Anthem Blue Cross and Blue Shield Healthcare Solutions Medicaid Managed Care Provider Bulletin June 2020 Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) Hot Tip: Diabetes

Your Anthem patients on nonpreferred products may experience a pharmacy claim rejection. To avoid additional steps or delays at the pharmacy, consider prescribing preferred products whenever possible. Prior authorization and step therapy may apply to select preferred products. Coverage should be verified by reviewing the Preferred Drug List (PDL) on the Anthem provider website. The PDL is subject to change quarterly.

Therapeutic Nonpreferred products Preferred products class Short-acting Short-acting  Afrezza (insulin regular)  Admelog (insulin lispro)  Apidra (isulin glulisine)  Insulin Lispro (Humalog authorized generic)  Fiasp (insulin aspart)  Humalog (insulin lispro) Intermediate-acting  Insulin Aspart (Novolog  Humulin R & Novolin R (insulin regular) authorized generic)  Humulin N & Novolin N (insulin NPH)  Novolog (insulin aspart) Long-acting Insulin1 Long-acting  Basaglar (insulin glargine)  Lantus (insulin glargine)  Levemir (insulin detemir) Mixes  Toujeo (insulin glargine)  Humalog Mix (insulin lispro)  Tresiba (insulin degludec)  Humulin Mix (insulin NPH & insulin regular)  Insulin Aspart Mix (Novolog Mix authorized generic)  Novolin Mix (insulin NPH & insulin regular)  Novolog Mix (insulin aspart)

GLP-1s2  Adlyxin (lixisenatide)  Ozempic (semaglutide)  Bydureon (exenatide)  Victoza (liraglutide)  Byetta (exenatide)  Trulicity (dulaglutide)  Tanzeum (albiglutide)

GLP-1/long-  Soliqua (lixisenatide/insulin acting insulin glargine) combo3  Xultophy (liraglutide/insulin degludec)

DPP4-s2  Alogliptin (generic Nesina)  Januvia (sitagliptin)  Nesina (alogliptin)  Onglyza (saxagliptin)

https://mediproviders.anthem.com/nv Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc., an independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. ANVPEC-1242-20 June 2020 Anthem Blue Cross and Blue Shield Healthcare Solutions Medicaid Managed Care Hot Tip: Diabetes Page 2 of 3

Therapeutic Nonpreferred products Preferred products class  Tradjenta (linagliptin)  Janumet & Janumet XR (sitagliptin/ metformin) 2 DPP4 Combo  Alogliptin/metformin (generic Products3 Kazano)  Alogliptin/pioglitazone2 (generic Oseni)  Jentadueto & Jentadueto XR (linagliptin/metformin)  Kazano (alogliptin/metformin)  Kombiglyze XR (saxagliptin/ metformin)  Oseni2 (alogliptin/pioglitazone)

SGLT22  Farxiga (dapagliflozin)  Jardiance (empagliflozin)  Invokana (canagliflozin)  Streglatro (ertugliflozin)

SGLT2  Glyxambi (empagliflozin/  Synjardy & Synjardy XR (empaglflozin/ Combo linagliptin) metformin) Products3  Invokamet & Invokamet XR (canagliflozin/metformin)  Qtern (dapagliflozin/ saxagliptin)  Segluromet (ertugliflozin/ metformin)  Steglujan (ertugliflozin/ sitagliptin)Xigduo XR (dapagliflozin/ metformin) TZDs4  Actos (pioglitazone)  Pioglitazone (generic Actos)  Avandia (rosiglitazone)  Duetact  Pioglitazone-Metformin (generic Actoplus Met) (pioglitazone/glimepiride)  Pioglitazone-Glimepiride (generic Duetact)  Actoplus Met & Actoplus Met XR (pioglitazone/metformin)  Avandamet (rosiglitazone/ metformin) Diabetic All other manufacturers for Pen BD Pen Needles & Insulin Syringes are the preferred Supplies Needles & Insulin Syringes are product for diabetic supplies. nonpreferred products and may require Prior Authorization. 1 Insulin quantities are limited to 30 ml per 30 days. 2 All anti-diabetic agents require step therapy through metformin unless contraindicated. 3 Combination agents require trial of individual agents and rational regarding clinical necessity of combination product. 4 TZDs have step therapy through metformin AND one preferred drug within any of the following classes: DPP4s, GLP-1s, SGLT2s

Anthem Blue Cross and Blue Shield Healthcare Solutions Medicaid Managed Care Hot Tip: Diabetes Page 3 of 3

If you have questions regarding this Hot Tip, call Provider Services at 1-844-396-2330 or email your Provider Relations representative at [email protected].

PDL: https://mediproviders.anthem.com/nv/pages/formulary.aspx