Value and CHIP formulary update

(2nd and 3rd quarter 2020 effective January 1, 2021)

The Capital Blue Cross 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.

A Value formulary provides access to generic, brand preferred and select brand non-preferred medications. Under a 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.

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

Quantity Level Limit (QLL) Program

Effective January 1, 2021

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

Drug name(s)

Quantity limits 
(per 30 days or as specified)

FREESTYLE LIBRE 2 READER

1 Quantity/365 Days

FREESTYLE LIBRE 2 SENSOR

2 Quantity/28 Days

1Indicates specialty medication.

Impacted members will be notified prior to change.

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