Quarterly pharmacy formulary change notice

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1 Provider Bulletin December 2017 Quarterly pharmacy formulary notice The formulary s listed in the table below apply to all Anthem HealthKeepers Plus members. These s were reviewed and approved at the third quarter Pharmacy and Therapeutics Committee meeting. Effective February 1, 2018, formulary s, non-formulary s and prior authorization requirements will apply. Effective for all Anthem HealthKeepers Plus members on February 1, 2018 ANTIPSYCHOTICS PIMOZIDE 1 MG PIMOZIDE 2 MG ESTROGEN COMBINATIONS ESTROGEN COMBINATIONS HEPATITIS C IRON REPLACEMENT CAFFEINE SODIUM POLYSTYRENE SULFONATE SEVELAMER CARBONATE OPHTHALMOLOGICS OPTHALMIC ANTI-INFECTIVES EEMT DS MG EEMT HS MG COVARYX COVARYX H.S. MIMVEY LO MG LOPREEZA 1 MG-0.5 MG EPCLUSA 400 MG-100 MG MAVYRET MG HEMORRHOIDAL SUPPOSITORIES SOD FER GLUC CPLX 62.5 MG/5 ML NON- NON- WITH PA WITH PA AS OF 11/1/17 PREMPHASE PREMPRO MIMVEY LO LOPREEZA ZEPATIER MAVYRET WITH CAFFEINE CIT 60 MG/3 ML VIAL SPS 50 GM/200 ML ENEMA KIONEX 15 GM/60 ML SUSPENSION NON- AZO TEST STRIP SEVELAMER CARBONATE 800 MG TAB NON- PROPARACAINE 0.5% EYE DROPS NON- ARTIFICIALS TEARS DROPS GATIFLOXACIN 0.5% EYE DROPS MOXIFLOXACIN 0.5% EYE DROPS (GENERIC VIGAMOX) SPS 15 GM/60 ML SUSPENSION SPS 30 GM/120 ML ENEMA VELPHORO 500 MG CHEWABLE TAB The information in this bulletin may be an update or to your provider manual. Find the most current manual at: HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. AVAPEC December 2017

2 Quarterly pharmacy formulary notice Page 2 of 5 OXYTOCICS URINARY ANESTHETICS UROLOGICALS VAGINAL CLEANSER /ANTIINFECTIVES VAGINAL ANTIFUNGALS VASOCONSTRICTOR DECONGESTANTS METHYLERGONOVINE 0.2 MG/ML AMP METHYLERGONOVINE 0.2 MG/ML VL AZO-TABS 95 MG URETRON D-S URIN D.S. NON- FEM PH VAGINAL JELLY NON- MICONAZOLE 1 COMBINATION PACK TIOCONAZOLE 1 6.5% OINTMENT EYE ALLERGY RELIEF DROP VISINE-A EYE DROPS EYE DROPS ADVANCED RELIEF NAPHAZOLINE 0.1% EYE DROPS EDITS NO CHANGES IN /NON- STATUS REVISION OR ADDITION TO UM EDIT ONLY BPH 5-ALPHA- REDUCTASE INHIB-ALPHA1- ADRENOCEP ANTAG ADHD ANTI-INFECTIVES ANTIMETABOLITES ANTICOAGULANTS ANTINEOPLASTICS AVODART DUTASTERIDE DUTASTERIDE-TAMSULOSIN FINASTERIDE JALYN PROSCAR MYDAYIS ER 12.5 MG CAPSULE MYDAYIS ER 25 MG CAPSULE MYDAYIS ER 37.5 MG CAPSULE MYDAYIS ER 50 MG CAPSULE DAXBIA 333 MG CAPSULE XATMEP 2.5 MG/ML ORAL SOLUTION BEVYXXA 40 MG CAPSULE BEVYXXA 80 MG CAPSULE KISQALI FEMARA 200 MG KISQALI FEMARA 400 MG KISQALI FEMARA 600 MG RUBRACA 250 MG ZYTIGA 500 MG AL REMOVED 168 PER 30 ADD PA 31 PER 30 LIMIT OF 42 SUPPLY IN 60 1 CARTON PER 30

