PHARMACY UPDATE July 15, 2014 This update applies to: UPDATE #14-011 PAGE 1 of 5 Third Quarter 2014 Drug List Changes All retail pharmacies States: Oregon Washington The following update includes changes to all Commercial drug lists. These include the Preferred Drug List (PDL), Essential Rx Drug List (EDL) and the Aon Active Health Exchange Drug List (ADL). Changes apply to all drug lists, unless stated otherwise. Line of business: Commercial PHARMACY INQUIRIES ONLY: Claims Processing/ Technical Support Caremark Claims Processing Commercial Pharmacy Help Desk: 1-800-600-0180 *For optimal service, this telephone number is for pharmacy use only. MEMBER INQUIRIES: The PDL is used by all large group Commercial plans and small groups and individual plans using a 2013 plan. EDL is used by small business groups, individual and family plans that purchased or renewed with a 2014 ACA-compliant plan. The EDL is also used by individuals and families who purchased a Health Net plan on the Oregon exchange. The ADL is used by groups that purchased plans through the Aon Active Health Exchange. View the most current version of our drug lists on www.healthnet.com. QUESTIONS For questions regarding the information in this update, please contact the Health Net Pharmacy Department at 1-888-802-7001, Option 1, and then Option 4. Refer all member inquiries to the appropriate Customer Service phone number listed on their Health Net ID card. Confidentiality Note for Fax Transmission: This facsimile may contain confidential information. The information is intended only for the use of the individual or entity named above. If you are not the intended recipient, or the person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of the information contained in this transmission is strictly PROHIBITED. If you have received this transmission in error, please notify the sender immediately by telephone or by return fax and destroy this transmission, along with any attachments. Third Quarter 2014 Preferred Drug List (PDL) Changes THIRD QUARTER 2014 - COMMERCIAL PRODUCTS Brand Name Generic Name Therapeutic Category & Indication Comments Tier 1 Additions and Changes Astepro® azelastine HCl nasal spray 0.15% Differin® adapalene gel 0.3% Evista® raloxifene tablet Lidoderm® lidocaine patch 5% Lovaza® omega-3-acid ethyl esters capsule Malarone® atovaquone-proguanil 250-100mg tablet Ortho®-Evra norelgestromin-ethinyl estradiol patch Viramune® XR nevirapine SR 24 HR 400mg tablet Zyban® bupropion HCl SR 12HR 150mg tablet (smoking deterrent) Zymaxid® gatifloxacin ophththalmic solution Antihistamine Treatment of symptoms associated with seasonal allergic rhinitis Topical retinoid Treatment of acne Selective estrogen receptor modifier (SERM) Prevention of breast cancer and prevention and treatment of osteoporosis Topical anesthetic Treatment of postherpetic neuralgia Antilipemic Adjunct to diet to reduce hyperglyceridemia Anti-infective agent Treatment and prevention of malaria Transdermal combination contraceptive Prevention of pregnancy Non-nucleoside reverse transcriptase inhibitor (NNRTI) Treatment of human immunodeficiency virus (HIV) infection Smoking cessation agent Adjunct in the management of smoking cessation in patients with nicotine withdrawal Ophthalmic fluorquinolone Treatment of bacterial conjunctivitis New generic available at Tier 1 Limited to 1 spray bottle per month New generic available at Tier 1 Limited to 45gm per month New generic available at Tier 1* (PDL) Tier PV (EDL & ADL) Limited to 1 tablet per day New generic available at Tier 1 Limited to 3 patches per day New generic available at Tier 1 New generic available at Tier 1 New generic available at Tier 1* (PDL) Tier PV (EDL & ADL) Limited to 3 patches per fill New generic available at Tier 1 Changed to Tier 1* (PDL) Tier PV (EDL & ADL) Removed prior authorization New generic available at Tier 1 Tier 2 Additions and Changes Kuvan® Letaris® sapropterin dihydrochloride powder packet and soluble tablet ambrisentan tablet Metabolic enzyme Treatment of phenylketonuria (PKU) in conjunction with a phenylalanine-restricted diet Endothelin-receptor antagonist Treatment of pulmonary hypertension Tier 2 (PDL) Tier 3 (ADL) Tier SP (EDL) Removed prior authorization Tier 2 (PDL) Tier 3 (ADL) Tier SP (EDL) Removed quantity limit Health Net® is a registered service mark of Health Net, Inc. All rights reserved. 2 Third Quarter 2014 Tracleer® bosentan tablet Endothelin-receptor antagonist Treatment of pulmonary hypertension Tier 2 (PDL) Tier 3 (ADL) Tier SP (EDL) Removed quantity limit Tier 3 Additions and Changes Apriso® Aptiom® Avar® LS Cleanser Avar® E LS mesalamine SR 24HR capsule eslicarbazepine acetate tablet 5-aminosalicylate Treatment of ulcerative colitis Anticonvulsant Adjunctive treatment of partial seizures sulfacetamide sodium w/ sulfur emulsion 102% sulfacetamide sodium w/ sulfur 10-2% cream Topical sulfonamide Treatment of acne vulgaris, acne rosacea and seborrheic dermatitis Topical sulfonamide Treatment of acne vulgaris, acne rosacea and seborrheic dermatitis Nicotine receptor agonist Adjunct in the management of smoking cessation in patients with nicotine withdrawal Topical azole antifungal Treatment of tinea pedis Opiate agonist Treatment of acute and chronic moderate to severe pain Chantix® varenicline tartrate tablet Ecoza™ econazole nitrate foam hydromorphone HCI ER 24HR tablet Exalgo® Grastek® timothy grass pollen allergen extract sublingual tablet Hemangeol™ propranolol hcl oral solution Hetlioz™ tasimelteon capsule Lunesta® ezopiclone tablet Myfortic® mycophenolate