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
(G) = Generic 
(BP) = Brand Preferred
(BNP) = Brand Non-Preferred
(NC) = Not Covered
(NF) = Non-Formulary

Newly Marketed Drugs

Effective Immediately

Brand Name

Commercial
(Open/Closed)

Indication

Preferred Alternatives

AIMOVIG*
(PAR, QLL)

BNP/NF

Migraine

topiramate, atenolol, venlafaxine

BIKTARVY (PAR)

BNP

Anti-Retroviral

STRIBILD

DOPTELET* (PAR)

BP

Thrombocytopenia

platelet transfusions

ERLEADA* (PAR)

BP

Anti-neoplastic

XTANDI* (PAR)

LUCEMYRA (PAR)

BNP

Agents for narcotic
withdrawal

clonidine, gabapentin

OLUMIANT* (PAR)

BNP

Anti-Rheumatic

ENBREL* (PAR) HUMIRA* (PAR)

PALYNZIQ* (PAR)

BNP

Phenylketonuria treatment -
agents

KUVAN*

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

SYMDEKO* (PAR)

BP

Cystic Fibrosis

KALYDECO (PAR), ORKAMBI (PAR)

TAVALISSE* (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)

Prior Authorization (PAR) Program

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

Effective Immediately

  • AIMOVIG* (PAR)
  • BIKTARVY (PAR)
  • DOPTELET* (PAR)
  • ERLEADA* (PAR)
  • LUCEMYRA (PAR)
  • OLUMIANT* (PAR)
  • PALYNZIQ* (PAR)
  • RHOPRESSA (PAR)
  • SEGLUROMET (PAR)
  • SOLOSEC (PAR)
  • STEGLATRO (PAR)
  • STEGLUJAN (PAR)
  • SYMDEKO* (PAR)
  • TAVALISSE* (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 Relaxants** (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 Steriods** (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.

*Indicates Specialty Medication

**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.

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.