Advantage and Value Plus formulary update

2nd and 3rd quarter 2020

The Capital BlueCross formulary is a reference list of prescription drugs that contains a wide range of generic and brand drugs that have been approved by the U.S. Food and Drug Administration (FDA). The formulary is updated on a quarterly basis or when new generic or brand-name medications become available and as discontinued drugs are removed from the marketplace.

Several new drugs have come to market and are now included in our 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

Tier Status

Indication

Preferred Alternatives

DAYVIGO (PA, QLL)

BNP

Insomnia

ZOLPIDEM, trazodone

DOJOLVI1 (PA)

BNP

Long-chain fatty acid oxidation disorders (LC-FAOD)

N/A

DOVATO

BP

Anti-retroviral

COMBIVIR, KALETRA

FINTEPLA1 (PA, QLL)

BNP

Dravet Syndrome

valproate, topiramate

 

ISTURISA

BNP

Cushing’s disease

SIGNIFOR, dexamethasone

KOSELUGO (PA, QLL)

BNP

Antineoplastic

No current pharmacy alternatives

NEXLETOL

BP

High Cholesterol

simvastatin, rosuvastatin, ezetimibe

PEMAZYRE1 (PA, QLL)

BNP

Antineoplastic

No current pharmacy alternative

QINLOCK1 (PA, QLL)

BNP

Antineoplastic

Surgery, GLEEVAC

 

RETEVMO1 (PA, QLL)

BNP

Antineoplastic

Oral Formulary Oncology Products

REYVOW (PA, QLL)

BNP

Anti-Migraine

rizatriptan, sumatriptan

RISDIPLAM (PA)

BNP

Spinal muscular atrophy

No current pharmacy alternatives

RUKOBIA

BNP

HIV

anti-retroviral agents

 

TABRECTA1

BP

Antineoplastic

Surgery

TUKYSA (PA,QLL)

BNP

Antineoplastic

trastuzumab, capecitabine

 

XCOPRI

BNP

Anti-seizure

lamotrigine, levetiracetam, valproate

ZEPOSIA (PA,QLL)

BP

Multiple sclerosis

COPAXONE, GLATIRAMER, REBIF

Products changing tier status

Effective January 1, 2021 (unless otherwise noted below)

Impacted members will be notified prior to change

Brand Name

Current Tier

New Tier

Effective Date

butalbital/acetaminophen/caffeine 50-300-40 mg capsule

GNP

Exclude

1/1/21

FERRIPROX Twice-A-Day 1000 mg tablet

BNP

Exclude

1/1/21

PRALUENT 75 mg/ml, 150 mg/ml injection

BP

BNP

1/1/21

TECFIDERA capsule

BP

BNP

10/1/20

TERIPARATIDE 620 mcg/2.48ml solution

BP

BNP

10/1/20

TIMOPTIC-XE 0.25 %, 0.5% gel

BNP

Exclude

1/1/21

Prior Authorization (PAR) Utilization Management Program changes or updates

Effective January 1, 2021

Drug Class/Drug

Purpose/Guidelines

ACTEMRA

CIMZIA

COSENTYX

ENBREL

HUMIRA

KEVZARA

KINERET

OLUMIANT

ORENCIA

RINVOQ

SILIQ

SIMPONI

SKYRIZI

STELARA

TALTZ

TREMFYA

XELJANZ /-XRNURTEC

Anti-Arthritis

BONJESTA

DICLEGIS

Anticonvulsant

NURTEC

REYVOW

UBREVLY

Anti-migraine

EPIDIOLEX

Anti-seizure

BYNFEZIA

MYCAPSSA

SANDOSTATIN

SOMATULINE

SOMAVERT

XERMELO

Carcinoid Syndrome diarrhea

NEXLETOL

NEXLIZET

Cardiovascular Agent

AMITIZA

LINZESS

MOTEGRITY

MOVANTIK

RELISTOR

SYMPROIC

TRULANCE

ZELNORM

Constipation agents

ISTURISA

Cushing’s disease

ADVATE

ADYNOVATE

AFSTYLA

ELOCTATE

ESPEROCT

HELIXATE FS

HEMLIBRA

HEMOFIL

JIVI

KOATE /-DVI

KOGENATE FS

KOVALTRY

MONOCLATE-P

NOVOEIGHT

NUWIQ

RECOMBINATE

XYNTHA /-SOLOFUSE

Hemophilia A

ALPHANINE SD

ALPROLIX

BEBULIN

BENEFIX

IDELVION

IXINITY

MONONINE

PROFILNINE

REBINYN

RIXUBIS

Hemophilia B

DAKLINZA

EPCLUSA

HARVONI

MAVYRET

OLYSIO

SOVALDI

TECHNIVIE

VIEKIRA /-PAK /-XR

VOSEVI

ZEPATIER

Hepatitis C

TEGSEDI

VYNDAMAX

VYNDAQEL

Hereditary Transthyretin-Mediated Amyloidosis

CARIMUNE

Immune Globulin

OFEV

ESBRIET

Lung disease

OXERVATE

Neurotrophic Keratitis

LUCEMYRA

Opioid Withdrawal

OCALIVA

Primary Biliary Cholangitis (PBC)

BIVIGAM

CARIMUNE

CUTAQUIG

CUVITRU

FLEBOGAMMA

FLEBOGAMMA

GAMASTAN

GAMMAGARD

GAMMAGARD

GAMMAKED

GAMMAPLEX

GAMUNEX

HIZENTRA

HYQVIA

OCTAGAM

PANZYGA

PRIVIGEN

XEMBIFY

Primary Immunodeficiency

REPATHA

PRALUENT

Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9)

EVRYSDI

Spinal Muscular Atrophy

ADIPEX-P

BELVIQ

BELVIQ XR

BONTRIL PDM

BONTRIL RELEASE 

CONTRAVE

DIDREX

DIETHYLPROPION

LOMAIRA

PHENTERMINE

QSYMIA

REGIMEX

SAXENDA

SUPRENZA

XENICAL

Weight Loss

Quantity Level Limit (QLL) Program

Effective January 1, 2021 (unless otherwise noted below)

Drug Name(s)

Quantity Limits 
(per 30 days or as specified)

NURTEC ODT (rimegepant)

75 mg orally disintegrating tablet

EVRYSDI (risdiplam)

0.75 mg/mL (60 mg/80 mL reconstituted powder)

ZIOPTAN (tafluprost)

0.3 mL/single-use container

XELPROS (latanoprost emulsion)

2.5 mL bottle

XALATAN (latanoprost)

2.5 mL bottle

VYZULTA (latanoprostene bunod)

2.5 mL, 5 mL bottle

TRAVATAN Z (travoprost)

2.5 mL, 5 mL bottle

RESCULA (unoprostone-0.15%)

5 mL bottle

bimatoprost-0.03%

2.5 mL, 5 mL, 7.5 mL bottle

LUMIGAN (bimatoprost–0.01%)

2.5 mL, 5 mL bottle


1Indicates Specialty Medication

Impacted members will be notified prior to change. Drugs 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.