Advantage and Value Plus Formulary Update

Updated January 2020 to 2nd and 3rd Quarter 2019 effective Jan 1, 2020

The following formulary updates may affect Commercial members who have prescription drug coverage through Capital BlueCross on Advantage and Value Plus Formulary.

Pharmacy Management Program Update

KEY:

(PAR) = Prior Authorization Required

(EPA) = Enhanced Prior Authorization Required

(QLL) = Quantity Level Limits Apply — Quantity Level Limit (QLL) Program

(BP) = Brand Preferred

(BNP) = Brand Non-Preferred

(NC) = Not Covered

(NF) = Non-Formulary

UPPERCASE names = Brand

lowercase names = Generic

Newly Marketed Drugs

Effective Immediately

Brand Name

Commercial (Open/Closed)

Indication

Preferred Alternatives

AEMCOLO (PAR) BNP Traveler’s Diarrhea azithromycin, ciprofloxacin 
ARAKODA BNP Malaria N/A
BALVERSA1 (PAR,QLL) BNP Cancer N/A
CUTAQUIG1 (PAR) BNP Immunodeficiency Syndromes HIZENTRA, CUVITRU
COPIKTRA1 (PAR, QLL) BNP Chronic Lymphocytic Leukemia ARZERRA, ZYDELIG
DELSTRIGO1 (PAR) BNP HIV-1 lamivudine, tenofovir disoproxil fumarate
DIACOMIT1 BNP Dravet Syndrome DEPAKOTE, valproic acid
KRINTAFL BNP Malaria atovaquone/proguanil, mefloquine
MAVENCLAD (PAR) BNP Multiple Sclerosis Relapsing GILENYA, TECFIDERA
MAYZENT (PAR) BNP Multiple Sclerosis GILENYA, TECFIDERA
MOTEGRITY (PAR) BNP Chronic Idiopathic Constipation LINZESS
NUZYRA BNP Pneumonia, Acquired Skin and Skin Structure Infections ZYVOX
OXERVATE1 (PAR, QLL) BNP Neurotrophic Keratitis prophylactic antibiotic
PIFELTRO BNP HIV-1 lamivudine, tenofovir disoproxil fumarate
PIQRAY1 (PAR, QLL) BNP Breast Cancer, Advanced or Metastatic tamoxifen, letrozole, fulvestrant
REVCOVI1 (PAR) BNP Adenosine Deaminase Severe Combined Immune Deficiency N/A
RUZURGI1 (PAR, QLL) BNP Lambert-Eaton Myasthenic Syndrome FIRDAPSE
SKYRIZI1 (PAR, QLL) BNP Plaque Psoriasis TREMFYA, STELARA, EMBREL, HUMIRA
SUNOSI (PAR, QLL) BNP Narcolepsy or Obstructive Sleep Apnea armodafinil, modafinil
VYNDAQEL1/VYNDAMA X1 (PAR, QLL) BNP Multiple Myeloma N/A
XPOVIO1 (PAR, QLL) BNP Amyloid Cardiomyopathy EMPLICITI, ninlaro, farydak
YUPELRI (PAR) BNP Chronic Abstructive Pulmonary Disease  SPIRIVA

Products Changing Tier Status

Effective January 1, 2020

Brand Name

Current Status

New Status

Preferred Alternatives

SKYRIZI1 (PAR, QLL)

BNP

BP

ENBREL, HUMIRA, cyclosporine

QTERN

BNP

BP

alogliptin/metformin 

Changing to Enhanced Prior Authorization (EPA) Program

Effective January 1, 2020

  • ALOCRIL 
  • ALOMIDE 
  • AMCINONIDE oint 
  • AMERGE 
  • APEXICON E 
  • ATACAND / -HCT 
  • AZOR 
  • BENICAR / -HCT 
  • BEPREVE 
  • CLOBEX 
  • CLODERM 
  • CORDORAN
  • COZAAR
  • CUTIVATE
  • DESONATE
  • DESOWEN
  • DIOVAN / -HCT
  • DIPROLENE AF
  • DIPROLENE lotion
  • DOPROLENE oint
  • EDARBI
  • ELESTAT
  • ELOCON
  • EMADINE
  • EXFORGE /-HCT
  • FROVA
  • HALOG
  • HYZAAR
  • IMITREX
  • IMPOYZ
  • KENALOP spray
  • LASTACAFT 
  • LOCOID LIPCREAM 
  • LUMIGAN
  • LUXIQ FOAM
  • MAXALT/ MLT
  • MICARDIS / -HCT
  • olopatadine 
  • OLUX 
  • ONZETRA 
  • PANDEL 
  • PATADAY 
  • PATANOL
  • PAZEO
  • PSORCON
  • RELPAX
  • SYNALAR
  • TEMOVAT
  • TEXACORT 
  • TOPICORT
  • TOPICROT LOCOID 
  • TRAVANTAN Z 
  • TRIANEX 
  • TRIBENZOR 
  • ULTRAVATE 
  • VANOS 
  • VERDESO 
  • VYZULTA 
  • XALATAN 
  • XSAIL 
  • ZEMBRACE SYMTOUCH 

