Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect May 2016
Provider update: Quarterly pharm...
Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect May 2016
Provider update: Quarterly pharmacy formulary change notice Effective May 1, 2016, the preferred formulary changes detailed in the table below will apply to Anthem Blue Cross and Blue Shield (Anthem) members enrolled in Hoosier Healthwise and Healthy Indiana Plan. Additionally, effective May 1, 2016, there will be changes to the nonpreferred and prior authorization requirements of these formulary items as well. These formulary changes were reviewed and approved at the fourth quarter Pharmacy and Therapeutics (P&T) committee meetings held on December 14, 2015. Effective for all patients on May 1, 2016
THERAPEUTIC CLASS TESTOSERONE REPLACEMENT AGENTS TESTOSERONE REPLACEMENT AGENTS PCSK-9 INHIBITORS HIV AGENTS
anthem.com/inmedicaiddoc Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AINPEC-0678-16 March 2016
N/A NYSTATIN 100;000 UNIT/GM CREAM/OINTMEN T TRIAMCINOLONE CREAM/OINTMEN T LOTRIMIN 1% CREAM TERBINAFINE CREAM 1% CERAM CICLOPIROX 0.77% CREAM
NON-PREFERRED
CICLOPIROX 8% SOLUTION
PREFERRED
N/A
Anthem Blue Cross and Blue Shield May 2016 Page 3 of 7 PV ACNE PIMPLE 10% GEL ACNE MEDICATION 5% & 10% LOTION BP 10% FOAMING WASH CVS CREAMY ACNE 4% FACE WASH CVS FOAMING ACNE FACE 10% WASH ACNE TREATMENT CLEANSING 10% ADVANCED ACNE 4.4% WASH BP 5.5% GEL
APTENSIO XR BUNAVAIL 2.1/0.3 MG BUNAVAIL 4.2/0.7 MG BUNAVAIL 6.3/1 MG SUBOXONE SL TAB AND FILM 2/0.5 MG SUBOXONE SL FILM 4-1 MG SUBOXONE SL TAB AND FILM 8-2 MG SUBOXONE SL FILM 12-3 MG ZUBSOLV 1.4-0.36 MG ZUBSOLV 5.7-1.4 MG ZUBSOLV 8.6-2.1 MG
ADD QL
N/A
REVISED QL
N/A
ANTIMALARIALS
QUALAQUIN
REVISED QL
N/A
CARDIAC AGENTS
DIGOXIN 0.25 MG/5 ML SOLUTION DIGOXIN 0.125 MG/2.5 ML SOLN
PREFERRED
N/A
NON-PREFERRED
LAMIVUDINE 10 MG/ML ORAL SOLN
PREFERRED
N/A
NON-PREFERRED
SEE BELOW
PREFERRED
N/A
HIV AGENTS BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES INSULIN SYRINGES/MISC DURABLE MED EQUIPMENT
INSULIN SYRINGES/MISC DURABLE MED EQUIPMENT
EPIVIR 10 MG/ML ORAL SOLN
(BRAND)
ALCOHOL 70% SWABS BD NEEDLES 26GX0.5'' BD NEEDLES 27GX0.5'' EXEL HYPO NEEDLE 26GX0.5'' EXEL HYPO NEEDLE 26GX1.5'' EXEL HYPO NEEDLE 27GX0.5'' POLY HUB NEEDLE 27GX1/2'' MINI WRIGHT PEAK FLOW METER MINI-WRIGHT PEAK FLOW METER COMFORT EZ PEN NEEDLES 5MM 31G COMFORT EZ PEN NEEDLES 6MM 31G COMFORT EZ PEN NEEDLES 8MM 31G PEN NEEDLE 30G X 5/16'' PEN NEEDLE 31G X 3/16'' PEN NEEDLE 31G X 5/16'' TRUEPLUS SYR 0.5ML 31GX5/16'' ULTRA-THIN II INS 0.5 ML 31G ULTICARE SYR 1 ML 31GX5/16'' TRUEPLUS SYR 0.3ML 31GX5/16'' ULTRA-THIN II INS 0.3 ML 31G ULTICARE SYR 0.3 ML 29GX1/2'' ULTICARE SYR 0.3 ML 30GX5/16'' ULTICARE SYR 0.5 ML 29GX1/2'' ULTICARE SYR 0.5 ML 30GX5/16'' ULTRACOMFORT 29GX0.5 ML SYR ULTICARE SYR 1 ML 30GX5/16'' ULTICARE SYRINGE 1 ML 29GX1/2'' ULTRACOMFORT 29GX1 ML SYRINGE EASY TOUCH 1 ML SYR 30GX1/2'' EASY TOUCH 0.5 ML SYR 30GX5/16 BD AUTOSHIELD DUO NDL 5MMX30G LANCETS INSUPEN 33G 4MM PEN NEEDLE COMFORT EZ PEN NEEDLES 6MM 33G COMFORT EZ PEN NEEDLES 4MM 33G
