Jan. 8, 2015 Pharmacy Program Updates: Pharmacy Program Changes Effective Jan. 1, 2015 Standard Drug List (Formulary) Changes
Based on the availability of new prescription medications and the Prime National Pharmacy and Therapeutics Committee review of changes in the pharmaceutical market, some revisions were made to the Blue Cross and Blue Shield of Oklahoma (BCBSOK) standard drug list effective Jan. 1, 2015. Brand Medications Added to the Drug List, Effective Jan. 1, 2015 Preferred Brand1 | Drug Class/Condition Used For | Invokana | Diabetes | Invokamet | Diabetes | Sivextro | Antibiotic | Purixan | Cancer | Spiriva Respimat | COPD | Plegridy | Multiple Sclerosis |
Brand Medications Moved to a Higher Out-of-Pocket Payment Level, Effective Jan. 1, 2015
Non-preferred Brand1,2 | Condition Used For | Generic Preferred Alternative(s)2 | Preferred Brand Alternative(s)1,2 | Lilly Brand of Insulins
(Humulin R, Humulin N, Humalog, Humalog 75/25, Humalog 50/50, Humulin 70/30) | Diabetes | N/A | Novo Brand of Insulins (Novolin R, Novolin N, Novolin 70/30, Novolog, Novolog 70/30) | Zithromax (Pak) 1 gm | Antibiotic | Azithromycin | N/A | Dispensing Limit Changes
The BCBSOK standard prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on U.S. Food and Drug Administration (FDA) approved dosage regimens and product labeling. Effective Jan. 1, 2015, dispensing limits were added for the following drugs: Drug Class and Medication1 | Product Strength | Dispensing Limit | Biologic | Stelara (ustekinumab) | 45 mg / 0.5 mL, 90 mg / 1 mL | 1 syringe per 84 days | Diabetes | Farxiga (dapagliflozin) | 5 mg, 10 mg tablet | 30 tablets per 30 days | Invokana (canagliflozin) | 100 mg, 300 mg tablet | 30 tablets per 30 days | Invokamet (canagliflozin/metformin) | 50 mg / 500 mg, 50 mg / 1000 mg, 150 mg / 500 mg, 150 mg / 1000 mg | 60 tablets per 30 days | Jardiance (empagliflozin) | 10 mg, 25 mg | 30 tablets per 30 days | Utilization Management Program Changes
Effective Jan. 1, 2015, several drug categories were added to the BCBSOK Prior Authorization (PA) program for all standard pharmacy benefit plans as those plans are renewed. Drug Categories Added to the PA Program, Effective Jan. 1, 2105 Drug Category | Targeted Medications1 | Insulin | Humalog, Humulin | Pulmonary Arterial Hypertension (PAH) | Adempas (riciguat) and
Orenitram (treprostinil) |
Specialty Medication Benefit Processing Changes
Effective Jan. 1, 2015, professional and ancillary electronic (837P transactions) and paper (CMS-1500) claims submitted for the specialty medications listed below may be considered for coverage under the member’s medical benefit, as these medications require administration by a health care professional. Prior to Jan. 1, 2015, these medications may have processed under the member’s pharmacy benefit. Depending on the member’s benefit plan, a request for prior authorization may be required for coverage consideration.
Examples of specialty medications to be covered under the member’s medical benefit1 Actemra | Hizentra | Trelstar Mixject | Vivitrol | Xolair | | Targeted mailings were sent to members affected by standard drug list deletions, dispensing limits and utilization management program changes per our usual process of member notification. Additionally, targeted mailings were sent to members affected by the specialty drug benefit changes. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of our website at bcbsok.com/provider. 1Third party brand names are the property of their respective owners
2These lists are not all inclusive. Other medications may be available in this drug class. Prime Therapeutics LLC is a pharmacy benefit management company. BCBSOK contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSOK, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider. |
