PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Value October 1, 2018 Updates efavirenz 600mg (Brand = Sustiva ) trientine (Brand = Syprine ) hydrocortisone lot 0.1% (Brand = Locoid ) sumatriptan-naproxen 85-500mg (Brand = Treximet ) memantine HCL ER 7mg, 14mg, 21mg, 28mg (Brand = Namenda XR ) minocycline ER 65mg, 115mg (Brand = Solodyn ) methylphenidate cap 10mg ER (Brand = Ritalin LA ) lansoprazole tab 15mg, 30mg (Brand = Prevacid solutab) tiagabine 12mg, 16mg (Brand = Gabitril ) ritonavir tab 100mg (Brand = Norvir ) miglustat 100mg (Brand = Zavesca ) Current As of 10/1/18 G No Change Generic Addition No Change 2/5/18 G/SP* No Change Generic Addition No Change 2/19/18 G No Change Generic Addition No Change 2/19/18 G + QL + AL (18 per 30 days) No Change Generic Addition No Change 2/19/18 G + AL No Change Generic Addition No Change 2/26/18 G + QL No Change Generic Addition No Change 2/26/18 G + QL No Change Generic Addition No Change 3/5/18 G + PA + QL No Change Generic Addition No Change 3/19/18 G No Change Generic Addition No Change 3/19/18 G No Change Generic Addition No Change 3/19/18 G/SP* + PA No Change Generic Addition No Change 4/23/18
Current As of 10/1/18 praziquantel 600mg G No Change Generic Addition No Change 4/30/18 (Brand = Biltricide ) Biktarvy NF NPD Brand Addition No Change 10/1/18 Dutoprol NF NPD Brand Addition No Change 10/1/18 Cimduo NF NPD Brand Addition No Change 10/1/18 Symfi Lo tab NF NPD Brand Addition No Change 10/1/18 Symfi tab NF NPD Brand Addition No Change 10/1/18 Erleada 600mg NPD/SP* + PA No Change No Change No Change 2/19/18 Jynarque Pak 45-15mg, NPD + PA No Change No Change No Change 4/30/18 60-30mg, 90-30mg Eucrisa NPD + PA PB + PA Brand Downtier No Change 10/1/18 morphine sulfate G + QL + PA G + QL + D/S 30mg morphine sulfate sol G + QL + PA G + QL + D/S 20mg/ml (6ml per day) (6ml per day) oxycodone IR HCL G + QL + PA G + QL + D/S 15mg, 20mg, 30mg tab Nucynta 75mg, 100mg hydromorphone IR tablet G + QL + PA G + QL + D/S 4mg, 8mg oxymorphone IR G + QL + D/S 10mg oxycodone G + QL + PA G + QL + D/S 100mg/5ml sol (6ml per day) (6ml per day) Symdeko 100-150 NF NPD/SP* + PA Brand Addition PA Addition 10/1/18 Bonjesta 20-20mg NF NPD + PA Brand Addition PA Addition 10/1/18 Lonhala Magnair soln NF NPD + PA Brand Addition PA Addition 10/1/18 25mcg Elidel NPD NPD + PA
Current As of 10/1/18 Promacta NPD/SP* NPD/SP* + PA morphine sulfate ER capsule 10mg, 20mg, 30mg (Brand = Kadian ) morphine sulfate ER tablet 15mg, 30mg (Brand = MS Contin ) Kadian ER 40mg morphine beads ER cap 30mg, 45mg, 60mg, 75mg oxymorphone ER 12HR 5mg, 7.5mg, 10mg Nucynta ER 50mg, 100mg Belbuca Film 75mcg, 150mcg Xtampza ER 9mg, 13.5mg, 18mg G + QL + D/S G + QL + D/S G + QL + D/S G + QL + D/S NPD + QL+ D/S Embeda NPD + QL + (PA or D/S) Zohydro ER NPD + QL + (PA or D/S) Hysingla ER NPD + QL + (PA or D/S) Arymo ER NPD + QL + (PA or D/S) Morphabond ER NPD + QL + (PA or D/S) Opana ER NPD + QL + (PA or D/S) G + QL + PA G + QL + PA G + QL + PA G + QL + PA PB + QL + PA Brand Downtier PA Addition 10/1/18 Brand Deletion 10/1/18 Brand Deletion 10/1/18 Brand Deletion 10/1/18 Brand Deletion 10/1/18 Brand Deletion 10/1/18
oxycodone ER tablet 10mg, 15mg, 20mg Current G + QL + D/S As of 10/1/18 Xtampza XR Drug Deletion 10/1/18 oxycodone ER tablet G + QL + PA Xtampza XR Drug Deletion 10/1/18 30mg, 40mg, 60mg, 80mg Syprine NPD/SP* + PA NF/SP* Sustiva tab PB NF Namenda XR PB + AL NF + AL 7mg, 14mg, 21mg, 28mg Prevacid SoluTab NPD + PA + QL 15mg, 30mg Norvir tab 100mg PB NF Zavesca NPD/SP* + PA NF Biltricide NPD NF metoprolol succinate ER/HCTZ NPD NF Dutoprol Drug Deletion 10/1/18 Duragesic Patch NPD + QL+ PA (15 per 30 days) (15 per 30 days) Dilaudid 2mg Dilaudid 4mg, 8mg Dilaudid Liq 1mg/ml (12ml per day) (12ml per day) Demerol 50mg, 100mg Dolophine 5mg, 10mg NPD + PA MS Contin 15mg, 30mg MS Contin 60mg, 100mg, 200mg
