BCN Advantage Formulary Updates: April, 2018

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1 Attention BCN Advantage members: This is a list of changes made to the BCN Advantage formulary since its initial release in October, 2017 BCN Advantage may add or remove drugs from our formulary during the year. If we make any of the following changes, we ll notify you of the change at least 60 days before the effective date: Remove drugs from our formulary Add prior authorization, quantity limits and/or step therapy to a drug Move the drug to a higher cost-sharing tier Some formulary changes do not require advance notice but will be posted on this link. If your physician prescribes a drug that is not on our formulary, is not a preferred drug, or is subject to additional utilization requirements, you can ask us to make a coverage exception. You or your physician can initiate an exception request. While the use of a form isn t always required, they re available on the BCNA website at Coverage determinations will be made for standard and urgent requests within 72 and 24 hours, respectively. If BCN Advantage ever denies coverage for your prescription drugs, we ll explain our decision to you. You always have the right to appeal and ask us to review the claim that was denied. For more detailed information about your BCN Advantage prescription drug coverage, please review your BCN Advantage Formulary or Evidence of Coverage. If you have questions about the BCN Advantage drug formulary, please call the Customer Service number on the back of your ID card 8 a.m. to 8 p.m., Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. H5883_Ph_Apr18RxWebUpdate_ NM BCN Advantage SM is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

2 s made to the drugs in the BCN Advantage Formulary (additions, deletions, change in coverage) altavera (28) mg oral tablet levonorgestrel-ethin estradiol Addition ALUNBRIG 90 MG (7)- 180 MG (23) ORAL TABLETS,DOSE PACK brigatinib Addition ALUNBRIG 90MG, 180 MG ORAL TABLET brigatinib Addition atazanavir 150 mg, 200 mg oral capsule atazanavir sulfate Addition atazanavir 300 mg oral capsule atazanavir sulfate Addition carvedilol phosphate 10 mg, 20 mg, 40 mg oral capsule, er multiphase 24 hr carvedilol phosphate Addition efavirenz 50 mg oral capsule efavirenz Addition ELIQUIS 5 MG (74 TABS) ORAL TABLETS,DOSE PACK apixaban Addition enskyce mg oral tablet desogestrel-ethinyl estradiol Addition estradiol 0.01 % (0.1 mg/gram) vaginal cream estradiol Addition 2

3 fluoxetine 60 mg oral tablet fluoxetine hcl Addition HERCEPTIN 150 MG INTRAVENOUS RECON SOLN trastuzumab Addition kurvelo mg oral tablet levonorgestrel-ethin estradiol Addition levonorgestrel-ethinyl estrad mg oral tablet levonorgestrel-ethin estradiol Addition medroxyprogesterone 150 mg/ml intramuscular syringe medroxyprogesterone acetate Addition roweepra xr 500 mg, 750 mg oral tablet levetiracetam Addition SELZENTRY 20 MG/ML ORAL SOLUTION maraviroc Addition SHINGRIX (PF) 50 MCG/0.5 ML INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION varicella-zoster ge/as01b/pf Addition tenofovir disoproxil fumarate 300 mg oral tablet tenofovir disoproxil fumarate Addition VEMLIDY 25 MG ORAL TABLET tenofovir alafenamide fumarate Addition XIGDUO XR 2.5-1,000 MG ORAL TABLET, IR - ER, BIPHASIC 24HR dapagliflozin/metformin hcl Addition ST 3

4 ZENPEP 40, , ,000 UNIT ORAL CAPSULE,DELAYED RELEASE(DR/EC) lipase/protease/amylase Addition ADACEL(TDAP ADOLESN/ADULT)(PF) 2 LF-( MCG)-5LF/0.5 ML INTRAMUSCULAR SYRINGE diph,pertuss(acell),tet vac/pf Addition adapalene-benzoyl peroxide % topical gel with pump adapalene/benzoyl peroxide Addition ALIQOPA 60 MG INTRAVENOUS RECON SOLN copanlisib di-hcl Addition amnesteem 10 mg, 20 mg, 40 mg oral capsule isotretinoin Addition aripiprazole 1 mg/ml oral solution aripiprazole Addition BAXDELA 300 MG INTRAVENOUS RECON SOLN delafloxacin meglumine Addition BAXDELA 450 MG ORAL TABLET delafloxacin meglumine Addition BENLYSTA 200 MG/ML SUBCUTANEOUS AUTO- INJECTOR belimumab Addition BENLYSTA 200 MG/ML SUBCUTANEOUS SYRINGE belimumab Addition 4