3 Quarterly pharmacy formulary notice Page 3 of 5 ANTIPARKINSONISM ANTIPSORIATIC ANTIPSYCHOTICS ANTISPASMODICS ANTIVIRALS CODEINE CONTAINING HEPATITIS C GROWTH HORMONES GASTROINTESTINAL HYPERPARATHYROIDISM HYPNOTIC INTRANASAL STEROIDS LIPID/CHOLESTEROL LOWERING TO TREAT MULTIPLE SCLEROSIS XADAGO 50 MG XADAGO 100 MG ZELAPAR 1.25 MG ODT TREMFYA 100 MG/ML FAZACLO 200 MG ODT CLOZAPINE ODT 200 MG CLOZAPINE 200 MG GELNIQUE 10% GEL PUMP FAMCICLOVIR 125 MG FAMCICLOVIR 250 MG VALTREX 500 MG CAPLET VALACYCLOVIR HCL 500 MG ALL RX AND OTC PRODUCTS RIBAVIRIN 200 MG CAPSULE RIBAVIRIN 200 MG SAIZEN 8.8 MG CLICK.EASY CARTG SAIZEN 8.8 MG SAIZENPREP CART RENFLEXIS 100 MG VIAL RAYALDEE 30MCG SENSIPAR 30MG & 60MG SENSIPAR 90MG BUTISOL SODIUM 30 MG/5 ML ELX BUTISOL SODIUM 30 MG FLUTICASONE 50 MCG SPRAY NASACORT ALLERGY 24 HR FLONASE SENSIMIST 27.5 MCG SPR VASCEPA 0.5 MG ZINBRYTA 150 MG/ML 1 PER 56 QL REVISION 1 PUMP PER PER 30 ADD AL <12 YEARS OLD PA REMOVED 1 CARTRIDGE PER DAY 2 PER 28 NEW: 14 DAY TREATMENT PERIOD 1 PER 30 8 PER DAY 1 PER 28

4 Quarterly pharmacy formulary notice Page 4 of 5 NARCOTICS NARCOTIC ANTAGONISTS OSTEOPOROSIS THERAPY PROTON-PUMP INHIBITORS PULMONARY RHEUMATOLOGICAL SODIUM HENYLBUTYRATE CHOLESTEROL LOWERING VACCINES LAZANDA 300 MCG NASAL SPRAY EVZIO 0.4 MG AUTO-INJECTOR EVZIO 2 MG AUTO-INJECTOR NARCAN 2MG NASAL SPRAY TYMLOS 80 MCG DOSE PEN INJECTR ZEGERID OTC 20-1;100 MG CAP HAEGARDA 3;000 UNIT VIAL HAEGARDA 2;000 UNIT VIAL KEVZARA 150 MG/1.14 ML KEVZARA 200 MG/1.14 ML ORENCIA 50 MG/0.4 ML ORENCIA 87.5 MG/0.7 ML BUPHENYL 500MG BUPHENYL 250GM POWDER NIKITA 1MG, 2MG, 4MG ZYPITAMAG 1MG, 2MG, 4MG FENOFIBRATE 43 MG CAPSULE FENOFIBRATE 130 MG CAPSULE FLU VACCINATIONS 1 BOTTLE PER DAY 6 INJ PER 90 3 CARTONS PER 90 1 PEN PER 30 QL REVISION 16 VIALS PER VIALS PER 28 2 PER 28 4 PER PER DAY 250GM POWDER PER ML PER FILL 2 FILLS PER 180

5 Quarterly pharmacy formulary notice Page 5 of 5 What action do I need to take? Please review these s and work with your Anthem HealthKeepers Plus members 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 a Anthem HealthKeepers Plus member cannot be converted to a formulary alternative, call our Pharmacy department at and follow the voice prompts for pharmacy prior authorization. You can find the preferred drug list (formulary) on our provider website at If you need assistance with any other item, contact your local Provider Relations representative or call Provider Services at

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