Value and CHIP formulary update

(2nd and 3rd quarter 2020 effective January 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

Quantity Level Limit (QLL) Program

Effective January 1, 2021

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