One mission: you s September 7, 2017 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 Plans and Health Plans. This list does not apply to Federal Employee Program members or Medicare Advantage members. TABLE A. TABLED MEDICATIONS: Plan Class/Category Tier = Benefit Level for Drug Under The Tirosint Solution (Levothyroxine) Thyroid Product Used for Hypothyroidism and Pituitary thyrotropinstimulating hormone (TSH) suppression N/A No Tabled until the product hits the market Tabled until the product hits the market Tabled until the product hits the market Soliqua (insulin glargine & lixisenatide) Antidiabetic Agent Used to help control Type 2 Diabetes Mellitus in individuals who are inadequately controlled on basal insulin No Not Covered MN-PA MN-PA Xultophy (insulin degludec & liraglutide) Antidiabetic Agent Used to help control Type 2 Diabetes Mellitus in individuals who are inadequately controlled on basal insulin Added Tier 3 with PA Tier 2 with PA Tier 2 with PA Zejula (niraparib) Antineoplastic Agent Maintenance treatment of Ovarian, fallopian tube or primary peritoneal cancer Added Tier 5 with PA Tier 2 with PA Tier 4 with PA 2017 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association
TABLE B. NEWLY REVIEWED MEDICATIONS: Plan Xadago (safinamide) Austedo (deutetrabenazine) Class/Category Anti-Parkinson Agent, MAO Type B Inhibitor Adjunctive treatment to levodopa/carbidopa in patients with Parkinson disease experiencing off episodes. Central Monoamine- Depleting Agent, Vesicular Monoamine Transporter 2 Inhibitor Treatment of chorea associated with Huntington disease Tier = Benefit Level for Drug Under The No Not Covered Not Covered Not Covered Ingrezza (valbenazine) Central Monoamine- Depleting Agent, Vesicular Monoamine Transporter 2 Inhibitor Treatment of adults with tardive dyskinesia No Tabled Tabled Tabled Siliq (brodalumab) Anti-interleukin 17- Receptor Antibody Treatment of plaque psoriasis Added for No change for QHP Not Covered Tier 3 with PA Tier 4 with PA Kevzara (sarilumab) Antirheumatic, Disease Modifying, Interleukin-6 Receptor Antagonist Treatment of Rheumatoid Arthritis Tymlos (abaloparatide) Parathyroid Hormone Analog Treatment of Osteoporosis Added Tier 5 with PA Tier 2 with PA Tier 3 with PA
Plan Intrarosa (prasterone) Alunbrig (brigatinib) Rydapt (midostaurin) Brineura (cerliponase alfa) Ocrevus (ocrelizumab) Radicava (edaravone) Imfinzi (durvalumab) Synthetic Steroid Treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause Anaplastic Lymphoma Kinase Inhibitor, Tyrosine Kinase Inhibitor Treatment of non-small cell lung cancer, metastatic FLT3 Inhibitor, Tyrosine Kinase Inhibitor Treatment of Acute Myeloid Leukemia, FLT3- Postive. Treatment of Mast cell Leukemia Hydrolytic Lysosomal N- Terminal Tripeptidyl Peptidase Used to delay the loss of ambulation in symptomatic pediatric patients 3 years and older with late infantile neuronal ceroid lipofuscinosis type 2 (CLN2) Anti-CD20 Monoclonal antibody Treatment of relapsing or primary progressive forms of Multiple Sclerosis Free Radical Scavenger Treatment of Amyotrophic lateral sclerosis (ALS) Anti-PD-L1 Monoclonal Antibody Treatment of Urothelial carcinoma, locally advanced or metastatic Added for No for QHP Not Covered Tier 3 with PA Tier 3 with PA
TABLE C. PREVIOUSLY REVIEWED/LINE EXTENSIONS: Plan Class Tier = Benefit Level for Drug Under The Airduo RespiClick (fluticasone + salmeterol inhalation powder) Fluticasone + Salmeterol Inhalation Powder Corticosteroid, Inhalant (Oral), Beta2 Agonist, Beta2-Adrenergic Agonist Treatment of asthma in patients 12 years and older Corticosteroid, Inhalant (Oral), Beta2 Agonist, Beta2-Adrenergic Agonist Treatment of asthma in patients 12 years and older Corticosteroid, Inhalant (Oral) ArmonAir RespiClick Maintenance treatment of (fluticasone inhalation asthma as prophylactic powder) therapy in patients 12 years and older Ergocal (ergocalciferol 2500u capsule) Vitamin D Analog Used as dietary supplement. Treatment of familial hypophosphatemia, rickets, and Hypoparathyroidism No Not Covered MN-PA MN-PA Added Tier 2 Tier 1 Tier 1 No Not Covered MN-PA MN-PA No Not Covered Not Covered Not Covered Jadenu Sprinkle (deferasirox oral granules) Chelating Agent Treatment for chronic iron overload due to transfusions. Treatment of chronic iron overload in non-transfusion-dependent thalassemia syndromes Morphabond (morphine sulfate ER tablets) Analgesic, Opioid Management of severe pain requiring daily, around-the-clock, long-term opioid treatment Added for No for QHP Not Covered Tier 3 with PA Tier 3 with PA Mydayis (amphetaminedetroamphetamine ER capsules) Central Nervous System Stimulant Treatment of ADHD No Not Covered MN-PA MN-PA
Plan Rituxan Hycela (rituximab/hyaluronida se SC injection) Monoclonal Antibody Treatment of Follicular Lymphoma, Diffuse Large B-cell Lymphoma, Chronic Lymphocytic Leukemia Selzentry (maraviroc oral solution) Antiretroviral, CCR5 Antagonist Treatment of HIV-1 infection Added Tier 3 Tier 2 Tier 2 Xatmep (methotrexate 2.5mg/ml) Syndros (dronabinol oral solution) Antirheumatic, Disease Modifying Treatment of pediatric patients with acute lymphoblastic leukemia. Management/Treatment of pediatric patients with active polyarticular juvenile idiopathic arthritis. Antiemetic, Appetite Stimulant Treatment of anorexia associated with weight loss in patients with AIDS. Treatment for chemotherapy-induced nausea and vomiting No Not Covered MN-PA MN-PA Added Tier 4 with QL Tier 3 with QL Tier 3 with QL Haegarda (C1 esterase inhibitor (Human)) C1 Esterase Inhibitor Routine prophylaxis against angioedema attacks in adults and adolescents with HAE Selenium Sulfide (selenium sulfide lotion 2.25%) Antiseborrheic Agent, Topical Treatment of dandruff, scalp seborrhea and treatment of tinea versicolor No Not Covered Not Covered Not Covered Rayaldee (calcifediol ER capsules) Vitamin D Analog Treatment of secondary hyperparathyroidism No Not Covered Not Covered Not Covered
TABLE D. THERAPEUTIC CLASS REVIEW: Plan Class Tier = Benefit Level for Drug Under The No s