Open/Closed Quarterly Formulary Updates

Updated January 2019

The following formulary updates may affect Commercial members who have prescription drug coverage through Capital BlueCross on Open/Closed 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	Commercial (Open/Closed)	Indication	Preferred Alternatives
AIMOVIG¹ (PAR, QLL)	BNP/NF	Migraine	topiramate, atenolol, venlafaxine
BIKTARVY (PAR)	BNP	Anti-Retroviral	STRIBILD
DOPTELET¹ (PAR)	BP	Thrombocytopenia	platelet transfusions
ERLEADA¹ (PAR)	BP	Anti-neoplastic	XTANDI¹ (PAR)
LUCEMYRA (PAR)	BNP	Agents for narcotic withdrawal	clonidine, gabapentin
OLUMIANT¹ (PAR)	BNP	Anti-Rheumatic	ENBREL¹ (PAR) HUMIRA¹ (PAR)
PALYNZIQ¹ (PAR)	BNP	Phenylketonuria treatment - agents	KUVAN¹
RHOPRESSA (PAR)	BP	Glaucoma	latanoprost, timolol, brimonidine
SEGLUROMET (PAR)	BNP	Anti-Diabetic	SYNJARDY/-XR, XIGDUO XR
SOLOSEC (PAR)	BNP	Amebicides / Bacterial Vaginosis	clindamycin, metronidazole
STEGLATRO (PAR)	BNP	Anti-Diabetic	FARXIGA, JARDIANCE
STEGLUJAN (PAR)	BNP	Anti-Diabetic	GLYXAMBI, QTERN
SYMDEKO¹ (PAR)	BP	Cystic Fibrosis	KALYDECO (PAR), ORKAMBI (PAR)
TAVALISSE¹ (PAR)	BNP	Hemataologic	corticosteroids

Products Changing Tier Status

Effective January 1, 2019

Brand Name	Current Tier	New Tier	Preferred Alternatives
Anti-Diabetics: JENTADUETO/-XR (PAR) TRADJENTA (PAR)	BP	BNP	alogliptin, alogliptin/metformin, JANUMET (sitagliptin /-XR (sitagliptin/metformin)
Anti-Spasmodic; Urinary: GELNIQUE (PAR)	BP	BNP	oxybutynin, tolterodine
PCSK9 Agents: PRALUENT (PAR)	BP	BNP	REPATHA (PAR)

Brand Name

Current Tier

New Tier

Preferred Alternatives

Anti-Diabetics:

JENTADUETO/-XR (PAR) TRADJENTA (PAR)

BP

BNP

alogliptin,

alogliptin/metformin,

JANUMET (sitagliptin /-XR (sitagliptin/metformin)

Anti-Spasmodic; Urinary: GELNIQUE (PAR)

BP

BNP

oxybutynin, tolterodine

PCSK9 Agents: PRALUENT (PAR)

BP

BNP

REPATHA (PAR)

Prior Authorization (PAR) Program

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

Effective Immediately

AIMOVIG¹ (PAR)
BIKTARVY (PAR)
DOPTELET¹ (PAR)
ERLEADA¹ (PAR)

LUCEMYRA (PAR)
OLUMIANT¹ (PAR)
PALYNZIQ¹ (PAR)
RHOPRESSA (PAR)

SEGLUROMET (PAR)
SOLOSEC (PAR)
STEGLATRO (PAR)

STEGLUJAN (PAR)
SYMDEKO¹ (PAR)
TAVALISSE¹ (PAR)

The following medications, effective January 1, 2019 for Open/Closed Formulary, have been added to the Prior Authorization (PAR) Program:

Effective January 1, 2019

ACLOVATE CREAM, OINTMENT
ALCORTIN A
ALEVICYN
ALOQUIN
ALVESCO
APEXICON E CREAM, OINTMENT
ARISTOCORT A OINTMENT
BENSAL HP
BETAPACE/-AF
BONJESTA
CAFERGOT
CARNITOR/-SF
CLOBEX LOTION, SHAMPOO, SPRAY
CLODERM CREAM
COLAZAL
CORDRAN CREAM, LOTION, OINTMENT
CRINONE
CUTIVATE CREAM, LOTION, OINTMENT
DANTRIUM

