Advantage & 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 & 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 Authoriziation (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
  1. Pneumonia, community
  2. 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 & VYNDAMAX1 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

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
Noctivia
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
Ocalvia1
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 
Orlissa
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/day
200mg = 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

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.

On behalf of Capital BlueCross, CVS/caremark assists in the administration of our prescription drug program. CVS/caremark is an independent pharmacy benefit manager.

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross and BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.