Prior Authorization (PAR) Program

The following medications have been added to the Prior Authorization (PAR) Program:

Effective January 1, 2020

Drug Class/Drug

Purpose/Guidelines

AEMCOLO Travelers Diarrhea
ARAKODA Malaria
BALVERSA1 Cancer
COPIKTRA1 Cancer
CUTAQUIG1 Immunodeficiency Syndromes
DELSTRIGO1 HIV-1 infection
DIACOMIT1 Dravet Syndrome
KRINTAFEL Malaria
MAVENCLAD Multiple Sclerosis Relapsing
MAYZENT Multiple Sclerosis
NUZYRA Pneumonia, community 
Acquired skin and skin structure infection
OXERVATE1 Neurotrophic Keratitis
PIFELTRO HIV-1 Infection
PIQRAY1 Cancer
REVCOVI1 Adenosine Deaminase Severe Combined Immune Deficiency
RIZURGI1 Lambert-Eaton Myasthenic Syndrome
SKYRIZI1 Plaque Psoriasis
SUNOSI Narcolepsy or Obstructive Sleep Apnea
VYNDAQEL1 & VYNDAMAX 1 Amyloid Cardiomyopathy
XPOVIO1 Multiple Myeloma
YUPELRI Chronic Abstructive Pulmonary Disease
ZTLIDO Topical Local Anesthetic

Existing Prior Authorization (PAR) Program Changes

Drug or Drug Class

ATTENTION DEFICIT HYPERACTIVITY DISORDER BENLYSTA1
CORLANOR EMFLAZA1
ENDARI1 EPINEPHRINE
FIBROMYALGIA AGENTS GALAFOLD1
GATTEX1 GROWTH HORMONE
HEREDITARY ANGIOEDEMA PRODUCTS KORLYM1
MULTIPLE SCLEROSIS AGENTS OXERVATE1
QBREXZA ONCOLOGY
TEGSEDI1 TOPICAL CORTICOSTEROID
VMAT2 AGENTS (EXAMPLE: AUSTEDO, INGREZZA, XENAZINE)

Quantity Level Limits Program

The following medications have been updated to the Quantity Level Limit Program:

Effective January 1, 2020

Drug Class/Drug

Quantity Limits 
(per 30 days or as specified)

