Advantage and Value Plus formulary update

4th quarter 2020

The Capital Blue Cross 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.

The Advantage and Value Plus formularies were created by Capital Blue Cross to give members access to quality, affordable prescription drugs and to provide physicians with a list of preferred drugs for cost-effective prescribing.

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

Pharmacy Management Program update

Key:

(PAR) = Prior Authorization Required

(ST) = Step Therapy 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

ENSPRYNG1 (PA,QLL)

BNP

Neuromyelitis Optica Spectrum Disorder

azathioprine, prednisone

GAVRETO1, 2 (PA, QLL)

BNP

Antineoplastic

RETEVMO1, 2

INQOVI1 (PA, QLL)

BNP

Antineoplastic

REVLIMID1

KESIMPTA1 (PA, QLL)

BNP

Multiple Sclerosis

AUBAGIO1, 2, AVONEX1, BAFIERTAM

LAMPIT

BNP

Chagas Disease

BENZNIDAZOLE

ONGENTYS

BNP

Parkinson’s Disease

selegiline, NOURIANZ1, rasagiline

ONUREG1 (PA, QLL)

BNP

Antineoplastic

RYDAPT1, DAURISMO 2

XYWAV1 (PA, QLL)

BNP

Narcolepsy

XYREM1

Products changing tier status3

Effective July 1, 2021 (unless otherwise noted below)

Brand name

Current tier

New tier

Effective date

benzonatate 150 mg

GP

Exclude

7/1/2021

COPAXONE1

BP

BNP

7/1/2021

Prior Authorization (PAR) Utilization Management New Additions Programs

Effective July 1, 2021

Drug class/Drug

Purpose/Guidelines

ENSPRYNG1 (PA,QLL)

Neuromyelitis Optica Spectrum Disorder

GAVRETO1, DAURISMO 2 (PA, QLL)

Antineoplastic

INQOVI1 (PA, QLL)

Antineoplastic

KESIMPTA1 (PA, QLL)

Multiple Sclerosis

LAMPIT

Chagas Disease

ONGENTYS

Parkinson’s Disease

ONUREG1 (PA, QLL)

Antineoplastic

XYWAV1 (PA, QLL)

Narcolepsy

Prior Authorization (PAR) Utilization Management Changes or Updates

Effective July 1, 2021

Drug Class/Drug

Target drugs

Androgens/Anabolic Steroids

ANDROID / METHYLTESTOSTERONE, ANDROXY, JATENZO, METHITEST

Please refer to the formulary for the complete list of Androgen/Anabolic Steroids drugs.

Atopic Dermatitis

ELIDEL, EUCRISA, PROTOPIC

Atypical Antipsychotics, Long Acting

ABILIFY MAINTENA, ARISTADA, ARISTADA INITIO, INVEGA SUSTENNA, INVEGA TRINZA

Please refer to the formulary for the complete list of Atypical Antipsychotic drugs.

Atypical Antipsychotics, Short Acting

ABILIFY, ABILIFY MYCITE, CAPLYTA, CLOZARIL, FANAPT

Please refer to the formulary for the complete list of Atypical Antipsychotic drugs.

Biological Immunomodulators

ACTEMRA1, CIMZIA1, ENBREL1, HUMIRA1,  OTEZLA1

Please refer to the formulary for the complete list of Biological Immunomodulator drugs.

Corticosteroid

EMFLAZA1, RAYOS

Diclofenac Gel

DICLOFENAC GEL, FLUOROURACIL CREAM, imiquimod cream, ingenol gel

Endocrine and Metabolic Agents

ISTURISA1, KORLYM, KUVAN1, PALYNZIQ, SENSIPAR1, SIGNIFOR1, STRENSIQ1

Estrogens

ORIAHNN

Genitourinary Agents

PROCYBIS1

Growth Hormone

NORDITROPIN FLEXPRO1

IL-1 Inhibitors

ARCALYST1, ILARIS

Insulin Pumps

OMNIPOD

Multiple Sclerosis

AUBAGIO 2, AVONEX1, BAFIERTAM, BETASERON1, COPAXONE1

Please refer to the formulary for the complete list of Multiple Sclerosis drugs.

Ophthalmic Prostaglandins

LUMIGAN, TRAVATAN Z, travoprost, VYZULTA, XALATAN

Please refer to the formulary for the complete list of Ophthalmic Prostaglandins drugs.

Oncology

AFINITOR1, 2, INREBIC2, TIBSOVO1, TUKYSA1, ZYDELIG1

Please refer to the formulary for the complete list of Oncology drugs.

Oral NSAID

ANAPROX DS, ARTHROTEC, CAMBIA, CELEBREX, DICLOFENAC

Please refer to the formulary for the complete list of Oral NSAID drugs.

Oral Tetracycline

ACTICLATE, DORYX, ORACEA, SOLODYN, XIMINO

Please refer to the formulary for the complete list of Oral Tetracycline drugs.

Parathyroid Hormone Analog Osteoporosis

FORTEO1, NATPARA1, TYMLOS1

Quantity Level Limit (QLL) Program

Effective July 1, 2021 (unless otherwise noted below)

Drug name(s)

Quantity limits 
(per 30 days or as specified)

CAPLYTA

30 capsules/30 days

GAVRETO1, 2

4 capsules/30 days

INQOVI1

5 tablets/28 days

INVEGA

60 tablets/30 days

INVEGA SUSTENNA

60 tablets/30 days

INVEGA TRINZA

60 tablets/30 days

KESIMPTA1

0.4mL (1 pen)/28 days

LATUDA

30 tablets/30 days

OMNIPOD

30 pods/30 days

OMNIPOD DASH

30 pods/30 days

ONUREG1

14 tablets/28 days

SEROQUEL -/XR

60 tablets/30 days

VRAYLAR

30 capsules/30 days

XYWAV1

540mL/30 days

ZYPREXA - /ZYDIS

30 tablets/30 days

ZYPREXA RELPREVV

30 tablets/30 days

Specialty Drug Program

Effective July 1, 2021

Brand name

Tier status

Indication

ALKINDI1

BNP

Adrenocortical Insufficiency

CYSTADROPS1

BNP

Ophthalmic Cystinosis

ENSPRYNG1 (PA,QLL)

BNP

Neuromyelitis Optica Spectrum Disorder

GAVRETO1, 2 (PA, QLL)

BNP

Antineoplastic

INQOVI1 (PA, QLL)

BNP

Antineoplastic

KESIMPTA1 (PA, QLL)

BNP

Multiple Sclerosis

ONUREG1 (PA, QLL)

BNP

Antineoplastic

SEVENFACT1

BNP

Hemophilia

XYWAV1 (PA, QLL)

BNP

Narcolepsy

1Indicates specialty medication

2Split Fill Program available

3Impacted members will be notified prior 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.