5 BORTEZOMIB 3.5 MG INTRAVENOUS RECON SOLN bortezomib Addition BOSULIF 400 MG ORAL TABLET bosutinib Addition BYDUREON BCISE 2 MG/0.85 ML SUBCUTANEOUS AUTO- INJECTOR exenatide microspheres Addition CALQUENCE 100 MG ORAL CAPSULE acalabrutinib Addition carvedilol phosphate 80 mg oral capsule, er multiphase 24 hr carvedilol phosphate Addition CASPOFUNGIN 50 MG, 70 MG INTRAVENOUS RECON SOLN caspofungin acetate Addition dactinomycin 0.5 mg intravenous recon soln dactinomycin Addition desogestrel-ethinyl estradiol mg oral tablet desogestrel-ethinyl estradiol Addition doxycycline hyclate 75 mg, 150 mg oral tablet doxycycline hyclate Addition eletriptan hbr 20 mg, 40 mg oral tablet eletriptan hbr Addition estradiol 10 mcg vaginal tablet estradiol Addition PA QL QL QL 5

6 ethynodiol diac-eth estradiol 1-35 mg-mcg oral tablet ethynodiol d-ethinyl estradiol Addition fosamprenavir 700 mg oral tablet fosamprenavir calcium Addition glatiramer 20 mg/ml, 40 mg.ml subcutaneous syringe glatiramer acetate Addition GLEOSTINE 10 MG, 40 MG, 100 MG ORAL CAPSULE lomustine Addition haloperidol decanoate 100 mg/ml (1 ml) intramuscular solution haloperidol decanoate Addition HAVRIX (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE hepatitis a virus vaccine/pf Addition HAVRIX (PF) 720 ELISA UNIT/0.5 ML INTRAMUSCULAR SUSPENSION hepatitis a virus vaccine/pf Addition HUMALOG JUNIOR KWIKPEN 100 UNIT/ML SUBCUTANEOUS INSULIN PEN insulin lispro Addition IDHIFA 50 MG, 100 MG ORAL TABLET enasidenib mesylate Addition Isibloom mg oral tablet desogestrel-ethinyl estradiol Addition ST 6

7 JULUCA MG ORAL TABLET dolutegravir/rilpivirine Addition KADCYLA 160 MG INTRAVENOUS RECON SOLN ado-trastuzumab emtansine Addition klor-con 20 meq oral packet potassium chloride Addition l norgest/e.estradiol-e.estrad 0.15 mg-20 mcg/ 0.15 mg-25 mcg oral tablets,dose pack,3 month l-norgest/e.estradiol-e.estrad Addition lanthanum 500 mg, 750 mg, 1,000 mg oral tablet,chewable lanthanum carbonate Addition LARTRUVO 10 MG/ML (19 ML) INTRAVENOUS SOLUTION olaratumab Addition LUPRON DEPOT-PED (3 MONTH) 30 MG INTRAMUSCULAR SYRINGE KIT leuprolide acetate Addition LYNPARZA 100 MG, 150 MG ORAL TABLET olaparib Addition MAVYRET MG ORAL TABLET glecaprevir/pibrentasvir Addition meropenem 1 gram intravenous recon soln meropenem Addition mesalamine 1.2 gram oral tablet,delayed release (dr/ec) mesalamine Addition Enhancement 1 7

