Provider Bulletin

May 2016

Quarterly pharmacy formulary change notice Summary of change The formulary changes listed in the table below were reviewed and approved at the 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

MEDICATION ANDRODERM PATCH ANDROGEL TESTIM GEL TESTOSTERONE 50 MG/5 GRAM GEL TESTOSTERONE 25 MG/2.5 GM PKT TESTOSTERONE 50 MG/5 GRAM PKT TESTOSTERONE 12.5 MG/1.25 GRAM TESTOSTERONE 12.5 MG/1.25 GRAM REPATHA 140 MG/ML SYRINGE REPATHA 140 MG/ML SURECLICK GENVOYA LOPINAVIR/RITONAVIR

FORMULARY STATUS CHANGE

POTENTIAL ALTERNATIVES (PREFERRED PRODUCTS)

NON-PREFERRED

TESTOSTERONE (SEE BELOW)

PREFERRED (PA REQUIRED)

N/A

PREFERRED (PA REQUIRED)

N/A

PREFERRED

N/A

PA REQUIRED PREFERREDREMOVE PA

N/A

HIV AGENTS

FUZEON

HIV AGENTS

STRIBILD

ANTICONVULSANTS

GABITRIL SSB AND GENERIC LEVETIRACETAM XR STAVZOR

REMOVE PA

N/A

MISC ANTIBIOTICS

DARAPRIM 25 MG TABLET

NON-PREFERRED ADD QUANTITY LIMIT (QL)

N/A

MISC ANTINEOPLASTIC DRUGS

ARIMIDEX AROMASIN FEMARA FUNGOID 2% TINCTURE ALOE VESTA 2% ANTIFUNGAL OINT ALOE VESTA 2% OINTMENT LOTRIMIN AF 2% POWDER LOTRIMIN AF 2% LIQUID SPRAY PV ANTI-FUNGAL 2% LIQUID SPRAY ANTI-FUNGAL 2% CREAM DERMAFUNGAL 2% OINTMENT ATHLETE'S FOOT 2% POWDER TRIPLE PASTE AF 2% OINTMENT AZOLEN 2% TINCTURE REMEDY PHYTPLX ANTIFUNGAL OINT REMEDY PHYTOPLEX ANTIFUNGAL 2% CRITIC-AID CLEAR AF 2% OINT DESENEX 2% SPRAY LIQUID

REMOVE PA

N/A

PREFERRED

N/A

TOPICAL ANTIFUNGALS

N/A

https://mediproviders.anthem.com/va HealthKeepers, Inc. is an 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. AVAPEC-1143-16 March 2016

Anthem HealthKeepers Plus Quarterly pharmacy formulary change notice May 2016 Page 2 of 7 FUNGI-NAIL TINCTURE FUNGI-NAIL TOE & FOOT OINTMENT GORDOCHOM SOLUTION TINACTIN 1% CREAM TINACTIN JOCK ITCH 1% CREAM TINACTIN 1% LIQUID SPRAY BLIS-TO-SOL 1% LIQUID EQ ATHLETE'S FOOT 1% CREAM PV FOOT ODOR CONTROL 1% POWDER NIZORAL A-D 1% SHAMPOO CVS ITCH RELIEF 1% CREAM LOTRIMIN AF 1% CREAM FUNGI CURE INTENSIVE 1% SPRAY ALEVAZOL 1% OINTMENT ANTI-FUNGAL 25% LIQUID RA ANTI-FUNGAL 25% SOLUTION ANTI-FUNGAL LIQUID UNDELENIC TINCTURE MYCO NAIL A 25% SOLUTION ELON DUAL DEFENSE 25% SOLUTION HONGO CURA ANTI-FUNGAL 25% SPR MYCO NAIL LIQUID LAMISIL ANTIFUNGAL 1% SPRAY CVS ATHLETE'S FOOT 1% CREAM EQ TERBINAFINE 1% CREAM TERBINAFINE HCL 1% CREAM CVS JOCK ITCH 1% CREAM TOPICAL ANTIFUNGALS TOPICAL ANTIFUNGALS

