Value Formulary Update

2nd and 3rd Quarter 2019 effective Jan 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.

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) Program

Effective January 1, 2020

Drug Class/Drug

Drug Class/Drug

ATTENTION DEFICIT HYPERACTIVITY DISORDER CORLANOR
EPINEPHRINE GROWTH HORMONE
HEREDITARY ANGIOEDEMA PRODUCTS MULTIPLE SCLEROSIS AGENTS
LYRICA SELF ADMINISTERED ONCOLOGY
QBREXZA VMAT2 AGENTS (EXAMPLE: AUSTEDO, INGREZZA,XENAZINE)
TOPICAL CORTICOSTEROID  

Quantity Level Limit (QLL) Program

Effective January 1, 2020

Drug Class/Drug

Quality Limits (30 Days)

Addyi (PAR) 100mg = 1 tab/day
Berinert1 (PAR) 500 IU/10ml = 10 vials/30 days
Cinryze1 (PAR) 500 IU/10ml = 20 vials/30 days
Corlanor (PAR) 5mg = 2 tabs/day 7.5mg = 2 tabs/day 5mg/5ml = 20ml/day
Esbriet1 (PAR) 267mg = 6 caps/day 267mg = 6 tabs/day 801mg = 3 tabs/day
Jublia (PAR) 4ml
Kalydeco1 (PAR) 25mg = 2 packets/day
Lyrica CR (PAR) 82.5mg = 1 tab/day 165mg = 1 tab/day 330mg = 2 tabs/day
Relenza (QLL) 1 Diskhaler
Restasis multidose (PAR) 1 bottle/30 days
Restasis vial (PAR) 2 vials/day
Nuplazid1 (PAR) 10mg = 1 tab/day 17mg = 2 tabs/day 34mg = 1 tab/day

1Indicates specialty medication.

Impacted members will be notified prior to change.