8 methotrexate sodium (pf) 25 mg/ml (10 ml) injection solution methotrexate sodium/pf Addition methylphenidate hcl 30 mg oral capsule,er biphasic methylphenidate hcl Addition morphine 5 mg/ml injection syringe morphine sulfate Addition moxifloxacin 0.5 % ophthalmic (eye) drops moxifloxacin hcl Addition MYLOTARG 4.5 MG (1 MG/ML INITIAL CONC) INTRAVENOUS RECON SOLN gemtuzumab ozogamicin Addition NERLYNX 40 MG ORAL TABLET neratinib maleate Addition NOVAREL 5,000 UNIT INTRAMUSCULAR RECON SOLN chorionic gonadotropin, human Addition NYMALIZE 30 MG/10 ML ORAL SOLUTION nimodipine Addition OPDIVO 100 MG/10 ML INTRAVENOUS SOLUTION nivolumab Addition oseltamivir 6 mg/ml oral suspension for reconstitution oseltamivir phosphate Addition oxaliplatin 100 mg intravenous recon soln oxaliplatin Addition QL PA QL 8

9 paroxetine mesylate(menop.sym) 7.5 mg oral capsule paroxetine mesylate Addition peg 3350-electrolytes gram oral recon soln peg3350/sod sulf,bicarb,cl/kcl Addition PERTZYE 16,000-57,500-60,500 UNIT ORAL CAPSULE,DELAYED RELEASE(DR/EC) lipase/protease/amylase Addition PERTZYE 4,000-14,375-15,125 UNIT ORAL CAPSULE,DELAYED RELEASE(DR/EC) lipase/protease/amylase Addition PERTZYE 8,000-28,750-30,250 UNIT ORAL CAPSULE,DELAYED RELEASE(DR/EC) lipase/protease/amylase Addition piperacillin-tazobactam 2.25 gram intravenous recon soln piperacillin sodium/tazobactam Addition prasugrel 5 mg, 10 mg oral tablet prasugrel hcl Addition profeno 600 mg oral tablet fenoprofen calcium Addition RADICAVA 30 MG/100 ML INTRAVENOUS PIGGYBACK edaravone Addition RITUXAN 10 MG/ML INTRAVENOUS CONCENTRATE rituximab Addition 9

10 scopolamine base 1 mg over 3 days transdermal patch 3 day scopolamine Addition sevelamer carbonate 800 mg oral tablet sevelamer carbonate Addition SOLU-MEDROL (PF) 1,000 MG/8 ML INTRAVENOUS RECON SOLN methylprednisolone sod succ/pf Addition STELARA 45 MG/0.5 ML SUBCUTANEOUS SOLUTION ustekinumab Addition testosterone 30 mg/actuation (1.5 ml) transdermal solution in metered pump w/app testosterone Addition timolol maleate 0.5 % ophthalmic (eye) drops, once daily timolol maleate Addition topiramate 15 mg, 25 mg, 50 mg, 100 mg, 200 mg oral tablet topiramate Removed PA TRACLEER 32 MG ORAL TABLET FOR SUSPENSION bosentan Addition tramadol 100 mg, 200 mg, 300 mg oral tablet, er multiphase 24 hr tramadol hcl Addition TREANDA 25 MG INTRAVENOUS RECON SOLN bendamustine hcl Addition TRISENOX 2 MG/ML INTRAVENOUS SOLUTION bendamustine hcl Addition 10 PA Enhancement 1

11 TWINRIX (PF) 720 ELISA UNIT - 20 MCG/ML INTRAMUSCULAR SYRINGE hepatitis a and b vaccine/pf Addition TYMLOS 80 MCG (3,120 MCG/1.56 ML) SUBCUTANEOUS PEN INJECTOR abaloparatide Addition VAQTA (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION hepatitis a virus vaccine/pf Addition VAQTA (PF) 50 UNIT/ML INTRAMUSCULAR SUSPENSION hepatitis a virus vaccine/pf Addition VERZENIO 50 MG, 150 MG, 100 MG, 200MG ORAL TABLET abemaciclib Addition vigabatrin 500 mg oral powder in packet vigabatrin Addition VOSEVI MG ORAL TABLET sofosbuvir/velpatas/voxilaprev Addition VYXEOS MG INTRAVENOUS RECON SOLN daunorubicin/cytarabine lipos Addition XATMEP 2.5 MG/ML ORAL SOLUTION methotrexate Addition ZENPEP 20,000-63,000-84,000 UNIT ORAL CAPSULE,DELAYED RELEASE(DR/EC) lipase/protease/amylase Addition B/D 11

12 zonisamide 25 mg, 50 mg, 100 mg oral capsule zonisamide Removed PA 12

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