 4 mg 01/15/2018 Kisqali Femara Co-Pack (ribociclib; letrozole) 200/2.5 mg tablets 01/15/2018 Lynparza (olaparib) 100 mg and 150 mg tablets 01/15/2018 memantine (generic for Namenda ) ST requirement removed QL 5 mg and 10 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, SP. MPC011712 Page 3 of 10 Centennial Care #2704
Drug Name Description of Formulary Coverage Formulary Alternative(s) 03/01/2018 Alecensa (alectinib) 150 mg capsules 03/01/2018 alfuzosin extended release (generic for Formulary addition QL Uroxatral) 10 mg tablets 03/01/2018 armodafinil (generic for Nuvigil) 150 mg tablets removed from formulary PA, QL 50 mg, 200 mg, and 250 mg tablets 03/01/2018 azelastine (generic for Astelin) Step therapy requirement removed Formulary 137 mcg/actuation (0.1%) nasal spray 03/01/2018 Calquence (acalabrutinib) 100 mg capsules 03/01/2018 diclofenac 1% topical gel (generic for Formulary addition QL Voltaren gel) 03/01/2018 Fiasp (insulin aspart injection) Formulary addition QL 100 units/ml, 10 ml multi-dose vial or 3 ml FlexTouch pen 03/01/2018 glatiramer acetate 40 mg/ml (generic for Copaxone 40 mg/ml) Formulary addition ST, QL, SP Glatopa 20 mg/ml (glatiramer acetate) QL, SP 03/01/2018 Heplisav-B [Hepatitis B Vaccine Formulary addition AL, QL (Recombinant), Adjuvanted] Solution for intramuscular injection 03/01/2018 Juluca (dolutegravir and rilpivirine) Formulary addition QL 50-25 mg tablets 03/01/2018 KedRab Rabies Immune Globulin (Human) Solution for imtramuscular injection Formulary addition MB MPC011712 Page 4 of 10 Centennial Care #2704
Drug Name Description of Formulary Coverage Formulary Alternative(s) 03/01/2018 Ocrevus (ocrelizumab) Specialty Pharmacy mandated MB, PA, SP 30 mg/ml intravenous solution 03/01/2018 QVAR RediHaler (beclomethasone dipropionate HFA) inhalation aerosol 40 mcg /actuation and 80 mcg/actuation 03/01/2018 rosuvastatin (generic for Crestor) 5 mg, 10 mg, 20 mg, 40 mg tablets 03/01/2018 Shingrix (zoster vaccine recombinant, adjuvanted) 03/01/2018 Vyxeos (daunorubicin and cytarabine) 44 mg/100 mg for injection 03/01/2018 Xeljanz XR (tofacitinib) 11 mg extended-release tablets Formulary addition ST Asmanex HFA (mometason furoate) 100 mcg/act or 200 mcg/act metered dose inhaler Flovent Diskus(fluticasone propionate) 50 mcg/inhalation, 100 mcg/inhalation, or 250 mcg/inhalation dry powder inhaler Flovent HFA (fluticasone propionate) 44 mcg/act, 110 mcg/act, or 220 mcg/act metered dose inhaler Formulary addition QL Formulary addition QL, AL Formulary addition MB, SP leflunomide tablets methotrexate tablets hydroxychloroquine tablets sulfasalazine tablets 03/01/2018 Zostavax (varicella virus vaccine) PA requirement added PA, QL, AL 06/01/2018 acitretin (generic for Soriatane ) Quantity limit changed PA, QL, SP 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 Formulary addition MB, SP MPC011712 Page 5 of 10 Centennial Care #2704
Drug Name Description of Formulary Coverage Formulary Alternative(s) 06/01/2018 alogliptin/pioglitazone (generic for Formulary addition ST, QL 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 Formulary addition ST, QL 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 06/01/2018 aripiprazole (generic for Abilify ) PA requirement removed QL 5 mg, 10 mg, 15 mg, 20 mg, and 30 mg tablets 06/01/2018 Biktarvy (bictegravir, emtricitabine, Formulary addition QL and tenofovir alafenamide) 50-200-25 mg tablets 06/01/2018 Bosulif (bosutinib) Formulary addition (400 mg tablets) PA, QL, SP 100 mg, 400 mg, and 500 mg tablets PA requirements updated 06/01/2018 Cabometyx (cabozantinib), PA requirements updated PA, QL, SP 20 mg, 40 mg, and 20 mg tablets 06/01/2018 celecoxib (generic for Celebrex ) ST requirement removed QL 50 mg, 100 mg, 200 mg, and 400 mg capsules 06/01/2018 Cinvanti (aprepitant) Formulary addition MB, PA 130 mg/18 ml injectable emulsion 06/01/2018 Codeine containing medications listed on the formulary PA requirements added AL, PA* *Codeine containing products are not covered for patients < 12 years of age. A prior authorization will be required for patients aged 12 to 18 years. MPC011712 Page 6 of 10 Centennial Care #2704