Anthem Blue Cross and Blue Shield May 2016 Page 5 of 7
PEAK FLOW METERS PEAK FLOW METERS INSULIN THERAPY
CONTRACEPTIVES
H2 ANTAGONISTS ANTIDIARRHEALS
ANTIDIARRHEALS
DIGESTIVE ENZYMES
ANTACIDS
MISCELLANEOUS GASTROINTESTINAL AGENTS
COMFORT EZ PEN NEEDLES 5MM 33G COMFORT EZ PEN NEEDLES 5MM 32G COMFORT EZ PEN NEEDLES 8MM 33G COMFORT EZ PEN NEEDLES 6MM 32G COMFORT EZ PEN NEEDLES 8MM 32G PEN NEEDLE 30G X 5/16'' ULTRA-THIN II INS 0.5 ML 31G TRUEPLUS SYR 0.5ML 31GX5/16'' VANISHPOINT U-100 29X1/2 SYR ULTICARE SYR 1 ML 31GX5/16'' ULTRA-THIN II INS 0.3 ML 31G TRUEPLUS SYR 0.3ML 31GX5/16'' EASY TOUCH 1 ML SYR 30GX1/2'' BD AUTOSHIELD DUO NDL 5MMX30G PEN NEEDLE 31G X 3/16'' PEN NEEDLE 31G X 5/16'' ASTHMAPACK CHILDREN'S CARE KIT ASTHMAPACK I ASTHMAPACK II
NON-PREFERRED
MIN WRIGHT PEAK FLOW METER
PREFERRED
N/A
PREFERRED
N/A
PREFERRED
N/A
PREFERRED
N/A
PREFERRED
N/A
PAREGORIC LIQUID
NON-PREFERRED
PINK BISMUTH SUSPENSION K-PEC SUSPENSION
VIOKASE 16 TABLET VIOKASE 8 TABLET
NON-PREFERRED (CURRENT UITLIZERS WILL BE GRANDFATHERED )
N/A
PREFERRED
N/A
PREFERRED
N/A
MINI WRIGHT PEAK FLOW METER HUMULIN N 100 UNITS/ML KWIKPEN HUMULIN N 100 UNITS/ML KWIKPEN HUMULIN 70/30 KWIKPEN HUMULIN 70/30 KWIKPEN FC2 FEMALE CONDOM WIDE SEAL DIAPHRAGM 60MM WIDE SEAL DIAPHRAGM 90MM WIDE SEAL DIAPHRAGM 95MM ZANTAC 150 MG TABLET ZANTAC 75 MG TABLET PEPTO-BISMOL TABLET CHEW PEPTO-BISMOL TO-GO 262 MG CHEW SOOTHE 262 MG CHEWABLE TABLET
ALMACONE TABLET CHEWABLE ANTACID-ANTIGAS II LIQ ANTACID-SIMETHICONE TAB CHEW LIQUID ANTACID SUSP KRO ADV ANTACID-ANTIGAS LIQUID MAALOX MAXIMUM STRENGTH SUSP SM ADV ANTACID-ANTIGAS SUSP RIGINIC SUSPENSION RI MAG PLUS LIQUID RI-MAG PLUS SUSPENSION RI-MAG SUSPENSION MAGIC BULLET 10 MG SUPPOS GLYCERIN SUPPOSITORY INFANT & CHILD GLYCERIN SUPPOS PEDIATRIC GLYCERIN SUPPOSITORY PV INFANT GLYCERIN SUPPOS MAJOR-PREP HEMORRHOIDAL SUPPOS RA HEMORRHOID RLF 0.25 % SUPP HEMORRHOIDAL OINTMENT LIDOCAINE-HC 3-0.5% CREAM
Anthem Blue Cross and Blue Shield May 2016 Page 6 of 7 LIDOCAINE-HC 3-0.5% CREAM EQ HEMORRHOIDAL SUPPOSITORIES HEMORRHOIDAL SUPPOSITORIES
What action do I need to take? Please review these changes and work with your patients to transition them to formulary alternatives. If you determine preferred formulary alternatives are not clinically appropriate for specific patients, you will need to obtain prior authorization to continue coverage beyond the applicable effective date. What if I need assistance? We recognize the unique aspects of patients’ cases. If, for medical reasons, your patient cannot be converted to a formulary alternative, call our Pharmacy department at 1-866-398-1922 and follow the voice prompts for pharmacy prior authorization. You can find the preferred drug lists on our provider website at www.anthem.com/inmedicaiddoc via the following steps:
Select Member Eligibility & Benefits from the blue navigation tabs at the top of the screen. Choose Pharmacy Benefits from the drop-down menu. Under Preferred Drug Lists, choose the appropriate list.
If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-866-408-6132 for Hoosier Healthwise or 1-800-345-4344 for Healthy Indiana Plan.