Download Standard Drug Formulary

BLUE SHIELD OF CALIFORNIA
MARCH 2016 STANDARD 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 Standard Drug Formulary from the March 2016 P&T Committee meeting are outlined
below. To view a copy of the Standard 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)
Tier Status
cyclopentolate 2% drops
(generic Cyclogyl)
Mydriasis, Cycloplegia
fluticasone propionate
(generic Flonase)
Allergic and non-allergic
rhinitis
Quantity limit
Tier 1
metformin extendedrelease tablet (generic
Glumetza)
Type 2 diabetes
Prior authorization required.
Quantity limit
Tier 1
naftifine 2% cream
(generic Naftin)
Tinea pedis, Tinea cruris,
Tinea corporis
Step therapy required
Tier 1
naloxone 0.4mg/ml vial
and syringe, 2mg/2ml
syringe
Opioid overdose
Add quantity limit
Tier 1
norgestimate-ethinyl
estradiol, tri-lo-sprintec,
tri-lo-estarylla, trinessa lo,
tri-lo-marzia (generic
Ortho Tri-Cyclen Lo)
Prevent pregnancy
olopatadine 0.1% drops
(generic Patanol)
Allergic conjunctivitis
Quantity limit
Tier 1
Otezla
Psoriatic arthritis, Plaque
psoriasis
Prior authorization required,
Quantity limit
Tier 4#
Praluent
Hypercholesterolemia
Prior authorization required,
Quantity limit
Tier 4#
pramipexole 2.25mg
extended-release
(generic Mirapex ER)
Parkinson’s disease
Quantity limit
Tier 1
Tanzeum
Type 2 diabetes
Step therapy required,
Quantity limit
Tier 3
Blue Shield of California
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Tier 1
Tier 1
March 2016
Drug
FDA Indication(s)
Coverage Restriction(s)
Tier Status
Diabetes
Quantity limit
Tier 2 (effective
Toujeo Solostar
1/1/2017)
# must be obtained through a network specialty pharmacy
2. FORMULARY DRUGS WITH CHANGES TO TIER AND/OR COVERAGE RESTRICTION
The following drugs have coverage restriction(s) added or removed, and/or change of tier status as
noted:
DRUG
FDA Indication(s)
Coverage Restriction(s)
Tier Status
aripiprazole (generic Abilify)
tablet, solution
Schizophrenia, Bipolar
mania, Depression,
Autistic disorder,
Tourette’s
Add quantity limit
Tier 3
Azilect
Parkinson’s disease
Quantity limit
Tier 3 (effective
budesonide (generic Entocort
EC)
Crohn’s disease
Add prior authorization
requirement, quantity
limit
Tier 1
clobetasol (generic Clobex)
lotion
Corticosteroid
responsive
dermatoses, Plaque
psoriasis
Step therapy required
Tier 2
clobetasol (generic Clobex)
shampoo
Scalp psoriasis
Step therapy required
Tier 3
clozapine odt (generic Fazaclo)
Schizophrenia
dihydroergotamine mesylate
(generic D.H.E. 45)
Migraine, Cluster
headache
Prior authorization
required
Tier 4
dihydroergotamine (generic
Migranal) nasal
Migraine
Quantity limit. Add step
therapy requirement.
Tier 4
Epivir HBV solution
Hepatitis B
Quantity limit. Remove
prior authorization
requirement
Tier 2
exemestane (generic Aromasin)
Breast cancer
Add prior authorization
requirement. Remove
age and gender edit
Tier 1
fluocinolone (generic Synalar)
solution
Corticosteroid
responsive dermatoses
Add step therapy
requirement
Tier 3
lamivudine (generic Epivir HBV)
tablet
Hepatitis B
Quantity limit. Remove
prior authorization
requirement
Tier 1
metformin extended-release
(generic Fortamet)
Type 2 diabetes
Add prior authorization
requirement
Tier 1
phenoxybenzamine (generic
Dibenzyline)
Pheochromocytoma
Add prior authorization
requirement
Tier 1
Blue Shield of California
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2017)
Tier 3
March 2016
risperidone odt (generic
Risperdal M-Tab)
Schizophrenia, Bipolar
disorder, Autistic
disorder
Tier 3
ziprasidone (generic Geodon)
Schizophrenia, Bipolar
disorder
Tier 3
Anti-retrovirals
abacavir (generic Ziagen)
tablet
HIV infection
Add quantity limit
Tier 1
abacavir/lamivudine/zidovudine
(generic Trizivir)
HIV infection
Add quantity limit
Tier 1
Atripla
HIV infection
Add quantity limit
Tier 3
Complera
HIV infection
Add quantity limit
Tier 3
Crixivan
HIV infection
Add quantity limit
Tier 2
didanosine (generic Videx EC)
HIV infection
Add quantity limit
Tier 1
Edurant
HIV infection
Add quantity limit
Tier 2
Emtriva
HIV infection
Add quantity limit
Tier 2
Epzicom
HIV infection
Add quantity limit
Tier 2
Intelence
HIV infection
Step therapy required.
