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.

¹Indicates specialty medication

²Split Fill

Impacted members will be notified prior to change.