Selectively Closed Formulary Update

4th quarter 2018 and 1st quarter 2019

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.

The Selectively Closed formulary1 serves as a reference for Exchange/Marketplace prescription drug benefit designs.

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

Products Changing Formulary Status

Effective January 1, 2019

The following chart indicates medications that have changed formulary status.

Brand Name

Current Status

New Status

Preferred Alternatives

XELJANZ2 / XR (PAR)
BNP
BP
N/A
VRAYLAR
BNP
BP
N/A


Prior Authorization (PAR) Program

Effective January 1, 2019

To obtain Prior Authorization, your physician or pharmacist should call or fax a request with supporting clinical information to the CVS/caremark 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 or by viewing the Preauthorization Requirements.

Brand Name

Formulary Status

Indication

Preferred Alternatives

ENBREL2 MINI
BP
Anti-inflammatory
N/A
PROCRIT2
BP
Erythropoiesis-Stimulating Agents (ESAS)
N/A
HUMIRA2 (PAR)
BP
Anti-inflammatory
N/A
methyltestosterone
GNP
Androgen
N/A
testosterone cypionate
GNP
Androgen
N/A
testosterone enanthate
GNP
Androgen
N/A
ZARXIO2
BP
Hematologic
N/A


Quantity Level Limit (QLL) Program

Effective July 1, 2019

Drug Class/Drug


Quality Limits (30 Days)


alclometasone dipropionate cream 0.05%
120 units
alclometasone dipropionate oint 0.05%
120 units
amcinonide lotion 0.1%
120 units
betamethasone dipropionate cream 0.05%
120 units
betamethasone dipropionate lotion 0.05%
120 units
betamethasone dipropionate oint 0.05%
120 units
betamethasone dipropionate augmented cream 0.05%
120 units
betamethasone dipropionate augmented gel 0.05%
120 units
betamethasone dipropionate augmented lotion 0.05%
120 units
betamethasone dipropionate augmented oint 0.05%
120 units
betamethasone valerate cream 0.1% (base equivalent)
120 units
betamethasone valerate lotion 0.1% (base equivalent)
120 units
betamethasone valerate oint 0.1% (base equivalent)
120 units
carisoprodol 250mg, 350mg
28 units
clobetasol propionate cream 0.05%
120 units
clobetasol propionate oint 0.05%
120 units
clocortolone pivalate cream 0.1%
120 units
desonide cream 0.05%
120 units
desonide lotion 0.05%
120 units
desonide oint 0.05%
120 units
desoximetasone cream 0.05%
120 units
desoximetasone cream 0.25%
120 units
desoximetasone gel 0.05%
120 units
desoximetasone oint 0.05%
120 units
fluocinolone acetonide oint 0.025%
120 units
diflorasone diacetate cream 0.05%
120 units
diflorasone diacetate oint 0.05%
120 units
fluocinolone acetonide cream 0.01%
120 units
fluocinolone acetonide cream 0.025%
120 units
fluocinolone acetonide oint 0.025%
120 units
fluocinonide cream 0.05%
120 units
fluocinonide gel 0.05%
120 units
fluocinonide oint 0.05%
120 units
fluocinonide emulsified base cream 0.05%
120 units
flurandrenolide lotion 0.05%
120 units
fluticasone propionate cream 0.05%
120 units
fluticasone propionate oint 0.005%
120 units
halcinonide cream 0.1%
120 units
halcinonide oint 0.1%
120 units
halobetasol propionate cream 0.05%
120 units
halobetasol propionate oint 0.05%
120 units
mometasone furoate cream 0.1%
120 units
mometasone furoate oint 0.1%
120 units
prednicarbate cream 0.1%
120 units
prednicarbate oint 0.1%
120 units


1A Selectively Closed formulary provides access to generic, brand preferred and select brand nonpreferred medications. Under a Selectively Closed formulary, only select brand non-preferred drugs (non-formulary drugs) are covered unless approved via a Non-Formulary Consideration Process. The provider may request that coverage be granted when medically necessary. The Non-Formulary Consideration Process may require the trial and failure of 2 formulary alternatives (if 2 are available) prior to approval of the non-formulary medication. Approvals will be member-and drug-specific. Each unique non-formulary drug exception must be reviewed and approved separately.

2Indicates specialty medication.

3Impacted members will be notified prior to change.