Value and CHIP formulary update
(4th Quarter 2020 effective April 1, 2021)
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.
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
Prior Authorization (PAR) utilization management changes or updates
Effective April 1, 2021
The following medications have been either added to the Prior Authorization (PAR) program or updates have been made to existing Prior Authorization Programs.
Drug Class/Drug |
Target Drugs |
Androgens/Anabolic Steroids |
methyltestosterone, testosterone cypionate, testosterone enanthate, testosterone gel, testosterone solution Please refer to the formulary for the complete list of Androgen/Anabolic Steroids drugs. |
Atopic Dermatitis |
pimecrolimus, tacrolimus |
Atypical Antipsychotics, Long Acting |
aripiprazole, olanzapine, paliperidone, risperidone |
Atypical Antipsychotics, Short Acting |
aripiprazole, cariprazine , clozapine, OTEZLA1, REXULTI Please refer to the formulary for the complete list of Atypical Antipsychotic drugs. |
Biological Immunomodulators |
adalimumab, ENBREL1, HUMIRA, KEVZARA, XENLANZ1 Please refer to the formulary for the complete list of Biological Immunomodulator drugs. |
Diclofenac Gel |
diclofenac gel, FLUOROURACIL CREAM, imiquimod cream |
Genitoury Agents |
cysteamine bitrate1 |
Growth Hormone |
NORDITROPIN FLEXPRO |
Multiple Sclerosis |
|
Ophthalmic Prostaglandins |
LUMIGAN, latanoprost, travoprost, XALATAN, ZIOPTAN Please refer to the formulary for the complete list of Ophthalmic Prostaglandins drugs. |
Oral Tetracycline |
doxycycline, minocycline |
Parathyroid Hormone Analog Osteoporosis |
NATPARA1 |
1Indicates specialty medication
2Split Fill
Impacted members will be notified prior to change.