Drug Name Description of Formulary Coverage Formulary Alternative(s) 06/01/2018 clindamycin 1% topical gel and lotion QL added QL (generic for Cleocin T ) 06/01/2018 duloxetine (generic for Cymbalta ) QL updated QL 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 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 06/01/2018 Erleada (apalutamide) 60 mg tablets 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 Removed from the formulary Non-formulary Nuwiq [antihemophilic factor (recombinant)], 250, 500, 1000, 2000, 2500, 3000 and 4000 IU - MB, SP, SP PA requirement added for quantities of enoxaparin that exceed plan quantity limits QL* *PA required for amounts that exceed plan quantity limits Removed from the formulary Non-formulary Zarxio (filgrastim-sndz), 300 mcg/0.5 ml and 480 mcg/0.8 ml prefilled syringes MB, PA PA requirements updated PA, QL, SP MPC011712 Page 7 of 10 Centennial Care #2704
Drug Name Description of Formulary Coverage Formulary Alternative(s) 06/01/2018 Imfinzi (durvalumab) injection, for Formulary addition MB, PA intravenous use 120/2.4 ml and 500 mg/10 ml solution in a single-dose vial 06/01/2018 Isentress (raltegravir) QL updated QL 25 mg and 100 mg chewable tablets 06/01/2018 Kalydeco (ivacaftor),, SP 150 mg tablets; 50 mg and 75 mg oral granules 06/01/2018 Kovaltry [antihemophilic factor (recombinant)] Formulary addition MB, SP 250, 500, 1000, 2000, and 3000 IU 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 06/01/2018 Paxil (paroxetine) 10 mg/5 ml oral suspension 06/01/2018 Renflexis (infliximab-abda) 100 mg/vial Formulary removal Non-formulary Zarxio (filgrastim-sndz), 300 mcg/0.5 ml and 480 mcg/0.8 ml prefilled syringes MB, PA AL added ST, QL, AL (Maximum age of 55 years) Formulary addition MB, SP, SP PA requirement added PA, QL Formulary addition MB, PA, SP MPC011712 Page 8 of 10 Centennial Care #2704
06/01/2018 Remicade (infliximab) 100 mg/vial 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 06/01/2018 Symfi Lo (efavirenz, lamivudine and tenofovir disoproxil fumarate) 400-300-300 mg tablets 06/01/2018 Tasigna (nilotinib) 150 mg and 200 mg capsules 06/01/2018 Tramadol containing medications listed on the formulary 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 Drug Name Description of Formulary Coverage Formulary Alternative(s) PA requirements updated MB, PA, SP Renflexis* (infliximab-abda) MB, PA, SP *Renflexis will be the preferred infliximab product on the Centennial Care formulary. PA requirements updated PA, QL, SP, SP Formulary addition QL PA requirements updated PA, QL, SP PA requirements added AL, PA* *Tramadol containing products are not covered for patients < 12 years of age. A prior authorization will be required for patients aged 12 to 18 years. Formulary addition MB from PA to ST ST, QL metronidazole 500 mg tablets PA requirements updated PA, QL metronidazole 500 mg tablets MPC011712 Page 9 of 10 Centennial Care #2704
Drug Name Description of Formulary Coverage Formulary Alternative(s) 06/01/2018 Verzenio (abemaciclib) 50 mg, 100 mg, 150 mg, and 200 mg tablets 06/01/2018 Victoza (liraglutide) PA requirements updated PA, QL 18 mg/3 ml pen injector 06/01/2018 Vimpat (lacosamide) PA requirements updated PA, QL 50 mg, 100 mg, 150 mg, 200 mg tablets and 10 mg/ml oral solution 06/01/2018 Xgeva (denosumab) injection, for PA requirements updated MB, PA, SP subcutaneous use 120 mg/1.7 ml (70 mg/ml) solution in a single-dose vial 06/01/2018 Xifaxan (rifaxamin) PA requirements updated PA, QL 200 mg and 550 mg tablets 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 06/01/2018 Xulane (norelgestromin/ethinyl estradiol) 150/35 mcg/day patch AL added ST, QL, AL (Maximum age of 55 years) Learn more about Presbyterian s Nondiscrimination Notice and Interpreter Services. MPC011712 Page 10 of 10 Centennial Care #2704