LOTRIMIN ULTRA NYSTATIN-TRIAMCINALONE CREAM AND OINT

TOPICAL ANTIFUNGALS

ECONAZOLE NITRATE 1% CR

TOPICAL ANTIFUNGALS

CICLOPIROX 0.77% GEL & SHAMPOO

REVISED QL

NON-PREFERRED

NON-PREFERRED

NON-PREFERRED

N/A NYSTATIN 100;000 UNIT/GM CREAM/OINTMENT TRIAMCINOLONE CREAM/OINTMENT LOTRIMIN 1% CREAM TERBINAFINE CREAM 1% CERAM CICLOPIROX 0.77% CREAM

TOPICAL ANTIFUNGALS

CICLOPIROX 8% TREATMENT KIT

NON-PREFERRED

CICLOPIROX 8% SOLUTION

ACNE AND ROSACEA AGENTS

ON-THE-SPOT 2.5% ACNE CREAM PANOXYL 10% ACNE CLEANSING BAR PANOXYL 3% CREAM BENZOYL PEROXIDE 5.3% & 9.8% FOAM BPO 4% & 8% CREAMY WASH PACK BP WASH 2.5% & 7% LIQ BP WASH ACNE 4% AND 8% TX PACK CVS ACNE SPOT TX 2.5% CRM BENZEPRO 5.3% & 9.8% FOAM OC8 GEL RIAZ 5.5% & 9.5% FOAM CVS ACNE CLEANSING BAR 10% ACNE MEDICATION 5% & 10% GEL PV ACNE PIMPLE 10% GEL ACNE MEDICATION 5% & 10% LOTION BP 10% FOAMING WASH CVS CREAMY ACNE 4% FACE WASH

PREFERRED

N/A

Anthem HealthKeepers Plus Quarterly pharmacy formulary change notice May 2016 Page 3 of 7

ACNE AND ROSACEA AGENTS

ACNE AND ROSACEA AGENTS

CVS FOAMING ACNE FACE 10% WASH ACNE TREATMENT CLEANSING 10% ADVANCED ACNE 4.4% WASH BP 5.5% GEL BENZOYL PEROXIDE 10% GEL BENZOYL PEROXIDE 4% CREAMY WASH BENZOYL PEROXIDE 6% CLEANSER BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 5% GEL BENZOYL PEROX 8% CREAMY WASH BENZOYL PEROXIDE 9% CLEANSER BENZOYL PEROXIDE 10% WASH DESQUAM-X 5% WASH DERMAPAK PLUS KIT MYORISAN 30 MG ZENATANE 30 MG

NON-PREFERRED

OTC GENERIC BENZOYL PEROXIDE : PANOXYL 3 % CREAM, BENZOYL PEROXIDE 5.3 FOAM , BENZOYL PEROXIDE 6% CLEANSER

ADD QL

N/A

IMMUNOMODULATO RS

ACTIMMUNE

REMOVE QL

N/A

MISCELLANEOUS ANTINEOPLASTIC DRUGS

AFINITOR XELODA VIDAZA TARGRETIN (ORAL)

REMOVE QL

N/A

MISCELLANEOUS ANTINEOPLASTIC DRUGS

IRESSA ODOMZO

ADD QL

N/A

REVISED QL

N/A

REVISED QL

N/A

RELENZA (ZANAMIVIR) 5MG DISKHALER TAMIFLU

REVISED QL

N/A

THIOLA

ADD QL

N/A

KEVEYIS

ADD QL

N/A

TRESIBA SYNJARDY

ADD QL

N/A

VARUBI

ADD QL

N/A

NEULASTA ON-BODY INJ.

