Pharmacy Benefit Updates

DATE: March 4, 2019 TO: All BMC HealthNet Plan Providers

PRODUCT: MassHealth ConnectorCare/Qualified Health Plan

Policy and Prior Authorization Program Changes

The following clinical policies have been updated, effective March 4, 2019:  9.023 Ophthalmic  *9.142 Antifungal agents  9.113 Bactroban Nasal Ointment Antibiotics  *9.043 Topical  9.196 Olumiant  9.027 Topical  9.195 Xeljanz Immunomodulators  *9.109 Proton Pump  9.155 Acne and Rosacea Agents  9.044 Acyclovir Ointment Inhibitors  9.107 Opioids (name change)  *9.111 Topical Medications  9.070 Ocaliva  9.104 Antiemetics (Misc)  9.071 Impavido  9.108 Antibiotics  *9.026 Metoclopramide  9.086 Nplate and Tavalisse (Systemic) ODT  9.162 Vaccines  9.122 Gastrointestinal  9.147 Ophthalmic Anti-Allergy  9.022 Restasis, Xiidra Agents & Inflammatory

*These policies have been discontinued.

The following drug(s) will move to step therapy requirement, effective March 4, 2019:  Dexilant  Dapsone  adapalene cream/gel  Esomeprazole (Rx)  Adapalene cream  Clindamycin/benzoyl peroxide  Omeprazole-bicarbonate  Adapalene gel gel 1%-5% (generic for  azelastine  propionate Benzaclin)  epinastine (Olux/Olux-E) 0.05% foam  Neuac gel 1.2-5%  ketorolac  (clindamycin/Benzoyl  bromfenac (Clobex®) 0.05% L, Sh,Sp Peroxide),  Lotemax gel  (DesOwen®)  Onexton™ gel 1.2-3.75%  Durezol 0.05% O (benzoyl  Olapatadine 0.1%  desonide (DesOwen®) peroxide/clindamycin)  Lidocaine 5% ointment 0.05% C, L  azelaic acid  Soolantra  Rhofade

The following drug(s) will require prior authorization under specific clinical pharmacy policies effective March 4, 2019  Olumiant  Tavalisse

The following drug(s) will be non-preferred, effective March 4, 2019:  Siklos  Acanya gel  Ameluz 10% gel  Omeprazole-bicarbonate powder  Aktipak  Tolak 4% cream packet  Epiduo Forte gel  Zyclara 2.5% and 3.75% pump  Aciphex Sprinkle  Nuox  Acuvail  Nexium granules  Veltin, clindaycin/tretinoin  Alocril  Prevacid SoluTab gel (Ziana)  Alomide  Prilosec powder packet  tretinoin micro gel and  Alrex

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 Protonix granules pump  Bepreve  Metoclopramide ODT  Fabior  Emadine  Relistor  differin lotion  Lastacraft  Trulance  Benziq/LS  Lotemax ointment  Viberzi  Riax  Lotemax suspension  Diclegis  Clindagel, clindamycin aer  Nevanac  Sancuso foam,  olapatadine 0.2%  Sustol  sulfacetamide  Pazeo  Zuplenz sodium/sulfur  Azasite  Baxdela  Absorica capsule  Besivance  Actilate  Oracea, doxycycline 40mg  Blephamide SOP ointment  minocycline ER  Finacea foam  Blephamide suspension  doxycycline delayed release  Noritate cream  Ciloxan  doxycycline monohydrate 75 mg  Ecoza  Moxeza capsule  Ertaczo  Tobrex ointment  doxycycline monohydrate 150  Exelderm  Tobradex ointment mg capsule  Jublia  Tobradex ST suspension  Denavir cream  Kerydrin  Zylet  Zovirax cream  Luzu  0.1% C  Sitavig buccal tablet  Mentax  Cordran® (flurandrenolide)  Xerese cream  oxiconazole tape 4 mcg/sqcm  Cloderm® (clocortolone) 0.1%  Oxistat  Ultravate® (halobetasol C  Xolegel propionate) 0.05% L  clocortolone 0.1% C  ciclopirox 0.77% gel and  Halog® () 0.1% C,  flurandrenolide (Cordran®) suspension O 0.05% O, C, L  naftifine cream  Apexicon E® () 0.05%  butyrate (Locoid  Naftin gel emollient cream Lipo®) 0.1% C  aerosol  0.05% O,  Pandel® (hydrocortisone  Capex® () C probutate) 0.1% C 0.01% shampoo  0.1% C, L, O  Locoid® (hydrocortisone  Nucort® 2% lotion  valerate 0.12% butyrate) 0.1% L () foam  Trianex® () 0.05%  Texacort® (hydrocortisone  Altabax (retapamulin) 1% O O acetate) 2.5% S  Bactroban® (mupirocin) 2%  triamcinolone (Kenalog®) Spray  Verdeso® (desonide) Nasal Ointment  Sernivo (betamethasone 0.05% F  Cortisporin® (bacitracin- dipropionate) 0.05% Spray  Anacaine® (benzocaine) polymyxin-neomycin) 1% O  Desonate® (desonide) 0.05% G 10% O  Cortisporin® (bacitracin-  (Cutivate®) 0.05% L  Lidorx® (Lidocaine HCl) polymyxin-neomycin) 0.5% C  Eurax® (crotamiton) 10% 3% G  NUVESSA (metronidazole  Taclonex® (calcipotriene-  lidocaine 3% L 1.3% G) betamethasone dipropionate)  lidocaine 5% O  Tersi Foam (selenium sufide) 0.005-0.064% Sus  Lidopin® (lidocaine) 3% 2.25% F  calcipotriene-betamethasone C, 3.25% C  Zithranol® (anthralin) 1% Sh, dipropionate) 0.005-0.064%  Lidovex® (lidocaine) 1.2% C  Enstilar (calcipotriene- 3.75% C  Ovace Plus 9.8% L, F; 10% C betamethasone dipropionate)  Synvexia® TC (lidocaine-  Sulfacetamide Sodium 10% 0.005-0.064% F menthol) 4-1% C (Ovace Plus) Sh, G  Selrx® (Selenium Sulfide-  Epifoam® (pramoxine-  calcitriol (compare to Pyrithione Zinc) 2.3% Sh hydrocortisone) aerosol Vectical®) O

 Vectical® (calcitriol) O Foam 1-1%  Sorilux® (calcipotriene) 0.005% F  Pramosone® (pramoxine- hydrocortisone) 1%, 2.5% L; 1% C C=cream, G=gel, L=lotion, S=solution, O=ointment, P=powder, Sp=spray, Sh= shampoo, Sus=suspension

The following drug(s) will be covered without a prior authorization, effective March 4, 2019:  Clindamycin/benzoyl peroxide  Firvanq gel 1.2-5% (generic for Duac)  Benznidazole  Adapalene/benzoyl peroxide  butenafine 1% cream (OTC) gel 0.1-2.5% gel (generic for Epiduo)

Please visit the Pharmacy section of BMCHP.org for complete policies and forms. The updated policies will be available in the provider notification section of the Pharmacy page at BMCHP.org by the first week of March.