Addyi

100mg = 1 tab/day

Arcalyst1

220mg/vial = 4 vials/28 days

Arikayce1

590mg/8.4ml = 235.2ml/28 days

Austedo1

6mg = 2 tabs/day 
9mg = 4 tabs/day 
12mg = 4 tabs/day

Benlysta1

200mg autoinj = 4/28 days 
200mg PFS = 4/28 days

Berinert1

500 IU/10ml = 10 vials/30 days

Bonjesta

20mg/20mg = 2 tabs/day

Cequa

2 vials/day

Cerdelga

84mg = 2 caps/day

Cinryze1

500 IU/10ml = 20 vials/30 days

Coagadex1

Dependent on patient weight and number of doses

Consensi

2.5mg/200mg = 1 tab/day 
5mg/200mg = 1 tab/day 
10mg/200mg = 1 tab/day

Corlanor

5mg = 2 tabs/day 
7.5mg = 2 tabs/day 
5mg/5ml = 20ml/day

Crinone

4% gel = 6.75gm/30 days 
8% gel = 67.5gm/30 days

Diclegis

10mg/10mg = 4 tabs/day

Duexis

800mg/26.6mg = 3 tabs/day

Dupixent1

200mg/1.14ml = 2 inj/28 days 
300mg/2ml = 2 inj/28 days

Duzallo

1 tab/day

Egrifta1

1mg powder = 60 vials/30 days 
2mg soln = 30 vials/30 days

Emflaza1

6mg = 2 tabs/day 
18mg = 1 tab/day

Endometrin

100mg = 84 inserts (4 cartons)/28 days

Esbriet1

267mg = 6 caps/day 
801mg = 3 tabs/day

Firazyr1

30mg/3ml inj = 6 inj/30 days

Forteo1

250mcg/ml = 2.4ml/28 days

Galafold1

123mg = 14 caps/28 days

Haegarda1

2000 IU/vial = weight dependent 
3000 IU/vial = weight dependent

Hemlibra1

Weight based QL

Hetlioz1

20mg = 1/day

Ingrezza1

40mg = 1 cap/day 
80mg = 1 cap/day 
Starter pack = 28 caps/180 days

Jublia

4ml

Juxtapid1

5-60mg = 1 cap/day

Kalbitor

3-10mg/ml vials = 12 ml (4 kits)/30 days

Kalydeco1

25mg = 2 packets/day 
50mg = 2 packets/day 
75mg = 2 packets/day 
150mg = 2 tabs/day

Kerydin

4ml

Keveyis1

50mg = 4 tabs/day

Korlym1

300mg = 4 tabs/day

Kynamro1

200mg/ml inj = 1 inj/week

Lyrica CR

82.5mg = 1 tab/day 
165mg = 1 tab/day 
330mg = 2 tabs/day 

Natpara1

25 - 100mcg = 2 cartridges/28 days

Nocdurna

22.7mcg = 1 tab/day 
55.3mcg = 1 tab/day

Noctiva

0.83mcg nasal sp = 1 bottle/30 days  
1.66mcg nasal sp = 1 bottle/30 days

Northera1

100mg = 15 caps/day 
200mg = 6 caps/day 
300mg = 6 caps/day 

Nuplazid1

10mg = 1 tab/day :
17mg = 2 tabs/day 
34mg = 1 tab/day

Nuvigil

5 - 250mg = 1 tab/day

Ocaliva1

5 - 10mg = 1 tab/day

Ofev1

100mg = 2 caps/day 
150mg = 2 caps/day

Onpattro

10mg/5ml vial = 3 vials (15ml)/21 days

Orkambi1

100mg/125mg = 2 packets/day 
150mg/188mg = 2 packets/day 
100mg/125mg = 4 tabs/day 
200mg/125mg = 4 tabs/day

Orilissa

150mg = 1 tab/day 
200mg = 2 tabs/day

Otezla1

Starter pack = 55 tabs/180 days 
30mg = 60 tabs/30 days

Penlac

6.6ml

Prevymis

240 - 480mg = 100 tabs/365 days (cumulative)

Provigil

100 - 200mg = 1 tab/day

Qudexy XR

25 - 150mg = 1 cap/day 
200mg = 2 caps/day

Regranex

0.01% gel = 15gm/30 days

Relenza

1 Diskhaler 

Restasis multidose

1 bottle/30 days

Restasis vial

2 vials/day

Ruconest1

2100 IU/vial = 8 vials/30 days

Samsca1

15mg = 30 tabs/365 days 
30mg = 60 tabs/365 days

Signifor1

0.3 - 0.9mg/ml ampules = 60/30 days

Symdeko1

50mg/75mg + 75mg = 2 tabs/day 
100mg/150mg + 150mg = 2 tabs/day

Takhzyro1

300mg/2ml vial = 2 vials/28 days

Tamiflu

30mg = 40 caps/120 days 
45mg = 20 caps/120 days 
75mg = 20 caps/120 days :
6mg/ml = 300ml/120 days

Tegsedi1

284mg/1.5ml inj = 4 inj/28 days

Trokendi XR

25 - 100mg = 1 cap/day200mg = 2 caps/day

Tymlos1

2000mcg/inj = 1.56ml/30 days

Various - see policy

Weight based QL

Vimovo

375mg/20mg = 2 tabs/day 
500mg/20mg = 2 tabs/day

Xenazine1

12.5mg = 8 tabs/day 
25mg = 4 tabs/day

Xermelo1

250mg = 3 tabs/day

Xiidra

2 containers/day

Xofluza

20mg = 4 tabs/120 days 
40mg = 4 tabs/120 days

Xyrem1

500mg/ml = 540ml/30 days

Yosprala

81mg/40mg = 1 tab/day 
325mg/40mg = 1 tab/day

Zavesca1

100mg = 3 caps/day

Zurampic

1 tab/day

Zavesca1

100mg = 3 caps/day

Zurampic

1 tab/day


Impacted members will be notified prior to change.

1Indicates Specialty Medication

2Drugs that are listed in the target drug box include both brand and generic unless otherwise stated; dosage forms are not all encompassing and is subject to change.

The information contained on this page is not all encompassing and is subject to change. Please refer to your Certificate of Coverage for specific terms, conditions, exclusions and limitations relating to your coverage.