Kadian ER 10mg, 20mg, 30mg Kadian ER 50mg, 60mg, 80mg, 100mg Roxicodone 5mg Roxicodone 15mg, 30mg Opana 5mg, 10mg Ibudone 5-200mg Exalgo ER 8mg, 12mg, 16mg, 32mg OxyContin 10mg, 15mg, 20mg OxyContin 30mg, 40mg, 60mg, 80mg methadone tablet 5mg, 10mg (Brand = Dolophine ) methadone con 10mg/ml methadone sol 5mg/5ml methadone sol 10mg/5ml buprenorphine hcl sub 8mg tramadol-acetaminophen tab 37.5-325mg Current (12 per day) (6 per day) NPD + QL + (PA or D/S) (6 per day) (5 per day) (4 per day) G + PA G + PA G + PA G + PA G + QL (4 per day) G+QL+ AL (40 per 5 day) As of 10/1/18 (12 per day) (6 per day) (6 per day) (5 per day) (4 per day) G + PA + QL (6 per day) G + PA + QL (6ml per day) G + PA + QL (60ml per day) G + PA + QL (30ml per day) G + QL G+ QL + AL (8 per day) Xtampza XR Brand Deletion 10/1/18 Xtampza XR Brand Deletion 10/1/18 No Change QL Addition 10/1/18 No Change QL Addition 10/1/18 No Change QL Addition 10/1/18 No Change QL Addition 10/1/18 No Change QL Update 10/1/18 No Change QL Update 10/1/18
Current As of 10/1/18 Firvanq soln NF NPD + AL Brand Addition AL Addition 10/1/18 Flurazepam 15mg, 30mg Triazolam 0.125mg, 0.25mg (Brand = Halcion ) Quazepam 15mg (Brand = Doral ) Estazolam 1mg, 2mg Temazepam 7.5mg, 15mg, 22.5mg, 30mg (Brand = Restoril ) Lorazepam 1mg, 2mg (Brand = Ativan ) Oxazepam 10mg, 15mg, 30mg Alprazolam (Brand = Xanax ) Alprazolam ER (Brand = Xanax XR) age less than 6) Varies age less than 15) age less than 12) age less than 12) No Change AL Addition 10/1/18 Dulera NF + AL NF No Change AL Removal 10/1/18 Linzess PB + AL PB No Change AL Removal 10/1/18
Opioids products containing the following active ingredients: codeine, dihydrocodeine, fentanyl, hydrocodone, hydromorphone, levorphanol, meperidine, methadone, morphine, opium, oxycodone, oxymorphone, tapentadol, and tramadol Select topical acne products Current As of 10/1/18 Varies Varies + MME Varies MME Addition 10/1/18 age greater than 35) age greater than 25)
Abbreviation Key G LCG PB NPD SP NF PA MME D/S QL AL Generic Addition Generic Downtier Generic Uptier Brand Downtier Brand Uptier Brand Addition Brand/Generic Deletion Generic Low Cost Generic Preferred Brand Non-Preferred Drug Specialty Drug. Specialty Tier cost-share will apply for those benefits that have a prescription drug specialty tier. Non-. Non- refers to drugs not covered on the formulary. A formulary exception is available upon request. Prior Authorization is required. Morphine Milligram Equivalent Days Supply Limit Quantity Limits Age Limit A generic drug that recently became available in the marketplace This generic drug will be covered at the appropriate preferred drug level of cost-sharing. This generic drug will be covered at the appropriate non-preferred drug level of cost-sharing. These brand drugs were added to the formulary as of the date indicated and are covered at the appropriate preferred brand formulary level of cost-sharing. These brand drugs will be covered at the appropriate non-preferred drug level of cost-sharing. Coverage was added to this drug. Coverage was removed from this drug. alternatives are available. DL 01 1608 0412 www.ibx.com Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association.
