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Formulary Drug Removals

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Formulary Drug Removals July 2018 Formulary Drug Removals Below is a list of medicines by drug class that have been removed from your plan’s formulary. If you continue using one of the drugs listed below and identified as a Formulary Drug Removal, you may be required to pay the full cost. If you are currently using one of the formulary drug removals, ask your doctor to choose one of the generic or brand formulary options listed below. Category Formulary Drug Formulary Options Drug Class Removals Allergies BECONASE AQ flunisolide spray, fluticasone spray, mometasone spray, triamcinolone spray, Nasal Steroids / Combinations OMNARIS DYMISTA QNASL ZETONNA Anticonvulsants ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT Anti-infectives, Antibacterials E.E.S. GRANULES erythromycins Erythromycins / Macrolides ERYPED Anti-infectives, Antibacterials MINOCIN minocycline Tetracyclines DORYX doxycycline hyclate DORYX MPC MONODOX Anti-infectives, Antibacterials MACRODANTIN nitrofurantoin Miscellaneous Anti-infectives, Antivirals VALCYTE valganciclovir Cytomegalovirus * Anti-infectives, Antivirals MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 1 Hepatitis C * DAKLINZA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) OLYSIO TECHNIVIE VIEKIRA PAK ZEPATIER Anti-infectives, Antivirals VALTREX acyclovir, valacyclovir Herpes * Anti-inflammatory PRED FORTE dexamethasone, prednisolone acetate 1%, DUREZOL, FLAREX, FML FORTE, Steroidal, Ophthalmic FML S.O.P., MAXIDEX, PRED MILD Antiobesity QSYMIA BELVIQ, BELVIQ XR, CONTRAVE, SAXENDA Asthma * PROVENTIL HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK Beta Agonists, Short-Acting VENTOLIN HFA XOPENEX HFA Asthma * AEROSPAN ASMANEX, FLOVENT, PULMICORT FLEXHALER, QVAR Steroid Inhalants ALVESCO Asthma * or Chronic Obstructive DULERA ADVAIR, BREO ELLIPTA, SYMBICORT Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations Category Formulary Drug Formulary Options Drug Class Removals Attention Deficit Hyperactivity ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel, methylphenidate ext-rel, Disorder * APTENSIO XR, MYDAYIS, QUILLIVANT XR, VYVANSE INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel, APTENSIO XR, MYDAYIS, QUILLIVANT XR, VYVANSE Autoimmune Conditions ACTEMRA ENBREL, HUMIRA, KEVZARA CIMZIA COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) ENTYVIO HUMIRA KINERET ENBREL, HUMIRA, KEVZARA ORENCIA CLICKJECT COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, ORENCIA INTRAVENOUS STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) ORENCIA SUBCUTANEOUS SIMPONI COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) XELJANZ ENBREL, HUMIRA, KEVZARA XELJANZ XR Cancer GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL Chronic Myelogenous TASIGNA Leukemia * Cancer NILANDRON bicalutamide, XTANDI, ZYTIGA Prostate * Hormonal Agents, Antiandrogens Cardiovascular BETAPACE sotalol Antiarrhythmics BETAPACE AF Cardiovascular ZETIA ezetimibe Antilipemics Cholesterol Absorption Inhibitors Cardiovascular TRICOR fenofibrate, fenofibric acid Antilipemics Fibrates Cardiovascular ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, Antilipemics CRESTOR rosuvastatin, simvastatin LESCOL XL HMG-CoA Reductase Inhibitors LIPITOR (HMGs or Statins) / Combinations 2 LIVALO Cardiovascular PRALUENT REPATHA Antilipemics PCSK9 Inhibitors Cardiovascular LANOXIN TABLET digoxin Digitalis Glycosides (125 MCG and 250 MCG only) Cardiovascular DYRENIUM amiloride Diuretics Carnitine Deficiency CARNITOR levocarnitine CARNITOR SF Category Formulary Drug Formulary Options Drug Class Removals Chronic Obstructive Pulmonary TUDORZA INCRUSE ELLIPTA, SPIRIVA Disease (COPD) * Anticholinergics Cystic Fibrosis * TOBI tobramycin inhalation solution, BETHKIS Inhaled Antibiotics TOBI PODHALER Depression * venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule Antidepressants, Selective (except 225 mg) CYMBALTA Norepinephrine Reuptake Inhibitors EFFEXOR XR (SNRIs) VENLAFAXINE EXT-REL TABLET (except 225 MG) Depression * OLEPTRO trazodone Antidepressants, Miscellaneous Agents Depression and/or ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, Schizophrenia * FANAPT VRAYLAR SEROQUEL XR Antipsychotics, Atypicals Dermatology Vanoxide-HC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, Acne * erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC Dermatology fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA Actinic Keratosis * CARAC Dermatology NORITATE metronidazole, FINACEA, SOOLANTRA Rosacea * Dermatology clobetasol spray clobetasol foam Skin Inflammation and Hives * CLOBEX SPRAY OLUX-E Corticosteroids APEXICON E desoximetasone, fluocinonide Dermatology ALEVICYN GEL desonide, hydrocortisone Wound Care Products ALEVICYN KIT ALEVICYN SG Alevicyn solution Dermatology ALCORTIN A desonide, hydrocortisone Miscellaneous Skin Conditions ALOQUIN BENSAL HP NOVACORT SYNERDERM Diabetes * FORTAMET metformin, metformin ext-rel Biguanides GLUMETZA RIOMET Diabetes * NESINA JANUVIA, TRADJENTA Dipeptidyl Peptidase-4 ONGLYZA (DPP-4) Inhibitors Diabetes * KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR Dipeptidyl Peptidase-4 KOMBIGLYZE XR OSENI (DPP-4) Inhibitor Combinations Diabetes * BYDUREON OZEMPIC, TRULICITY, VICTOZA Injectable Incretin Mimetics BYETTA TANZEUM Category Formulary Drug Formulary Options Drug Class Removals Diabetes * APIDRA FIASP, NOVOLOG Insulins HUMALOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN 70/30 3 NOVOLIN 70/30 3 HUMULIN N 3 NOVOLIN N 3 HUMULIN R 3 NOVOLIN R 3 NOTE: Humulin R U-500 concentrate will not be subject to removal and will continue to be covered. Diabetes * LANTUS BASAGLAR, LEVEMIR, TRESIBA Long Acting Insulins TOUJEO Diabetes * ACTOS pioglitazone Insulin Sensitizers Diabetes * JARDIANCE FARXIGA, INVOKANA Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors Diabetes * SYNJARDY INVOKAMET, INVOKAMET XR, XIGDUO XR Sodium-Glucose SYNJARDY XR Co-transporter 2 (SGLT2) Inhibitor / Biguanide Combinations Diabetes * NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES Supplies, Needles 4 OWEN MUMFORD NEEDLES PERRIGO NEEDLES ULTIMED NEEDLES All other insulin needles that are not BD ULTRAFINE brand Diabetes * ALLISON MEDICAL INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES Supplies, Syringes 4 TRIVIDIA INSULIN SYRINGES ULTIMED INSULIN SYRINGES All other insulin syringes that are not BD ULTRAFINE brand Diabetes * ACCU-CHEK STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS 5, ONETOUCH VERIO STRIPS AND KITS 5 Supplies, Test Strips and Kits 5, 6 BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS All other test strips that are not ONETOUCH brand Erectile Dysfunction * STENDRA CIALIS Phosphodiesterase Inhibitors VIAGRA Fertility Regulators FOLLISTIM AQ GONAL-F Follicle-Stimulating Hormones Gastrointestinal RELISTOR MOVANTIK Opioid-induced Constipation Gastrointestinal NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT Proton Pump Inhibitors (PPIs) PREVACID PROTONIX ZEGERID Gaucher Disease ELELYSO CERDELGA, CEREZYME Category Formulary Drug Formulary Options Drug Class Removals Genitourinary RIMSO-50 Consult doctor Interstitial Cystitis Growth Hormones GENOTROPIN HUMATROPE, NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN Hematologic PRADAXA warfarin, ELIQUIS, XARELTO Anticoagulants (oral) Hematologic HELIXATE FS KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ Hemophilia Hematologic NEUPOGEN ZARXIO Neutropenia Colony Stimulating Factors Hematologic PLAVIX clopidogrel, prasugrel, BRILINTA Platelet Aggregation Inhibitors High Blood Pressure * ATACAND candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan Angiotensin II Receptor BENICAR DIOVAN Antagonists EDARBI High Blood Pressure * ATACAND HCT candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, Angiotensin II Receptor BENICAR HCT losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, DIOVAN HCT telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide Antagonist / Diuretic Combinations EDARBYCLOR High Blood Pressure * EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan Angiotensin II Receptor Antagonist / Calcium Channel Blocker Combinations High Blood Pressure * EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, Angiotensin II Receptor olmesartan-amlodipine-hydrochlorothiazide Antagonist / Calcium Channel Blocker / Diuretic Combinations High Blood Pressure * DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide Beta-blocker Combinations High Blood Pressure * NORVASC amlodipine Calcium Channel Blockers CARDIZEM diltiazem ext-rel (except generic of CARDIZEM LA) CARDIZEM CD CARDIZEM LA (and its generics) Matzim LA Huntington's
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