DERMATOP CREAM, OINTMENT
DERMTEX HC SPRAY
DESONATE GEL
DESOWEN CREAM, LOTION
DEXPAK
DIPROLENE AF
CREAM
DIPROLENE LOTION
DIPROLENE OINTMENT
DUTOPROL
DYRENIUM
E.E.S. GRANULES
ERYPED
ELOCON CREAM, LOTION, OINTMENT
FEXMID
FLUNISOLIDE NASAL
HALOG SOLN
IMPOYZ CREAM
INDOCIN
JENTADUETO/-XR
KENALOG AER SPRAY
KENALOG OINTMENT
LANOXIN

LIDEX CREAM
LOCOID CREAM, LIPO CREAM, LOTION, OINTMENT, SOLN
LORZONE
LUXIQ FOAM AEROSOL
LYRICA CR
MACRODANTIN
MIACALCIN
INJECTION, NASAL SPRAY
MILLIPRED
MINOCIN
MOMETASONE NASAL
NILANDRON
NOVACORT
OLUX FOAM,
AEROSOL
PANDEL CRE 0.1%
PENECORT SOL 1%
PRED FORTE
OMNIPRED
PSORCON CREAM, E
OINTMENT
QUDEXY
RIMSO-50
ROBAXIN
ROBAXIN-750

SERNIVO SPRAY
SOMA
SPRIX
SUMATRIPTAN/NAPROXEN
SYNALAR CREAM, OINTMENT, SOLN,-HP CREAM
TEMOVATE CREAM, E-CREAM EMOLLIENT, GEL OINTMENT
TEXACORT SOLN
TROKENDI
TOPICORT CREAM, GEL, OINTMENT, SPRAY
TOPIRAMATE XR
TRADJENTA
TRIANEX OINTMENT
ULTRAVATE CREAM, LOTION, OINTMENT
UROXATRAL
VANOS CREAM
VERDESO AEROSOL
WESTCORT CREAM, OINTMENT
ZANAFLEX
ZONEGRAN

Drugs Not Covered

The following medications will be removed from the Pharmacy Benefit:

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

DESMPORESSIN ACETATE INJ
DIHYDROERGOTAMINE MESY INJ
ELIGARD
HALDOL DECONATE

HYDROXYZINE HCL (IM)
KALBITOR
KETOROLAC (IM)
LURON DEPOT (PEDIATRIC)

MOZOBIL
REMODULIN
SANDOSTATIN LAR

SOMATULINE DEPOT
STELARA VIAL
V-GO

Quantity Level Limits Program

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

Effective January 1, 2019

Drug Class/Drug	Quantity Limits (per 30 days)
ARNUITY ELLIPTA INHALER	1 inhaler
ZYPITAMAG	30 units

Muscle Relaxants² (Initial Quantity Limitations per 90 Days)

Drug Class/Drug	Quantity Limits (per 90 days)
AMRIX	21 units
BACLOFEN	120 units
CARISOPRODOL	84 units
CHLORZOXAZONE	84 units
CYCLOBENZAPRINE	63 units
DANTRIUM	90 units
DANTROLENE	90 units
FEXI MID	63 units
LORZONE	84 units
METHOCARBAMOL	84 units
ORPHENADRINE	42 units
ROBAXIN	180 units
ROBAXIN-750	132 units
SKELAXIN 400MG	168 units
SKELAXIN, METAXALL, metaxalone	84 units
SOMA COMPOUND (CARISOPRODOL/ASA)	168 units
SOMA COMPOUND WITH CODEINE	168 units
SOMA (CARISOPRODOL)	84 units
TIZANIDINE	126 units
ZANAFLEX	126 units

Topical Steriods² (Initial Quantity Limitations per 30 Days)

