Open/Closed Quarterly Formulary Updates

1st Quarter 2019 and 4th Quarter 2018

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

Formulary Status

Indication

Preferred Alternatives

AJOVY1 (PAR)

BNP

Migraine

topiramate, atenolol, venlafaxine

ARIKAYCE1 (PAR)

BNP

Lung disease

N/A

BRAFTOVI1 (PAR)

BNP

Cancer Kinase Inhibitor

N/A

DAURISMO1 (PAR)

BNP

Acute myeloid leukemia (AMK)

N/A

EMGALITY1 (PAR)

BNP

Migraine

topiramate, atenolol, venlafaxine

EPIDIOLEX1 (PAR, QLL)

BNP

Epilepsy/ Seizure Treatment

N/A

FIRDAPSE1 (PAR)

BNP

Lambert-Eaton myasthenic syndrome (LEMS)

N/A

GALAFOLD1 (PAR)

BNP

Fabry Disease

N/A

LOKELMA (PAR)

BNP

Hyperkalemia

furosemide, hydrochlorothiazide

LORBRENA1 (PAR)

BNP

Cancer

N/A

MEKTOVI1 (PAR)

BNP

Cancer

N/A

MULPLETA1 (PAR)

BNP

Thrombocytopenia

DOPTELET (PAR), PROMACTA (PAR)

ORILISSA (PAR)

BNP

Pain associate with endometriosis

N/A

SEYSARA (STEP)

BNP

Acne

minocycline, doxycycline

TAKHYZYRO1 (PAR)

BNP

Hereditary angioedema (HAE)

BERINERT (PAR), FIRAZYR (PAR)

TALZENNA1 (PAR)

BNP

Cancer

N/A

TEGSEDI1 (PAR)

BNP

Polyneuropathy of hereditary transthyretin-mediated amyloidosis

N/A

TIBSOVO1 (PAR)

BNP

Cancer

N/A

VITRAKVI1 (PAR)

BNP

Cancer

N/A

VIZIMPRO1 (PAR)

BP

Cancer

N/A

XEPI1 (PAR)

BNP

Impetigo

mupirocin ointment

XOFLUZA (QLL)

BNP

Influenza

N/A

XOSPATA1 (PAR)

BNP

Cancer

N/A


The Capital BlueCross formulary serves as a reference for all prescription drug benefit designs ranging from an open formulary to a closed formulary.
  • An open formulary provides access to generic preferred, generic non-preferred, brand preferred brand and brand non-preferred medications.
  • A closed 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.

Products Changing Formulary Status

Effective July 1, 2019

Brand Name

Current Status

New Status

Preferred Alternatives

COPAXONE1 (PAR)

BNP

BP

N/A

FANAPT (PAR)

BNP

BP

N/A

LATUDA

BNP

BP

N/A

SEROQUEL /XR (PAR)

BNP

BNP

quetiapine xr

VRAYLAR

BNP

BP

N/A

XELJANZ1 / XR (PAR)

BNP

BP

N/A

Prior Authorization (PAR) Program

The following medications have been added to the Prior Authorization (PAR) Program:

Effective July 1, 2019

Drug Class/Drug

Purpose/Guidelines

ACTEMRA1      

Interleukin-6 Receptor Antagonist

ACTIMMUNE1

Anti-neoplastic

AFINITOR1

Anti-neoplastic

AFREZZA     

Insulin

ANDROID

Androgen

APOKYN1

Anti-Parkinson Agent

ARCALYST1

Interleukin-1 Inhibitor

BONJESTA

Antiemetic Combination

BRYHALI     

Corticosteroid - Topical

CAPRELSA1

Anti-neoplastic

CEQUA       

Ophthalmic Immunomodulator

CETROTIDE1

Fertility Agent

CRYSVITA

X-Linked Hypophosphatemia (XLH) Treatment - Agent

DDAVP

Vasopressin

DEPO-TESTOSTERONE

Androgen

DICLEGIS

Antiemetic Combination

EPIDIOLEX1

Anti-epileptic

FLECTOR PATCH

Topical Anti-Inflammatory Agent

GATTEX1

GRANIX1

Granulocyte Colony-Stimulating Factor (G-CSF)

HYCAMTIN1

Anti-neoplastic

IRESSA1

Anti-neoplastic

KEVEYIS1

Carbonic Anhydrase Inhibitor

KUVAN1

Phenylketonuria Treatment

LEXETTE

Corticosteroid - Topical

LIDODERM (LIDOCAINE PATCH)

Topical Local Anesthetic

LUPANETA1

Endometriosis

MINIRIN

Vasopressin

NOCDURNA    

Vasopressin- Nocturnal Polyuria (NP) In Adults

NOCTIVA

Vasopressin

OTREXUP1

Anti-rheumatic

PENNSAID

Topical Anti-Inflammatory Agent

PROMACTA1

Thrombopoietin (TPO) Receptor Agonist

PULMOZYME1

Cystic Fibrosis Agent

QUDEXY XR

Anti-convulsant

RAVICTI1

Urea Cycle Disorder - Treatment Agent

SAMSCA1

Vasopressin Antagonist

SIKLOS1

Agent For Sickle Cell Anemia

SIVEXTRO

Anti-Infective Agents - Misc.- Oxazolidinone

SOMAVERT1

Growth Hormone Receptor Antagonist

SUTENT1

Anti-neoplastic

SYMPAZAN    

Anti-convulsant - Benzodiazepine

TARGRETIN GEL 1%1

Topical Selective Retinoid X Receptor Agonists

TESTOSTERONE

Androgen

TESTRED

Androgen

TIROSINT    

Thyroid Hormones

TOLSURA     

Anti-fungal - oral

TRESIBA    

Insulin

UDENYCA1    

Granulocyte Colony-Stimulating Factors (G-CSF)

VIRILON

Androgen

XELPROS     

Prostaglandin - Ophthalmic

XYOSTED 

Androgen

YONSA1

Anti-neoplastic

ZTLIDO

Topical - Local Anesthetic

Enhanced Prior Authoriziation (EPA) Program

Effective July 1, 2019

Drug Class/Drug

Purpose/Guidelines

SEYSARA

Antibiotic

 

TRUVADA

Anti-retroviral

Certain medications are subject to Enhanced Prior Authorization (EPA) due to health care 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.

To obtain Prior Authorization, your physician or pharmacist should call or fax a request with supporting clinical information to the CVS/caremarkTM Prior Authorization Department at 800.294.5979 (Fax: 888.836.0730). Members may initiate a Prior Authorization request by calling CVS/caremark at 800.585.5794.

Drugs Not Covered Under Pharmacy Benefit

Effective July 1, 2019. Available on the Medical Benefit.

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

  • VIVITROL

Quantity Level Limits Program

The following medications have been updated to the Quantity Level Limit Program:

Effective July 1, 2019

Drug Class/Drug

Purpose/Guidelines

XOFLUZA

Anti-Flu


Certain medications are subject to Quantity Level Limit (QLL) to help promote appropriate use of medications and enhance patient safety. Prescriptions written for more than the allowed quantity will only be filled up to the allowed amount. Your physician can direct quantity override requests to CVS/caremark by calling or faxing the request with supporting clinical information to 800.294.5979 (Fax: 888.836.0730).


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.