BLUE SHIELD OF CALIFORNIA MARCH 2016 PLUS 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 Plus Drug Formulary from the March 2016 P&T Committee meeting are outlined below. To view a copy of the Plus 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)
cyclopentolate 2% drops (generic Cyclogyl)
Mydriasis, Cycloplegia
fluticasone propionate (generic Flonase)
Allergic and non-allergic rhinitis
Quantity limit
metformin extended-release tablet (generic Glumetza)
Type 2 diabetes
Prior authorization required. Quantity limit
naloxone 0.4mg/ml vial and syringe, 2mg/2ml syringe
Opioid overdose
Quantity limit
Tanzeum
Type 2 diabetes
Toujeo Solostar
Diabetes
Step therapy required. Quantity limit Quantity limit
2. FORMULARY DRUGS WITH CHANGES TO RESTRICTIONS The following drugs remain at their current formulary status but have new coverage restriction(s) as noted. Drug
FDA Indication(s)
New Restriction(s)
aripiprazole (generic Abilify)
Schizophrenia, Bipolar mania, Depression, Autistic disorder, Tourette’s
Quantity limit
budesonide (generic Entocort EC)
Crohn’s disease
Prior authorization required. Quantity limit
dihydroergotamine mesylate nasal (generic Migranal)
Migraine
Step therapy required
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March 2016
Drug
FDA Indication(s)
New Restriction(s)
exemestane (generic Aromasin)
Breast cancer
Prior authorization required
metformin extended-release (generic Fortamet)
Type 2 diabetes
Prior authorization required
phenoxybenzamine (generic Dibenzyline)
Pheochromocytoma
Prior authorization required
Seroquel XR
Schizophrenia, Bipolar mania, Depression
Step therapy required
amcinonide cream, lotion, ointment
Corticosteroid responsive dermatoses
Step therapy required
ApexiCon E
Corticosteroid responsive dermatoses
Step therapy required
betamethasone valerate (generic Luxiq) foam
Corticosteroid responsive dermatoses of the scalp
Step therapy required
Capex shampoo
Corticosteroid responsive dermatoses of the scalp
Prior authorization required
clocortolone (generic Cloderm) cream
Corticosteroid responsive dermatoses
Step therapy required
desonide (generic Desowen) lotion
Corticosteroid responsive dermatoses
Step therapy required
desoximetasone (generic Topicort) cream , gel, ointment
Corticosteroid responsive dermatoses
Step therapy required
diflorasone cream, ointment
Corticosteroid responsive dermatoses
Step therapy required
fluocinolone (generic DermaSmoothe-FS) body oil
Atopic dermatitis
Step therapy required
fluocinolone (generic DermaSmoothe-FS) scalp oil
Scalp psoriasis
Step therapy required
fluocinolone (generic Synalar) solution
Corticosteroid responsive dermatoses
Step therapy required
fluticasone (generic Cutivate) lotion
Corticosteroid responsive dermatoses
Step therapy required
hydrocortisone butyrate/emollient (generic Locoid Lipocream)
Corticosteroid responsive dermatoses
Step therapy required
Scalacort
Corticosteroid responsive dermatoses
Step therapy required
Trianex ointment
Corticosteroid responsive dermatoses
Step therapy required
Topical Corticosteroids
Anti-retrovirals
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Drug
FDA Indication(s)
New Restriction(s)
Aptivus, Crixivan, Inverase, Kaletra, Lexiva, Norvir, Prezista, Reyataz capsule, Viracept
HIV infection
Quantity limit
lamivudine/zidovudine (generic Combivir), Emtriva, lamivudine (Epivir), Epzicom, zidovudine (generic Retrovir), abacavir/lamivudine/zidovudine (generic Trizivir), didanosine (generic Videx EC), stavudine (generic Zerit), abacavir (generic Ziagen)
HIV infection
Quantity limit
Atripla, Complera, Truvada
HIV infection
Quantity limit
Edurant, Intelence, Rescriptor, Sustiva, nevirapine (generic Viramune, Viramune XR)
HIV infection
Quantity limit
Selzentry, Isentress
HIV infection
Quantity limit