Add quantity limit
Tier 2
Invirase
HIV infection
Add quantity limit
Tier 2
Isentress
HIV infection
Add quantity limit
Tier 2
Kaletra
HIV infection
Add quantity limit
Tier 2
lamivudine (generic Epivir)
HIV infection
Add quantity limit
Tier 1
lamivudine/zidovudine (generic
Combivir)
HIV infection
Add quantity limit
Tier 1
Lexiva
HIV infection
Add quantity limit
Tier 2
nevirapine (generic Viramune)
HIV infection
Add quantity limit
Tier 1
nevirapine extende-release
(generic Viramune R)
HIV infection
Add quantity limit
Tier 1
Norvir
HIV infection
Add quantity limit
Tier 2
Prezista
HIV infection
Add quantity limit
Tier 2
Rescriptor
HIV infection
Add quantity limit
Tier 2
Reyataz capsule
HIV infection
Add quantity limit
Tier 2
Selzentry
HIV infection
Prior authorization
required. Add quantity
limit
Tier 2
stavudine (generic Zerit)
HIV infection
Add quantity limit
Tier 1
Sustiva
HIV infection
Add quantity limit
Tier 2
Truvada
HIV infection
Add quantity limit
Tier 2
Blue Shield of California
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March 2016
Viracept
HIV infection
Add quantity limit
Tier 2
zidovudine (generic Retrovir)
capsule, syrup
HIV infection
Add quantity limit
Tier 1
3. DRUGS REMOVED FROM THE FORMULARY
The following drugs will be removed from the formulary starting January 2017. Non-formulary drugs
require a formulary exception based on medical necessity for coverage.
Drug
FDA Indication(s)
Formulary Alternative(s)
Bydureon, Bydureon pen,
Byetta
Type 2 diabetes
metformin, sulfonylurea, TZD, Tanzeum (steptherapy required)
Glucophage
Type 2 diabetes
metformin (generic Glucophage)
Glucophage XR
Type 2 diabetes
metformin extended release (generic
Glucophage XR)
Glucovance
Type 2 diabetes
glyburide/metformin (generic Glucovance)
Kasano, Nesina, Oseni
Type 2 diabetes
Januvia, Janumet (step therapy required for
both)
Kombiglyze XR, Onglyza
Type 2 diabetes
Januvia, Janumet (step therapy required for
both)
Latuda
Schizophrenia, Bipolar
disorder
olanzapine, quetiapine, risperidone
Levemir, Levemir Flextouch
Diabetes
Lantus, Toujeo
metformin extended-release
(generic Fortamet)
Type 2 diabetes
metformin extended-release (generic
Glucophage XR)
Nasonex
Allergic rhinitis
fluticasone nasal
Nuvigil
Obstructive sleep apnea,
Narcolepsy, Shift work
disorder
modafinil (PA required)
olanzapine-fluoxetine
(generic Symbyax)
Bipolar disorder,
Depression
olanzapine, quetiapine, risperidone
Saizen
Growth hormone
deficiency
Nutropin, Nutropin AQ (PA required)
Saphris
Schizophrenia, Bipolar
disorder
olanzapine, quetiapine, risperidone
Seroquel XR
Schizophrenia, Bipolar
mania, Depression
quetiapine (generic Seroquel)
Topical Corticosteroids
Blue Shield of California
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March 2016
Drug
FDA Indication(s)
Formulary Alternative(s)
amcinonide cream, lotion,
ointment
Corticosteroid responsive
dermatoses
fluocinonide 0.05% gel, cream, ointment,
solution; betamethasone augmented 0.05%
cream, lotion, ointment, gel
ApexiCon E
Corticosteroid responsive
dermatoses
fluocinonide 0.05% gel, cream, ointment,
solution; betamethasone augmented 0.05%
cream, lotion, ointment, gel
betamethasone valerate
(generic Luxiq) foam
Corticosteroid responsive
dermatoses of the scalp
betamethasone dipropionate 0,05% cream,
ointment, lotion; betamethasone valerate
0.1% cream, ointment, lotion; TAC 0.1%
cream, ointment, lotion; fluticasone 0.05%