Drug Class/Drug	Quantity Limits (per 30 days)
ACLOVATE (ALCLOMETASONE) CREAM, OINTMENT	120 units
AMCINONIDE	120 units
APEXICON E (DIFLORASONE DIACETATE)	120 units
BETAMETHASONE DIPR (UNAUG CREAM, LOTION/AUG CREAM, GEL, LOTION, OINTMENT)	120 units
BETAMETHASONE VAL CREAM, LOTION, OINTMENT	120 units
CLOBEX (CLOBETASOL) LOTION	120 units
CLODERM (CLOCORTOLONE) CREAM	120 units
CORDRAN (FLURANDRENOLIDE) CREAM, LOTION, OINTMENT	120 units
CUTIVATE (FLUTICASONE) CREAM, LOTION	120 units
DERMATOP (PREDNICARBATE) CREAM, OINTMENT	120 units
DESONATE (DESONIDE) GEL	120 units
DESONIDE CREAM, LOTION, OINTMENT	120 units
DESOWEN (DESONIDE) CREAM, LOTION	120 units
DIFLORASONE	120 units
DIPROLENE (BETAMETHASONE DIPROPIONATE AUG) LOTION, OINTMENT	120 units
DIPROLENE AF (BETAMETHASONE DIPROPIONATE AUGMENTED) CREAM	120 units
ELOCON (MOMETASONE) CREAM, LOTION, OINTMENT	120 units
FLUOCINOLONE CREAM, OINTMENT	120 units
FLUOCINONIDE CREAM, OINTMENT	120 units
FLUTICASONE CREAM, LOTION, OINTMENT	120 units
HALOG (HALCINONIDE) CREAM, OINTMENT	120 units
HYDROCORTISONE VALERATE	120 units
IMPOYZ (CLOBETASOL) CREAM	120 units
LOCOID (HYDROCORTISONE BUTYRATE) CREAM, LIPOCREAM, LOTION, OINTMENT	120 units
LOKARA (DESONIDE)	120 units
NOLIX (FLURANDRENOLIDE) LOTION	120 units
PANDEL (HYDROCORTISONE PROBUTATE) CREAM	120 units
PSORCON (DIFLORASONE) CREAM	120 units
SYNLAR (FLUOCINOLONE) CREAM, OINTMENT	120 units
TEMOVATE (CLOBETASOL) CREAM, GEL, OINTMENT	120 units
TEMOVATE E (CLOBETASOL EMOLLIENT BASE) CREAM	120 units
TOPICORT (DESOXIMETASONE) CREAM GEL, OINTMENT	120 units
TRIANEX (TRIAMCINOLONE)	120 units
TRIDESILON (DESONIDE CREAM	120 units
ULTRAVATE (HALOBETASOL) CREAM, LOTION, OINTMENT	120 units
VANOS (FLUOCINONIDE) CREAM	120 units
WESTCORT (HYDROCORTISONE VALERATE)	120 units

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.

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Open/Closed Quarterly Formulary Updates

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Pharmacy Management Program Update

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Newly Marketed Drugs

Brand Name

Commercial (Open/Closed)

Indication

Preferred Alternatives

Products Changing Tier Status

Brand Name

Current Tier

New Tier

Preferred Alternatives

Prior Authorization (PAR) Program

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

The following medications, effective January 1, 2019 for Open/Closed Formulary, have been added to the Prior Authorization (PAR) Program:

Drugs Not Covered

The following medications will be removed from the Pharmacy Benefit:

Quantity Level Limits Program

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

Drug Class/Drug

Quantity Limits(per 30 days)

Muscle Relaxants2 (Initial Quantity Limitations per 90 Days)

Drug Class/Drug

Quantity Limits (per 90 days)

Topical Steriods2 (Initial Quantity Limitations per 30 Days)

Drug Class/Drug

Quantity Limits (per 30 days)

Plain Page Single Section DnD

Commercial
(Open/Closed)

Quantity Limits
(per 30 days)

Muscle Relaxants² (Initial Quantity Limitations per 90 Days)

Quantity Limits
(per 90 days)

Topical Steriods² (Initial Quantity Limitations per 30 Days)

Quantity Limits
(per 30 days)