PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Value July 1, 2018 Updates Drug Name oseltamivir sus 6mg/ml (Brand = Tamiflu ) carvedilol cap ER 10mg, 20mg, 40mg, 80mg (Brand = Coreg CR ) timolol maleate sol 0.5% (Brand = Istalol Sol 0.5% OP) tenofovir 300mg (Brand = Viread ) efavirenz cap 50mg, 200mg (Brand = Sustiva ) carbinoxamin 6mg (Brand = Ryvent ) G No Change Generic Addition 11/6/17 G No Change Generic Addition 11/13/17 G No Change Generic Addition 12/4/17 G No Change Generic Addition 12/25/17 G No Change Generic Addition 12/2517 G No Change Generic Addition 12/25/17 atazanavir G No Change Generic Addition 1/1/18 150mg, 200mg, 300mg (Brand = Reyataz ) estradiol cre 0.01% G No Change Generic Addition 1/8/18 (Brand = Estrace vag cre 0.01%) Repatha NPD/SP* + PA PB/SP* + PA Brand Downtier 7/1/18 Otezla NF PB/SP* + PA Brand Addition PA Addition 7/1/18 Tremfya NF PB/SP* + PA Brand Addition PA Addition 7/1/18 Anoro Ellipta NPD + PA PB Brand Downtier PA Removal 7/1/18 Stiolto Respimat NPD + PA PB Brand Downtier PA Removal 7/1/18 Incruse Ellipta NPD PB Brand Downtier 7/1/18 (continued)
Drug Name Glyxambi NPD PB Brand Downtier 7/1/18 Glucagen Hypokit NPD PB Brand Downtier 7/1/18 Calquence cap 100mg NPD/SP* + PA No Change 11/6/17 Rebinyn Sol NPD/SP*+ PA No Change 11/27/17 500 unit, 1000 unit, 2000 unit Hemlibra Inj 30mg/ml, NPD/SP*+ PA No Change 11/27/17 60/0.4, 105/0.7 Admelog NPD + PA No Change 1/1/18 dihydroergotamine mesylate Excluded G + PA Coverage Added PA Addition 7/1/18 Inj 1mg/ml Tirosint NPD NPD + PA PA Addition 7/1/18 Odactra Sub NF NPD + PA Brand Addition PA Addition 7/1/18 Actemra SQ NF NPD/SP* + PA Brand Addition PA Addition 7/1/18 Kineret NF NPD/SP* + PA Brand Addition PA Addition 7/1/18 Orencia NF NPD/SP* + PA Brand Addition PA Addition 7/1/18 Xeljanz NF NPD/SP* + PA Brand Addition PA Addition 7/1/18 Xeljanz XR NF NPD/SP* + PA Brand Addition PA Addition 7/1/18 Taltz NF NPD/SP* + PA Brand Addition PA Addition 7/1/18 Kevzara NF NPD/SP* + PA Brand Addition PA Addition 7/1/18 alendronate sodium G LCG Generic Downtier 7/1/18 amoxicillin G LCG Generic Downtier 7/1/18 ampicillin G LCG Generic Downtier 7/1/18 carteolol hcl G LCG Generic Downtier 7/1/18 carvedilol G LCG Generic Downtier 7/1/18 chlorhexidine gluconate G LCG Generic Downtier 7/1/18 diazepam G LCG Generic Downtier 7/1/18 isoniazid G LCG Generic Downtier 7/1/18 levofloxacin G LCG Generic Downtier 7/1/18 (continued)
Drug Name losartan potassium G LCG Generic Downtier 7/1/18 meclizine hcl G LCG Generic Downtier 7/1/18 medroxyprogesterone acetate G LCG Generic Downtier 7/1/18 meloxicam G LCG Generic Downtier 7/1/18 pediatric multivitamin G LCG Generic Downtier 7/1/18 with fluoride prednisone G LCG Generic Downtier 7/1/18 promethazine/codeine G LCG Generic Downtier 7/1/18 promethazine-dm G LCG Generic Downtier 7/1/18 sertraline hcl G LCG Generic Downtier 7/1/18 tobramycin op soln G LCG Generic Downtier 7/1/18 vitamin D G LCG Generic Downtier 7/1/18 allopurinol LCG G Generic Uptier 7/1/18 amiloride-hydrochlorothiazide LCG G Generic Uptier 7/1/18 amitriptyline hcl LCG G Generic Uptier 7/1/18 atenolol/chlorthalidone LCG G Generic Uptier 7/1/18 bumetanide LCG G Generic Uptier 7/1/18 buspirone hcl LCG G Generic Uptier 7/1/18 captopril LCG G Generic Uptier 7/1/18 cimetidine LCG G Generic Uptier 7/1/18 clonidine hydrocloride LCG G Generic Uptier 7/1/18 diltiazem hcl LCG G Generic Uptier 7/1/18 diltiazem hcl ER LCG G Generic Uptier 7/1/18 doxepin hcl LCG G Generic Uptier 7/1/18 enalapril maleate LCG G Generic Uptier 7/1/18 erythromycin ethylsuccinate LCG G Generic Uptier 7/1/18 famotidine LCG G Generic Uptier 7/1/18 (continued)
Drug Name fluoxetine LCG G Generic Uptier 7/1/18 glimepiride LCG G Generic Uptier 7/1/18 glipizide LCG G Generic Uptier 7/1/18 haloperidol LCG G Generic Uptier 7/1/18 indapamide LCG G Generic Uptier 7/1/18 isosorbide dinitrate LCG G Generic Uptier 7/1/18 jantoven LCG G Generic Uptier 7/1/18 levothyroxine sodium LCG G Generic Uptier 7/1/18 metformin hcl LCG G Generic Uptier 7/1/18 metoclopramide hcl LCG G Generic Uptier 7/1/18 nortriptyline hcl LCG G Generic Uptier 7/1/18 oxybutynin ER LCG G Generic Uptier 7/1/18 propranolol hcl LCG G Generic Uptier 7/1/18 ranitidine hcl LCG G Generic Uptier 7/1/18 simvastatin LCG G Generic Uptier 7/1/18 triamterene-hctz LCG G Generic Uptier 7/1/18 verapamil hcl LCG G Generic Uptier 7/1/18 warfarin sodium LCG G Generic Uptier 7/1/18 fluocinonide 0.1% cream G Exclude Generic Deletion 7/1/18 (Brand: Vanos cre 0.1%) clindamycin/benzoyl peroxide G NF Generic Deletion 7/1/18 1%/5% D.H.E. 45 Excluded NF 7/1/18 Vanos cre 0.1% NPD + PA Excluded Brand Deletion 7/1/18 (Generic: fluocinonide 0.1% cream) Glucagon Emergency Kit PB NF Brand Deletion 7/1/18 Coreg CR NPD NF Brand Deletion 7/1/18 (continued)
Drug Name Istalol Sol 0.5% OP PB NF Brand Deletion 7/1/18 Viread tab 300mg PB NF Brand Deletion 7/1/18 Reyataz cap 150mg, 200mg, 300mg PB NF Brand Deletion 7/1/18
Abbreviation Key G LCG PB NPD SP NF PA QL 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. Quantity limits 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.