cream, ointment; mometasone 0.1% cream,
ointment
clobetasol (generic Clobex)
spray
Plaque psoriasis
clobetasol cream, ointment, solution, gel,
cream emollient
Clodan
Scalp psoriasis
clobetasol cream, ointment, solution, gel,
cream emollient
clocortolone (generic
Cloderm) cream
Corticosteroid responsive
dermatoses
betamethasone dipropionate 0,05% cream,
ointment, lotion; betamethasone valerate
0.1% cream, ointment, lotion; TAC 0.1%
cream, ointment, lotion; fluticasone 0.05%
cream, ointment; mometasone 0.1% cream,
ointment
desonide (generic Desowen)
lotion
Corticosteroid responsive
dermatoses
hydrocortisone 2.5% cream, ointment, lotion;
alclometasone 0.05% cream, ointment
desoximetasone (generic
Topicort) 0.05% cream
Corticosteroid responsive
dermatoses
betamethasone dipropionate 0,05% cream,
ointment, lotion; betamethasone valerate
0.1% cream, ointment, lotion; TAC 0.1%
cream, ointment, lotion; fluticasone 0.05%
cream, ointment; mometasone 0.1% cream,
ointment
desoximetasone (generic
Topicort) gel, ointment, 0.25%
cream
Corticosteroid responsive
dermatoses
fluocinonide 0.05% gel, cream, ointment,
solution; betamethasone augmented 0.05%
cream, lotion, ointment, gel
diflorasone cream, ointment
Corticosteroid responsive
dermatoses
betamethasone, augmented 0.05% lotion,
ointment, gel, cream
fluocinolone (generic DermaSmoothe-FS) body oil
Atopic dermatitis
hydrocortisone 2.5% cream, ointment, lotion;
alclometasone 0.05% cream, ointment
fluocinolone (generic DermaSmoothe-FS) scalp oil
Scalp psoriasis
hydrocortisone 2.5% cream, ointment, lotion;
alclometasone 0.05% cream, ointment
Corticosteroid responsive
dermatoses
betamethasone dipropionate 0,05% cream,
ointment, lotion; betamethasone valerate
0.1% cream, ointment, lotion; TAC 0.1%
cream, ointment, lotion; fluticasone 0.05%
cream, ointment; mometasone 0.1% cream,
ointment
fluticasone (generic
Cutivate) lotion
Blue Shield of California
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March 2016
FDA Indication(s)
Formulary Alternative(s)
hydrocortisone
butyrate/emollient (generic
Locoid Lipocream) cream
Corticosteroid responsive
dermatoses
betamethasone dipropionate 0,05% cream,
ointment, lotion; betamethasone valerate
0.1% cream, ointment, lotion; TAC 0.1%
cream, ointment, lotion; fluticasone 0.05%
cream, ointment; mometasone 0.1% cream,
ointment
Scalacort
Corticosteroid responsive
dermatoses
hydrocortisone 2.5% cream, ointment, lotion;
alclometasone 0.05% cream, ointment
Corticosteroid responsive
dermatoses
betamethasone dipropionate 0,05% cream,
ointment, lotion; betamethasone valerate
0.1% cream, ointment, lotion; TAC 0.1%
cream, ointment, lotion; fluticasone 0.05%
cream, ointment; mometasone 0.1% cream,
ointment
Corticosteroid responsive
dermatoses
betamethasone dipropionate 0,05% cream,
ointment, lotion; betamethasone valerate
0.1% cream, ointment, lotion; TAC 0.1%
cream, ointment, lotion; fluticasone 0.05%
cream, ointment; mometasone 0.1% cream,
ointment
Drug
triamcinolone acetonide
(generic Kenalog) spray
Trianex ointment
4. DRUGS REMOVED FROM COVERAGE
The following drugs were excluded from coverage because they are not approved by the Food and Drug
Administration (FDA):
Drug
Drug
Ala-quin cream
Nicomide
hydrocortisone-iodoquinol cream, cream pack
Ultrasal ER
Iodosorb gel
Vytone
Blue Shield of California
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March 2016