PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand = Sabril Pak) lanthanum chewable tab (Brand = Fosrenol ) lamotrigine starter kit (Brand = Lamictal Starter Kit) paroxetine cap (Brand = Brisdelle ) fosamprenavir calcium tab (Brand = Lexiva ) sodium phenylbutyrate tab (Brand = Buphenyl ) abacavir sulfate soln 20 mg/ml (Brand = Ziagen ) glatiramer acetate 40 mg/ml (Brand = Copaxone ) dapsone gel 5% (Brand = Aczone ) G No Change Generic Addition 8/7/17 G No Change Generic Addition 8/21/17 G/SP* No Change Generic Addition 8/28/17 G No Change Generic Addition 9/4/17 G No Change Generic Addition 9/18/17 G No Change Generic Addition 9/25/17 G No Change Generic Addition 9/25/17 G/SP* No Change Generic Addition 9/25/17 G No Change Generic Addition 10/2/17 G/SP* No Change Generic Addition 10/9/17 G No Change Generic Addition 10/23/17
sildenafil citrate G + PA + QL No Change Generic Addition 12/18/17 (Brand = Viagra ) (8 per 30 days) Epiduo Gel 0.1-2.5% PB NPD adapalene-benzoyl-peroxide Gel Brand Uptier 4/1/18 (generic = adapalenebenzoyl-peroxide Gel 0.1-2.5%) 0.1-2.5% Lexiva PB NPD fosamprenavir calcium Brand Uptier 4/1/18 (generic = fosamprenavir calcium) Viagra PB + QL + PA NPD + QL + PA sildenafil citrate 25 mg, 50 mg, Brand Uptier 4/1/18 (generic = sildenafil citrate) 100 mg tramadol ER cap 100 mg, G + QL NPD + QL tramadol IR/ER tabs Generic Uptier 4/1/18 150 mg, 200 mg, 300 mg Cotempla XR ODT NPD + PA +QL No Change 8/7/17 Duzallo NPD + PA No Change 9/4/17 Trelegy Ellipta NPD + PA No Change 10/9/17 Ximino NPD + PA No Change 10/16/17 Xhance MIS 93 mcg NPD + PA No Change 10/16/17 ArmonAir RespiClick NPD + PA No Change 8/14/17 Idhifa NPD/SP + PA No Change 8/7/17 Verzenio NPD/SP + PA No Change 10/9/17 Symproic NPD + PA No Change 10/9/17 Proctocort supp 30 mg Excluded NPD + PA Coverage Added PA Addition 4/1/18 Endari powder NPD NPD + PA PA Addition 4/1/18 Baxdela NPD NPD + PA PA Addition 4/1/18 dihydroergotamine G G + PA PA Addition 4/1/18 nasal spray Aplenzin NPD NPD + PA PA Addition 4/1/18 Focalin XR 25 mg, 35 mg NPD + QL NPD + QL + PA PA Addition 4/1/18
Topamax Tab NPD NPD + PA PA Addition 4/1/18 Topamax Sprinkle NPD NPD + PA PA Addition 4/1/18 Avidoxy G + PA G No Change PA Removal 4/1/18 Fiasp Soln NPD + QL No Change 10/9/17 Fiasp Flex NPD + QL No Change 10/9/17 Migranal Nasal Spray NPD + PA No Change No Change Updated PA Criteria 4/1/18 Bevyxxa NPD NPD + QL No Change 42 days supply per 4/1/18 180 days acetaminophen-codeine 300/15 mg, 300/30 mg codeine 15 mg, 30 mg dihydrocodeine-aspirincaffeine 6 per 1 day 10 per 1 day No Change Updated QL 3/1/18 356.4-30-16 caps (Brand = Synalgos ) hydrocodoneacetaminophen 2.5/325 mg, 5/300 mg, 7.5/300 mg, 7.5/325 mg (Brand = Vicodin, Norco, Lortab, Xodol ) morphine 10 mg/5 ml liq 34 ml per 1 day 45 ml per 1 day No Change Updated QL 3/1/18 morphine 20 mg/5 ml liq 34 ml per 1 day 23 ml per 1 day No Change Updated QL 3/1/18 morphine 5 mg Supp 6 per 1 day 18 per 1 day No Change Updated QL 3/1/18 Oxaydo 5 mg Oxaydo 7.5 mg 6 per 1 day 8 per 1 day No Change Updated QL 3/1/18 oxycodone 5 mg tab/cap oxycodone 5 mg/5 ml liq 90 ml per 1 day 60 ml per 1 day No Change Updated QL 3/1/18
2.5/325 mg, 5/300 mg, 5/325 mg, Endocet (Brand = Percocet, Primlev ) 7.5/325mg, Endocet (Brand = Percocet, Primlev ) 5 mg/325 mg/5 ml liq oxycodone-aspirin 4.8355/325 mg oxycodone-ibuprofen 5/400 mg tramadol-acetaminophen 37.5/325 mg 6 per 1 day 8 per 1 day No Change Updated QL 3/1/18 1000 ml per 60 ml per 1 day No Change Updated QL 3/1/18 30 days 28 per 30 days 4 per 1 day No Change Updated QL 3/1/18 40 per 30 days 40 per 5 days No Change Updated QL 3/1/18
Abbreviation Key G PB NPD SP NF PA QL Generic Addition Generic Uptier Brand Downtier Brand Uptier Brand Addition Brand/Generic Deletion Generic Preferred Brand Non-Preferred Drug Specialty Drug. Specialty Tier cost-share will apply for those benefits that have a prescription drug specialty tier. Non-. Non- refers to drugs not covered on the formulary. A formulary exception is available upon request. Prior authorization is required. Quantity limits A generic drug that recently became available in the marketplace. These generic drugs will be covered at the appropriate non-preferred drug level of cost-sharing. These brand drugs were added to the formulary as of the date indicated and are covered at the appropriate preferred brand formulary level of cost-sharing. These brand drugs will be covered at the appropriate non-preferred drug level of cost-sharing. Coverage was added to this drug. Coverage was removed from this drug. alternatives are available. DL 01 1608 0412 www.ibx.com Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association.