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For Health Professionals

Formulary Instructions

The Drug Formulary Index


THE FORMULARY

The Formulary represents the cornerstone of drug therapy quality assurance and cost containment efforts. Capital BlueCross has created the Formulary to give members access to quality, affordable medications and to provide physicians with a reference list of preferred medications for cost-effective prescribing.

The Capital BlueCross Formulary was developed by the Capital BlueCross Pharmacy and Therapeutics Committee (P&T Committee). This committee, composed of practicing physicians from various medical specialties, practicing pharmacists, and other health care providers, reviewed the medications in all therapeutic categories based on safety, effectiveness, and cost and selected the most cost-effective agent(s) in each class. Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers. As you use the Formulary, we invite your suggestions to improve the format or content. A provider may request a reconsideration of tier status for a medication on the Capital BlueCross Formulary by writing a letter indicating the significant advantages of the drug product over current preferred medications and mailing it to the address below. This request will be reviewed by the Capital BlueCross P&T Committee.

  • Pharmacy Services
  • Capital BlueCross P&T Committee
  • P.O. Box 773735
  • Harrisburg, PA 17177-3735

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HOW TO USE THE FORMULARY

The Formulary lists the most commonly prescribed medications by therapeutic class. Medications listed in bold lower case print indicate generic medications. Drugs listed in all UPPER CASE PRINT indicate brand name medications. For each drug listed, it is indicated whether that drug falls in the Generic category, Preferred Brand category or Non-Preferred Brand category. These categories are defined as follows:

  • Generics (G): Drugs that contain the same active ingredient(s) as their corresponding brand name drug and have been approved by the Food and Drug Administration (FDA) for therapeutic equivalency to their brand name product.
  • Preferred Brands (P): Drugs that have been reviewed by the Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost.
  • Non-Preferred Brands (NP): Drugs that have been reviewed by the Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative preferred brands or their generic equivalents.

To help maximize the pharmacy benefit, preferred formulary alternatives where applicable are provided. Please note that the information provided is not intended to substitute the physician's independent medical judgment based on the member's specific needs. The Formulary serves as a reference guide suitable for various prescription drug programs with applicable single-, two-, or three-tiered copayment or coinsurance benefit plan designs. As determined by the member's benefit plan, the member may share more of the cost for brand name drugs, especially non-preferred brand drugs. Despite formulary listing, please note that some drugs are excluded by benefit design and therefore are not covered (see Benefit Exclusions/Limitations below). Newly released brand name drugs are placed in the nonpreferred category until the P&T Committee reviews the medication for final tier placement. Multi-source brand name drugs that have an available generic equivalent, deemed suitable for substitution by the P&T Committee, are placed in the non-preferred category. The Formulary applies only to prescription medications dispensed to outpatients by participating pharmacies. The Formulary does not apply to inpatient medications or to medication obtained from and/or administered by a physician or a home health agency.

At the end of the Formulary is an index listing formulary medications alphabetically with the corresponding chapter number where other medications in that class can be found. While Capital BlueCross strives to provide prompt notice of changes and updates, our Formulary, as well as our medication management programs such as prior authorization and quantity level limits, are subject to change. Visit our pharmacy benefit manager website for current information. If preferred, contact our pharmacy benefit manager via phone at the number listed below.

  • CVS Caremark, Inc.
    800.585.5794 (for provider and member inquiries)

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RELATIVE COST INDEX

Most drug listings are preceded by a "relative cost index," represented by a series of one to five dollar signs ($) or five exclamation points (!!!!!). This provides comparative cost to the health plan for medications within selected therapeutic categories. The relative cost index is as follows:

 

$

$$

$$$

$$$$

$$$$$

!!!!!

product A least expensive

product B more expensive than "A"

product C more expensive than "B" or "A"

product D more expensive than "C", "B", or "A"

product E more expensive than "D", "C", "B", or "A"

product F is substantially more expensive than "A-E"

 

Cost ranges reflect cost per day of therapy or cost per prescription based on prevalent dosing patterns as indicated. The relative cost index does not necessarily reflect the actual cost that may be incurred by non-health plan members due, in part, to contract pricing negotiated by the health plan to manage overall pharmacy costs.