ADD QL

N/A

COSENTYX 150 MG/ML

ADD QL

N/A

OTEZLA 28 DAY STARTER PACK

ADD QL

N/A

HUMIRA

REVISED QL

N/A

MISCELLANEOUS ANTIINFECTIVES

ANTIIFECTIVES

ANTIVIRALS KIDNEY STONE AGENTS MISCELLANEOUS NEUROLOGICAL THERAPY DIABETIC AGENTS ANTIVERTIGO & ANTIEMETIC AGENTS MYELOID STIMULANTS ANTIPSORIATIC/ ANTISEBORRHEIC MISCELLANEOUS RHEUMATOLOGICAL AGENTS MISCELLANEOUS RHEUMATOLOGICAL AGENTS

XIFAXIN 550MG SIVEXTRO TINDAMAX CIPRO 10% ORAL CIPRO 5% ORAL LEVAQUIN ORAL CIPRO IR ZITHROMAX 600MG ZITHROMAX

Anthem HealthKeepers Plus Quarterly pharmacy formulary change notice May 2016 Page 4 of 7

ANTIHYPERTENSIVE AGENTS

TARKA 2 MG/180 MG TARKA 1 MG/ 240 MG TARKA 2 MG/ 240 MG; 4 MG/240 MG DILTIAZEM ER 12-HOUR 90 MG, 120 MG NORVASC 5 MG VERAPAMIL ER 200 MG

REVISED QL

N/A

ANTIHYPERTENSIVE AGENTS

PRESTALIA

ADD QL

N/A

ADHD

APTENSIO XR

ADD QL

N/A

REVISED QL

N/A

REVISED QL

N/A

PREFERRED

N/A

NON-PREFERRED

LAMIVUDINE 10 MG/ML ORAL SOLN

PREFERRED

N/A

NON-PREFERRED

SEE BELOW

PREFERRED

N/A

OPIOID DEPENDANCE

ANTIMALARIALS CARDIAC AGENTS HIV AGENTS BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES INSULIN SYRINGES/MISC DURABLE MED EQUIPMENT

INSULIN SYRINGES/MISC DURABLE MED EQUIPMENT

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 QUALAQUIN DIGOXIN 0.25 MG/5 ML SOLUTION DIGOXIN 0.125 MG/2.5 ML SOLN 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

Anthem HealthKeepers Plus Quarterly pharmacy formulary change notice May 2016 Page 5 of 7 BD AUTOSHIELD DUO NDL 5MMX30G LANCETS INSUPEN 33G 4MM PEN NEEDLE COMFORT EZ PEN NEEDLES 6MM 33G COMFORT EZ PEN NEEDLES 4MM 33G 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'' PEAK FLOW METERS

ASTHMAPACK CHILDREN'S CARE KIT ASTHMAPACK I ASTHMAPACK II

NON-PREFERRED

MIN WRIGHT PEAK FLOW METER

PEAK FLOW METERS

MINI WRIGHT PEAK FLOW METER

PREFERRED

N/A

PREFERRED

N/A

PREFERRED

N/A

ZANTAC 150 MG TABLET ZANTAC 75 MG TABLET

PREFERRED

N/A

PEPTO-BISMOL TABLET CHEW PEPTO-BISMOL TO-GO 262 MG CHEW SOOTHE 262 MG CHEWABLE TABLET

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

ALMACONE TABLET CHEWABLE ANTACID-ANTIGAS II LIQ ANTACID-SIMETHICONE TAB CHEW LIQUID ANTACID SUSP KRO ADV ANTACID-ANTIGAS LIQUID

PREFERRED

N/A

INSULIN THERAPY

CONTRACEPTIVES

H2 ANTAGONISTS ANTIDIARRHEALS

ANTIDIARRHEALS

DIGESTIVE ENZYMES

ANTACIDS

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 ORTHO ALL-FLEX DIAPHRAGM 65MM ORTHO ALL-FLEX DIAPHRAGM 70MM ORTHO ALL-FLEX DIAPHRAGM 75MM ORTHO ALL-FLEX DIAPHRAGM 80MM

Anthem HealthKeepers Plus Quarterly pharmacy formulary change notice May 2016 Page 6 of 7

