Value and CHIP formulary update

(4th Quarter 2020 effective April 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

(ST) = Step Therapy 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

Genitourinary Agents

cysteamine bitrate1

Growth Hormone

NORDITROPIN FLEXPRO

Multiple Sclerosis

AUBAGIO1 2, AVONEX1, BETASERON1

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.