sodium tablet Nicotrol® nicotine inhaler and spray Sublingual immunotherapy Treatment of allergic rhinitis induced by Timothy grass or cross-reactive grass pollens Beta blocker Treatment of infantile hemangioma requiring systemic therapy Melatonin-receptor agonist Treatment of non-24-hour sleepwake disorder Non-benzodiazepine sedative hypnotic Treatment of insomnia Immunosuppressive For prevention of kidney transplant rejection Smoking cessation agent Use as an aid in the treatment of nicotine withdrawal after smoking cessation Changed to Tier 3 from Tier 2 Prior authorization required Tier 3 Limited to 2 tablets per day (200mg, 400mg, 600mg) Limited to 1 tablet per day (800mg) New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) Changed to Tier 3* (PDL) Tier PV (EDL & ADL) Removed prior authorization Tier 3 Limited to 1 bottle per month New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) Limited to 2 tablets per day (32mg) Limited to 4 tablets per day (8, 12, and 16mg) Tier 3 Tier 3 (PDL & ADL) Non-formulary (EDL) Tier 3 (PDL & ADL) Tier SP (EDL) Prior authorization required New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) Prior authorization required Limited to 1 per day New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) Changed to Tier 3* (PDL) Tier PV (EDL & ADL) Removed prior authorization Health Net® is a registered service mark of Health Net, Inc. All rights reserved. 3 Third Quarter 2014 Oralair® grass mixed pollen extract sublingual tablet Orenitram™ treprostinil diolamine CR tablet Otezla® apremilast tablet Ovace® Plus sulfacetamide sodium cleansing gel and shampoo 10% diclofenac sodium 1.5% topical solution Pennsaid® Ragwitek® Rhinocort® Aqua short ragweed pollen allergen extract sublingual tablet budesonide nasal suspension 32mcg Sitavig® acyclovir buccal tablet Taclonex® ointment calcipotrienebetamethasone ointment Ultrasal® ER salicylic acid filmforming solution 28.5% icosapent ethyl capsule Vascepa® Versacloz™ clozapine suspension Zemplar® paricalcitol capsule Sublingual immunotherapy Treatment of allergic rhinitis induced by grass pollen, specifically Sweet Vernal, Orchard, Perennial Rye, Timothy or Kentucky Blue Grass Prostaglandin Treatment of pulmonary hypertension Phosphodiesterase-4 (PDE-4) inhibitor Treatment of active psoriatic arthritis Topical sulfonamide Treatment of seborrheic dermatitis Topical NSAID Treatment of osteoarthritis Sublingual immunotherapy Treatment of allergic rhinitis induced by ragweed pollen Nasal corticosteroid Management of nasal symptoms associated with allergic rhinitis or perennial vasomotor rhinitis Antiviral agent Treatment of recurrent herpes labialis (cold sores) in immunocompetent adults Topical Vitamin D analog and corticosteroid combination Treatment of plaque psoriasis Topical keratolytic Topical treatment and removal of common and plantar warts Antilipemic Adjunct to diet in adults with severe hypertriglyceridemia Atypical antipsychotic agent Treatment of refractory schizophrenia Vitamin D analog Prevention and treatment of secondary hyperparathyroidism and resultant metabolic bone disease Tier 3 Tier 3 Prior authorization required Tier 3 (PDL & ADL) Tier SP (EDL) Prior authorization required New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) Limited to 1 bottle per month Tier 3 New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) Limited to 1 bottle per month Tier 3 (PDL & ADL) Non-Formulary (EDL) New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) Prior authorization required Limited to 60gm per month Tier 3 (PDL & ADL) Non-formulary (EDL) Tier 3 Prior authorization required Tier 3 Limited to 18 ml per day New generic available at Tier 3 (PDL) Tier 1 (EDL & ADL) Health Net® is a registered service mark of Health Net, Inc. All rights reserved. 4 Third Quarter 2014 Zohydro™ ER hydrocodone bitartrate SR 12HR capsule Zontivity™ vorapaxar sulfate tablet Opiate agonist Management of severe pain that requires daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate Protease-activated receptor-1 (PAR-1) antagonist For secondary prophylaxis of myocardial infarction or stroke or thrombosis Tier 3 Prior authorization required Tier 3 (PDL & ADL) Non-formulary (EDL) Specialty (SP) Tier Additions and Changes Myalept™ metreleptin subcutaneous injection Tanzeum™ albiglutide solution for pen-injector Recombinant human leptin analog Treatment of patients with congenital or acquired generalized lipodystrophy Glucagon-like peptide-1 (GLP-1) receptor agonist Treatment of type 2 diabetes mellitus Tier SP (OR PDL & OR and WA EDL) Tier 3 (WA PDL & OR and WA ADL) Prior authorization required Tier SP (OR PDL & EDL OR and WA), Tier 3 (WA PDL & ADL OR and WA) Prior authorization required Anticancer (AC) Tier Additions and Changes Xeloda® capecitabine tablet Zykadia™ ceritinib capsule Pyrimidine analog antineoplastic agent Treatment of breast cancer and treatment of colorectal cancer Signal transduction inhibitor Treatment of anaplastic lymphoma kinase (ALK) positive metastatic non-small cell lung cancer (NSCLC) Tier AC New generic available Tier AC Prior authorization required * Changes listed in the table apply to PDL, EDL and ADL unless a specific formulary is noted. Tier 1*, Tier 2*, Tier 3*, PV - These preventive medications are covered at a $0 cost-share for members with a Preventive Pharmacy benefit. PDL – Preferred Drug List EDL – Essential Rx Drug List ADL – Aon Active Health Exchange Drug List Health Net® is a registered service mark of Health Net, Inc. All rights reserved. 5
© Copyright 2024 ExpyDoc