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GENERIC DRUG SUBSTITUTION POLICY

Generic drug substitution is permitted if the FDA has determined the generic drug to be equivalent to the brand-name product. Depending on the member's prescription drug benefit plan, one of the following generic substitution policies will be applied. The member's financial responsibility for a brand-name medication when a generic equivalent is available will vary depending on the member's generic substitution program.

  • For members with a "mandatory" generic substitution policy, if the physician indicates "Dispense As Written" (DAW) or if a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost (ancillary charge) in addition to the member's applicable brand copayment, up to the original cost of the brand-name medication.
  • For members with a "restricted" generic substitution policy, if a member requests a brandname product when a generic is available, the member is responsible for the cost difference between the brand name medication and its generic cost in addition to the member's applicable brand copayment, up to the original cost of the brand-name medication. If the physician indicates DAW, then the member pays the applicable copayment for the brand product and is not required to pay the ancillary charge.
  • For members with a "voluntary" generic substitution policy, the member will pay only the applicable copayment for the brand product.

Capital BlueCross encourages generic substitution, when possible and appropriate, to help reduce the member's out-of-pocket expense, plus help contain the overall cost of the prescription drug benefit.

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NON-PRESCRIPTION MEDICATION (OTC) POLICY

Over-the-counter (OTC) products are not covered. In addition, if a prescription drug is available in the same active ingredient(s), identical strength and dosage form as an OTC product, the prescription product will not be covered. Physicians and pharmacists should guide and refer members to the OTC equivalent product.

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BENEFIT EXCLUSIONS / LIMITATIONS

Depending on the pharmacy benefit plans, some medications listed may not be covered for individual members based on benefit design purchased by the member or employer group.

Examples of contractual exclusions include, but are not limited to:

  • Appetite suppressants
  • Infertility medications
  • Drugs used for cosmetic purposes (wrinkles, hair loss, etc.)
  • Erectile dysfunction medications
  • Smoking cessation products
  • Oral contraceptives
  • Injectable drugs (Insulin is covered for all members)
  • Allergy serums
  • Experimental and Investigational (including off-label use) use
  • Some types of vitamins (non-prenatal)

Some members' employer groups may choose to purchase additional coverage for these drug classes, while other employer groups may choose to completely carve out the prescription drug benefit from their Capital BlueCross health benefit plan.

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PRIOR AUTHORIZATION PROGRAM

Most pharmacy benefit plans include the prior authorization program. Prior authorization helps encourage the appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met.

Drugs requiring prior authorization are designated in the Formulary by "PAR" (Prior Authorization Required) after the drug name. These drugs require prior authorization before members can obtain them as a covered benefit. Drugs requiring prior authorization are subject to change. Please check your provider manual, contact Capital BlueCross or contact our pharmacy benefit manager for a current list of drugs requiring prior authorization and for their coverage criteria. If prior authorization is required, the physician (or his/her representative) or pharmacist must call or fax the request with supporting clinical information to Capital BlueCross's pharmacy benefit manager:

  • CVS Caremark
  • Telephone: 800.585.5794

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QUANTITY LEVEL LIMITS

Some drug products may be subject to quantity level limits based on the drug manufacturer's packaging size or adopted clinical guidelines. These drugs are designated in the Formulary by "QL" (Quantity Limits) after the drug name. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity level limits are subject to change. Please check your provider manual, contact Capital BlueCross or contact our pharmacy benefit manager for a current list of drugs and their quantity limit criteria.

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The information provided is intended to establish a guideline to help promote Formulary compliance, but it is in no way to be considered all-encompassing. The Formulary is also in no way meant to interfere with the physician's independent medical judgment based on specific needs of the patients.