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 Corticosteroids 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 clobetasol propionate Benzaclin) epinastine (Olux/Olux-E) 0.05% foam Neuac gel 1.2-5% ketorolac clobetasol propionate (clindamycin/Benzoyl bromfenac (Clobex®) 0.05% L, Sh,Sp Peroxide), Lotemax gel desonide (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 fluocinonide 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® (halcinonide) 0.1% C, flurandrenolide (Cordran®) suspension O 0.05% O, C, L naftifine cream Apexicon E® (diflorasone) 0.05% hydrocortisone butyrate (Locoid Naftin gel emollient cream Lipo®) 0.1% C ketoconazole aerosol diflorasone diacetate 0.05% O, Pandel® (hydrocortisone Capex® (fluocinolone) C probutate) 0.1% C 0.01% shampoo Amcinonide 0.1% C, L, O Locoid® (hydrocortisone Nucort® 2% lotion betamethasone valerate 0.12% butyrate) 0.1% L (hydrocortisone acetate) foam Trianex® (triamcinolone) 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- fluticasone (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.