The following drugs remain at their current formulary status but have coverage restriction(s) removed as noted. Drug
FDA Indication(s)
Restriction removed
lamivudine (generic Epivir HBV) tablet
Hepatitis B
Prior authorization requirement
Epivir HBV solution
Hepatitis B
Prior authorization requirement
3. NON-FORMULARY DRUGS WITH CHANGES TO RESTRICTIONS The following drugs remain at their current formulary status but have new coverage restriction(s) as noted. Drug
FDA Indication(s)
New Restriction(s)
Formulary Alternative(s)
Evzio
Opioid overdose
Prior authorization required
naloxone 0.4mg/1ml vial or syringe
Quillivant XR
ADHD
Prior authorization required, Age-limit
methylphenidate extended-release (generic Ritalin LA, Concerta, Metadate CD)
Rayos
Corticosteroid responsive disease
Quantity limit
prednisone, methylprednisolone, dexamethasone, hydrocortisone
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March 2016
Drug
FDA Indication(s)
New Restriction(s)
Formulary Alternative(s)
Tresiba Flextouch
Diabetes
Step therapy required
Lantus, Toujeo
Xerese
Cold sores
Prior authorization required
oral acyclovir, valacyclovir tablet, famciclovir tablet, acyclovir 5% ointment (PA required)
Corticosteroid responsive dermatoses
Step therapy required
hydrocortisone 2.5% cream, ointment, lotion; alclometasone 0.05% cream, ointment
Prior authorization required
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
Topical Corticosteroids Ala-Scalp lotion
Cordran cream, lotion, ointment, tape
Corticosteroid responsive dermatoses
Locoid lotion
Corticosteroid responsive dermatoses
Prior authorization required
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
Verdeso foam
Atopic dermatitis
Prior authorization required
hydrocortisone 2.5% cream, ointment, lotion; alclometasone 0.05% cream, ointment
4. DRUGS REMOVED FROM THE FORMULARY The following drugs were moved from Formulary to Non-formulary: Drug
FDA Indication(s)
Restriction(s)
Formulary Alternative(s)
Azilect
Parkinson’s disease
Quantity limit
selegiline (generic Eldepryl)
Type 2 diabetes
Step therapy required. Quantity limit
metformin, sulfonylurea, TZD, Tanzeum (steptherapy required)
Type 2 diabetes
Step therapy required. Quantity limit
metformin, sulfonylurea, TZD, Tanzeum (steptherapy required)
Seborrheic dermatitis
Prior authorization required
hydrocortisone 2.5% cream, ointment, lotion; alclometasone 0.05% cream, ointment
Bydureon, Bydureon pen Byetta
Capex shampoo
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Drug
FDA Indication(s)
Restriction(s)
Formulary Alternative(s)
Kasano, Nesina, Oseni
Type 2 diabetes
Step therapy required. Quantity limit
Januvia, Janumet (step therapy required for both)
Levemir
Diabetes
Step therapy required. Quantity limit
Lantus, Toujeo
Nasonex
Allergic rhinitis
Step therapy required. Quantity limit
fluticasone nasal
Nuvigil
Obstructive sleep apnea, Narcolepsy, Shift work disorder
Quantity limit
modafinil (PA required)
The following brand-name drug was removed from the formulary because generic is now available and was added to the formulary: Brand-name Drug
FDA Indication(s)
Restriction(s)
Formulary Alternative
Zyvox suspension
Bacterial infection
Prior authorization required
5. DRUGS ADDED TO THE SPECIALTY TIER The following drugs were added to the Blue Shield specialty tier: Specialty Drug
Coverage Restriction(s)
Alecensa
Prior authorization required. Quantity limit.
Chenodal
Prior authorization required. Quantity limit.
Uptravi
Prior authorization required. Quantity limit.
Veltessa
Prior authorization required. Quantity limit.
Viberzi
Prior authorization required. Quantity limit.
Xuriden
Prior authorization required. Quantity limit.
Zepatier
Prior authorization required. Quantity limit.
6. 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
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