Value and CHIP Formulary Update

(4th Quarter 2019 and 1st Quarter 2020 effective July 1, 2020)

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

Effective July 1, 2020

Brand Name

Current Status

New Status

Preferred Alternatives

XELJANZ1 / XR (PAR) BNP BP N/A
LATUDA BNP BP N/A
VRAYLAR BNP BP N/A

Effective July 1, 2020

Brand Name

Formulary Status

Indication

Preferred Alternatives

ANDRODERM BNP Androgen N/A
ANDROGEL BNP Androgen N/A
ANDROXY BNP Androgen N/A
AXIRON BNP Androgen N/A
EPOGEN1 /PROCRIT1 /RETACRIT1 N/A Erythropoiesis-Stimulating Agents (ESAS) N/A
FORTESTA BNP Androgen N/A
HUMIRA1 (PAR) BP DMARDS N/A
HYCAMTIN1 (PAR) BNP Antineoplastic N/A
methyltestosterone GNP Androgen N/A
NATESTO BNP Androgen N/A
NUPLAZID1 (PAR) BNP Antipsychotics N/A
STRIANT BNP Androgen N/A
TESTIM BNP Androgen N/A
TESTONE CIK BNP Androgen N/A
testosterone cypionate GNP Androgen N/A
testosterone enanthate GNP Androgen N/A
testred GNP Androgen N/A
virilon GNP Androgen N/A
VOGELXO BNP Androgen N/A

1Indicates specialty medication.

Impacted members will be notified prior to change.