MISCELLANEOUS GASTROINTESTINAL AGENTS

MISCELLANEOUS GASTROINTESTINAL AGENTS

ANTIVERTIGO & ANTIEMETIC AGENTS

LAXATIVES AND CATHARTICS

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 LIDOCAINE-HC 3-0.5% CREAM EQ HEMORRHOIDAL SUPPOSITORIES HEMORRHOIDAL SUPPOSITORIES HEMRIL-30 30 MG SUPPOSITORY RECTACORT-HC 25 MG SUPPOSITORY PV HEMORRHOIDAL SUPPOSITORY Z-PRAM CREAM KIT LIDOCAINE 3%-HC 2.5% GEL KIT LIDOCAINE-HC 2.8-0.55% GEL LIDOCAINE-HC 2-2% CREAM KIT PV HEMORRHOIDAL SUPPOSITORY DIMENHYDRINATE 50 MG TABLET DRAMAMINE 50 MG TABLET DRIMINATE 50 MG TABLET MOTION SICKNESS 50 MG TABLET TRAVEL SICKNESS 50 MG TABLET WAL-DRAM 50 MG TABLET KONSYL PSYLLIUM FIBER POWDER NATURAL FIBER POWDER QC NATURAL VEGETABLE POWDER WAL-MUCIL 100% NATURAL FIBER NATURAL FIBER LAXATIVE POWDER WAL-MUCIL NTRL FIBER LAX POWD CVS NATURAL FIBER SUPP POWDER KONSYL POWDER REGULOID LAXATIVE POWDER REGULOID POWDER QC NATURAL VEG LAXATIVE TABLET SENNA-TIME S TABLET NATURAL PSYLLIUM FIBER POWDER KONSYL FORMULA-D FIBER POWDER GAVILAX POWDER PACKET KONSYL 520 MG CAPSULE REGULOID CAPSULE MEDI-MUCIL CAPSULE WAL-MUCIL 0.52 G CAPSULE KONSYL FORMULA-D FIBER POWDER CVS SOLUBLE FIBER THERAPY CVS EASY FIBER POWDER KONSYL PSYLLIUM FIBER POWDER KONSYL PSYLLIUM FIBER POWDER (GENERIC) WAL-MUCIL NTRL FIBER LAX POWD

PREFERRED

N/A

NON-PREFERRED

HEMORRHOIDAL OINTMENT EQ HEMORRHOIDAL SUPPOSITORIES LIDOCAINE-HC 30.5 CREAM (NONE KIT)

PREFERRED

N/A

PREFERRED

N/A

Anthem HealthKeepers Plus Quarterly pharmacy formulary change notice May 2016 Page 7 of 7 GLYCOLAX POWDER CVS NATURAL FIBER SUPP POWDER NATURAL VEGETABLE FIBER POWDER WAL-MUCIL 100% NATURAL FIBER GNP NATURAL FIBER LAXATIVE CAP KONSYL ORIGINAL FIBER POWDER MEDI-MUCIL CAPSULE NATURAL FIBER LAXATIVE CAPSULE METAFIBER POWDER QC NATURAL VEGETABLE POWDER KONSYL EASY MIX FORMULA POWDER REGULOID LAXATIVE POWDER VEGETABLE LAXATIVE POWDER RA SOLUBLE FIBER 500 MG CPLT CITRUCEL 500 MG CAPLET EPSOM SALT (GENERIC) EPSOM SALT CRYSTALS EPSOM SALT GRANULES ALOPHEN PILLS SURFAK 240 MG SOFTGEL EX-LAX ULTRA PILLS LAXATIVES AND CATHARTICS

DOCUSATE CAL 240 MG SOFTGEL

NON-PREFERRED

DOCUSATE SODIUM 100MG TAB

LAXATIVES AND CATHARTICS

NATURAL FIBER LAXATIVE POWDER PV NATURAL FIBER LAXATIVE PWD

NON-PREFERRED

GLYCOLAX POWDER

What this means to you  Effective May 1, 2016, formulary changes apply.  Effective May 1, 2016, non-formulary changes and PA requirements will apply.  This notice applies to HealthKeepers, Inc. benefits for Anthem HealthKeepers Plus members. What action do I need to take? Please review these changes and work with your Anthem HealthKeepers Plus patients to transition them to formulary alternatives. If you determine 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 your Anthem HealthKeepers Plus patient cannot be converted to a formulary alternative, call our Pharmacy department at 1-800-901-0020 and follow the voice prompts for pharmacy prior authorization. You can find the preferred drug list (formulary) on our provider website at https://mediproviders.anthem.com/va. If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-800-901-0020.