Language Assistance Services Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al número telefónico de Servicio al Cliente que figura en el reverso de su tarjeta de identificación. Chinese: 注意 : 如果您讲中文, 您可以得到免费的语言协助服务 请致电您 ID 卡背面的客户服务电话号码. Korean: 안내사항 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 귀하의 ID 카드뒷면에있는고객서비스번호로전화해주십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para telefone do Atendimento ao Cliente que está no verso do seu cartão de identificação. Gujarati: ચન : જ તમ જર ત બ લત હ, ત ન: ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ પલ છ. પય તમ ર ડ ક ડ ન પ છળ હક સ વ ન બર પર ક લ કર. Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi số Dịch Vụ Chăm Sóc Khách Hàng ở mặt sau thẻ ID của bạn. Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Позвоните в службу поддержки клиентов по номеру телефона, указанном на обратной стороне вашей идентификационной карты. Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer Obsługi klienta znajdujący się na odwrocie Twojego identyfikatora. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiami il numero dell Assistenza clienti che troverà sul retro della sua tessera identificativa. Arabic: ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية متاحة لك بالمجان. الرجاء االتصال برقم "خدمة العمالء" الموجود على ظھر بطاقة ھويتك. French Creole: ATANSYON : Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Tanpri rele nimewo Sèvis Kliyantèl ki sou do kat idantifikasyon ou a. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Mangyaring tawagan ang numero ng Customer Service na nasa likod ng iyong ID card. French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Veuillez composer le numéro du service clientèle indiqué au dos de votre carte d'identité Médicale. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Number uff die hinnerscht Seit vun dei ID Card uff fer schwetze mit ebber as dich helfe kann. Hindi: य न द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए पल ह क पय अपन आईड क डर क प छ दए ग र हक स व न बर पर क ल कर German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Bitte rufen Sie unsere Kundendienstnummer auf der Rückseite Ihrer Identifikationskarte an. Japanese: 備考 : 母国語が日本語の方は 言語アシスタンスサービス ( 無料 ) をご利用いただけます ご自分の ID カードの裏面に記載されているカスタマーサービスの番号へお電話ください Persian (Farsi): توجه: اگر فارسی صحبت می کنيد خدمات ترجمه به صورت رايگان برای شما فراھم می باشد. لطفا با شماره خدمات مشتريان که در پشت کارت شناسايی شما درج شده است تماس بگيريد.
Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti go Diné Bizaad, saad bee 1k1 1n7da 1wo d66, t 11 jiik eh. T 11 sh--d7 h0d77lnih koj8!k1 an7daalwo j8 47 binumber naaltsoos nit[ izgo nantin7g77 bine d66 bik11. Urdu: توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں تو آپ کے لئے مفت ميں زبان معاون خدمات دستياب ہيں آپ کے شناختی کارڈ کے پيچھے دئيےگئے صارف خدمات نمبر پر برائے کرم کال کريں. Mon-Khmer, Cambodian: ស ម ម ត ចប រមមណ របស ន ប អនកន យ មន- ខមរ ខមរ ន ជ ន យ ផនក ន ងមនផ តល ជ នដល កអនក យ ត គ ត ថ ល ស មទ រសពទ លខ ស សមជ ក ដលមន ន ផនកខង រកយ នបណ ណសមគ ល ខ ល នរបស កអនក Discrimination is Against the Law This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides: Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats). Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA, 19103; By phone: 1-888-377-3933 (TTY: 711), By fax: 215-761-0245, By email: civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800- 368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.