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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 Page 1 of 6 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 Page 2 of 6 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 Page 3 of 6 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 Page 4 of 6 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 Page 5 of 6 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 Page 6 of 6 March 2016