Advantage and Value Plus Formulary Update

4th Quarter 2019 and 1st Quarter 2020 (Effective July 1, 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.

Additional Recall Information:

The FDA announced it is requesting manufacturers withdraw all prescription and over-the-counter (OTC) ranitidine drugs from the market immediately. This is the latest step in an ongoing investigation of a contaminant known as N-Nitrosodimethylamine (NDMA) in ranitidine medications (commonly known by the brand name Zantac). The agency has determined that the impurity in some ranitidine products increases over time and when stored at higher than room temperatures and may result in consumer exposure to unacceptable levels of this impurity. As a result of this immediate market withdrawal request, ranitidine products will not be available for new or existing prescriptions or OTC use in the U.S.

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

Effective Immediately

Brand Name

Commercial (Open/Closed)

Indication

Preferred Alternatives

AKLIEF (PAR) BNP Acne tazarotene (PAR), tretinoin (PAR)
AYVAKIT1 (PAR, QLL) BNP Oncology imatinib, SUTENT (PAR), GLEEVAC
BRUKINSA1 (PAR, QLL) BNP Oncology IMBRUVICA (PAR)
CAPLYTA (EPA, QLL) BNP Antipsychotic Atypical anti-psychotic agents, 
(aripiprazole, quetiapine, risperidone)
INREBIC1 (PAR, QLL) BNP Oncology JAKAFI (PAR)
NOURIANZ1 BNP Parkinson’s disease rotigotine, pramipexole, ropinirole
NUBEQA1 (PAR, QLL) BNP Oncology XTANDI (PAR)
NURTEC1 ODT (PAR, QLL) BNP Anti-migraine sumatriptan (QLL), topiramate
OXBRYTA1 (PAR, QLL) BNP Sickle Cell hydroxyurea
RINVOQ1 (PAR, QLL) BNP Rheumatoid arthritis XELJANZ (PAR, QLL), ENBREL (PAR, QLL), HUMIRA (PAR, QLL)
ROZYLTREK1 (PAR, QLL) BNP Oncology VITRAKVI (PAR), XALKORI1
RYBELSUS (EPA) BNP Diabetes BYDUREON (EPA), TRULICITY (EPA)
TAZVERIK 1 (PAR, QLL) BNP Oncology REVLIMID (PAR, QLL)
TRIKAFTA1 (PAR, QLL) BNP Cystic Fibrosis KALYDECO (PAR, QLL), ORKAMBI (PAR, QLL)
TURALIO1 (PAR, QLL) BNP Oncology N/A
UBREVLY1 (PAR, QLL) BNP Anti-migraine sumatriptan (QLL), topiramate
VUMERITY1 (PAR, QLL) BNP Multiple Sclerosis TECFIDERA (PAR, QLL)
VYLEESI1 (PAR, QLL) BP Hypoactive sexual desire disorder ADDYI
WAKIX1 (PAR, QLL) BNP Narcolepsy NUVIGIL (PAR, QLL), PROVIGIL (PAR, QLL)
XENLETA1 BNP Antibacterial cefuroxime, moxifloxacin, azithromycin
ZELNORM (PAR, QLL) BNP IBS-C LINZESS (QLL), AMITIZA (PAR, QLL)

Changing to Enhanced Prior Authorization (EPA) Program

The formulary serves as a reference for all prescription drug benefit designs ranging from an Advantage formulary to a Value Plus formulary.

  • The Advantage formulary provides access to generic preferred, generic non-preferred, brand preferred brand and brand non-preferred medications.
  • The Value Plus formulary provides access to generic preferred, generic non-preferred and brand preferred medications. Brand non-preferred medications are not covered under a closed formulary. You or your physician may request coverage for medically necessary brand non-preferred drugs through the Non-formulary Consideration Process. The following chart indicates medications that have changed formulary status.

Certain medications are subject to Enhanced Prior Authorization (EPA) due to healthcare concerns and/or safety reasons. In order to have these medications covered under your prescription drug benefit, you may be required to try a formulary alternative first or to complete the Prior Authorization process.

Effective July 1, 2020

Drug Class/Drug

Drug Class/Drug

BYVALSON Hypertension
CAPLYTA Antipsychotic
CLEOCIN-T Acne
CLINDAGEL Acne
CONTOUR Diabetes
COZAAR Hypertension
DARIO Diabetes
DETROL Overactive Bladder
DETROL LA Overactive Bladder
DITROPAN Overactive Bladder
DITROPAN XL Overactive Bladder
DIOVAN Hypertension
DIOVAN HCT Hypertension
DUAC Acne Vulgaris
EASYGLUCO Diabetes
EASYMAX Diabetes
EDARBI Hypertension
EDARBYCLOR Hypertension
EMBRACE Diabetes
ENABLEX Overactive Bladder
EPIDUO Acne Vulgaris
EPIDUO FORTE Acne Vulgaris
ERYGEL Acne
EVOCLIN Acne
EXFORGE Hypertension
EXFORGE HCT Hypertension
FIFTY50 Diabetes
FINACEA Acne Vulgaris
FORA Diabetes
FORTIS Diabetes
GELNIQUE Overactive Bladder
GENESIS GHT Diabetes
GLUCOCARD Diabetes
HYZAAR Hypertension
IHEALTH Diabetes
INFINITY Diabetes
JAZZ Diabetes
LIVONGO Diabetes
METROCREAM Rosacea
METROGEL Rosacea
METROLOTION Rosacea
MICARDIS Hypertension
MICARDIS HCT Hypertension
MYGLUCOHEALTH Diabetes
NEUAC Acne Vulgaris
NORITATE Rosacea
NOVA MAX Diabetes
ONE DROP Diabetes
ONE TOUCH Diabetes
ONEXTON Acne Vulgaris
OXYTROL®[RX] Overactive Bladder
PRESTO Diabetes
PRODIGY Diabetes
RELION Diabetes
RYBELSUS Diabetes
SANCTURA Overactive Bladder
SANCTURA XR Overactive Bladder
SIDEKICK Diabetes
TEKTURNA Hypertension
TELCARE Diabetes
TEVETEN/EPROSARTAN Hypertension
TOVIAZ Overactive Bladder
TRIBENZOR Hypertension
TRUE METRIX Diabetes
TWYNSTA Hypertension
VELTIN Acne
VERASENS Diabetes
VESICARE Overactive Bladder
ZIANA Acne

