Advantage and Value Plus formulary update

2nd and 3rd quarter 2021 - Effective January 1, 2022

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

BREXAFEMME (PA,QL)

BNP

Anti-fungal

fluconazole

EMPAVELI1 (PA,QL)

BP

Paroxysmal Nocturnal Hemogloburinia

SOLIRIS

FOTIVDA1 (PA,QL)

BNP

Oncology

everolimus, INLYTA, LENVIMA

KERENDIA (PA,QL)

BNP

Type 2 Diabetes

N/A

KLISYRI (PA,QL)

BNP

Actinic Keratosis

imiquimod, diclofenac gel 3%, fluorouracil

LUMAKRAS1 (PA,QL)

BNP

Oncology

N/A

LUPKYNIS1 (PA,QL)

BNP

Lupus Nephritis

BENLYSTA

PONVORY1 (PA,QL)

BNP

Multiple Sclerosis

AUBAGIO, AVONEX, BETASERON

QELBREE (PA)

BNP

Attention Deficit Hyperactivity Disorder (ADHD)

ATOMOXETINE, clonidine er, guanfacine er

TEPMETKO1 (PA,QL)

BNP

Oncology

TABRECTA

TRUSELTIQ1 (PA,QL)

BNP

Oncology

N/A

UKONIQ1 (PA,QL)

BNP

Oncology

IMBRUVICA, COPIKTRA

VERQUVO (PA,QL)

BP

Heart Failure

ENTRESTO, FARXIGA

Prior authorization (PAR) utilization management program changes or updates

Drug class/Drug

Purpose/Guidelines

BREXAFEMME (PA,QL)

Anti-fungal

EMPAVELI1 (PA,QL)

Paroxysmal Nocturnal Hemogloburinia

FOTIVDA1 (PA,QL)

Oncology

KERENDIA (PA,QL)

Type 2 Diabetes

KLISYRI (PA,QL)

Actinic Keratosis

LUMAKRAS1 (PA,QL)

Oncology

LUPKYNIS1 (PA,QL)

Lupus Nephritis

PONVORY1 (PA,QL)

Multiple Sclerosis

QELBREE (PA)

Attention Deficit Hyperactivity Disorder (ADHD)

TEPMETKO1 (PA,QL)

Oncology

TRUSELTIQ1 (PA,QL)

Oncology

UKONIQ1 (PA,QL)

Oncology

VERQUVO (PA,QL)

Heart Failure

Quantity level limit (QLL) program3

Drug names(s)

ACCRUFER

ADMELOG

ALDARA

ALOCRIL

APIDRA

AVONEX1

AZESCO

BASAGLAR

BREXAFEMME

CLEMANSTINE FUMARATE SYRUP

COLCRYS

CRESEMBA

ELEPSIA XR

EMPAVELI1

EXJADE1

FASENRA

FIASP

FOTIVDA1

HUMALOG

HUMALOG MIX

HUMULIN R/N

ISORDIL

JADENU1

JENLIVA

KERENDIA KERENDIA

KLISYR

LANTUS

LEVEMIR

LUMAKRAS1

LUPKYNIS1

LYUMJEV

METHITEST

METHYLTESTOSTERONE

MIGRANAL

MITIGARE, COLCHICINE

MYFEMBREE

MYTESI

NOVOLIN R/N

NOVOLOG

NOVOLOG MIX

NOXAFIL

NUCALA

OZEMPIC

PNV

PONVORY1

PREGEN DHA

PRENARA

PRENATRIX

REBIF1

RELTONE

SOLIQUA

TEPMETKO1

TOUJEO

TOUJEO MAX

travoprost

TRESIBA

TRINAZ

VFEND

WINLEVI

WYNZORA

XOLAIR

XULTOPHY

ZALVIT

Specialty drug program3

Drug names(s)

EMPAVELI1

FOTIVDA1

LUMAKRAS1

LUPKYNIS1

PONVORY1

TEPMETKO1

TRUSELTIQ1

UKONIQ1

 

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.