Prior Authorization (PAR) Program

The following medications exist on the Prior Authorization (PAR) program and will have requirement changes.

Effective July 1, 2020

Drug Class/Drug

Purpose/Guidelines

ACTICLATE Acne
ADAPALENE Acne Vulgaris
ADOXA/ADOXA PAK Acne
AKLIEF Acne
ALTRENO Acne Vulgaris
APLENZIN Major Depressive Disorder
ATRALIN Acne
AVITA Acne
AYVAKIT1 Oncology
BECONASE AQ Rhinitis
BRUKINSA1 Oncology
CELEXA Major Depressive Disorder
CYMBALTA Generalized Anxiety Disorder
DESVENLAFAXINE ER Major Depressive Disorder
DIFFERIN Acne Vulgaris
DORYX/DORYX MPC Acne
DOXYCYCLINE Acne
DULOXETINE DR Generalized Anxiety Disorder
DYMISTA Seasonal Allergic Rhinitis
EFFEXOR Generalized Anxiety Disorder
EFFEXOR XR Generalized Anxiety Disorder
FABIOR Acne Vulgaris
FETZIMA Major Depressive Disorder
FORFIVO XL Major Depressive Disorder
FLONASE Nonallergic Rhinitis
FLUVOXAMINE ER Obsessive-Compulsive Disorder
IRENKA Major Depressive Disorder
INREBIC1 Oncology
KHEDEZLA Major Depressive Disorder
LEXAPRO Generalized Anxiety Disorder
MAPROTILINE Depression
MINOCIN Acute intestinal amebiasis
MINOLIRA Acute intestinal amebiasis
MONODOX Acne
NASACORT/CHILDREN’S NASACORT Allergic Rhinitis
NASONEX Allergic Rhinitis
NOURIANZ Parkinson’s Disease
NUBEQA1 Oncology
NURTEC1 ODT Anti-migraine
OLEPTRO Major Depressive Disorder
OMNARIS Perennial Allergic Rhinitis
ORACEA Acne
OXBRYTA1 Sickle Cell
PAXIL Major Depressive Disorder
PAXIL CR Major Depressive Disorder
PEXEVA Major Depressive Disorder
PLIXDA Acne
PRISTIQ Major Depressive Disorder
PROZAC Bipolar Major Depression
QNASL Rhinitis
REMERON/REMERON SOLTAB Major Depressive Disorder
RETIN-A Acne Vulgaris
RETIN-A MICRO Acne Vulgaris
RHINOCORT Allergic Rhinitis
RINVOQ1 Rheumatoid Arthritis
ROZYLTREK1 Oncology
RYBELSUS Diabetes
SEYSARA Acne Vulgaris
SOLODYN/MINOCYCLINE ER Acute intestinal amebiasis
TARGADOX Acne
TAZVERIK1 Oncology
TAZORAC Acne Vulgaris
TRETIN-XB Acne Vulgaris
TRIKAFTA1 Cystic Fibrosis
TRINTELLIX Major Depressive Disorder
TURALIO1 Oncology
UBREVLY1 Anti-Migraine
VENLAFAXINE ER Generalized Anxiety Disorder
VUMERITY1 Multiple Sclerosis
VYLEESI1 Hypoactive Sexual Desire Disorder
WAKIX1 Narcolepsy
XENLETA1 Anti-Bacterial
ZELNORM IBS-C

The following medications have been added to the Quantity Level Limit Program (QLL)

Effective July 1, 2020

Drug Class/Drug

Quantity Limits (per 120 days or as specified)

AYVAKIT1

30 tablets / 30 days

BRUKINSA1

4 capsules / day

CAPLYTA

1 tablet / day

INREBIC

4 capsules / day

NURTEC ODT1

1 tablet / day

RELENZA

40 blisters per 120 days

RINVOQ1

1 tablet / day

ROZYLTREK1

1-3 capsules / day

TAMIFLU 30 mg cap

40 capsules per 120 days

TAMIFLU 45 mg cap

20 capsules per 120 days

TAMIFLU 75 mg cap

20 capsules per 120 days

TAMIFLU 6 mg/mL Susp

300 mL per 120 days

TAZVERIK1

8 tablets / day

TRIKAFTA1

3 tablets / day

TURALIO1

4 capsules / day

UBREVLY1

1 tablet / day

VUMERITY1

4 capsules / day

VYLEESI1

6 tablets / 30 days

WAKIX1

2 tablets / day

XOFLUZA

4 tablets per 120 days

ZELNORM

2 tablets / day


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.