Blue Cross and Blue Shield of Illinois

 

 

March 29, 2013

Pharmacy Program Changes Effective April 1, 2013

Standard Formulary Changes
Based on Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions will be made to the standard Blue Cross and Blue Shield of Illinois (BCBSIL) formulary effective April 1, 2013.

Standard Formulary Additions

Brand Medications Being Added to the Formulary Effective April 1, 2013

Formulary Brand*


Drug Class/Condition Used For

Delzicol

Gastrointestinal

Nuedexta

Central Nervous System

* Third-party brand names are the property of their respective owners.

Standard Formulary Deletion

Brand Medications Moving to a Higher Out-of-Pocket Payment Level Effective April 1, 2013

Non-Formulary Brand1


Condition Used For


Generic Formulary
Alternative(s)2


Formulary Brand Alternative(s)1,2

Ortho Tri-Cyclen Lo

Prevention of Pregnancy

All generic oral birth control (examples: Caziant, Cesia, Velivet)

N/A

1Third-party brand names are the property of their respective owners.
2 This list is not all-inclusive. Other medications may be available in this drug class.

Targeted mailings were sent to members affected by the formulary deletion per our usual process of notifying members at least 60 days prior to implementation. 

Standard Formulary Dispensing Limit Changes
BCBSIL’s standard prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on FDA-approved dosage regimens and product labeling.

Effective April 1, 2013, dispensing limits will be added for the following drugs:     
Drug Class and Medication*

Dispensing Limit

Bone Health

Alendronate 40 mg

30 tabs/30 days

Atelvia (risedronate delayed-release)

4 tabs/28 days

Binosto (alendronate)

4 tabs/28 days

Male Hormones

Androgel 1.62%, 1.25 g (testosterone)

30 packets/30 days

Androgel 1.62%, 2.5 g (testosterone)

60 packets/30 days

Pain Relief

Exalgo (hydromorphone)

60 tabs/30 days

Ulcer/GERD

Prilosec 2.5 mg, 10 mg oral suspension (omeprazole)

60 packets/30 days

Viral Infections

Aptivus 100 mg/mL oral solution (tipranavir)

380 mL/30 days

Aptivus 250 mg (tipranavir)

120 caps/30 days

Atripla (efavirenz/emtricitabine/tenofovir)

30 tabs/30 days

Combivir (lamivudine/zidovudine)

60 tabs/30 days

Complera (emtricitabine/rilpivirine/tenofovir)

30 tabs/30 days

Crixivan 100 mg (indinavir)

90 caps/30 days

Crixivan 200 mg (indinavir)

270 caps/30 days

Crixivan 400 mg (indinavir)

180 caps/30 days

Edurant (rilpivirine)

30 tabs/30 days

Emtriva 10 mg/mL oral solution (emtricitabine)

720 mL/30 days

Emtriva 200 mg (emtricitabine)

30 caps/30 days

Epivir 10 mg/10 mL oral solution (lamivudine)

960 mL/30 days

Epivir 150 mg, 300 mg (lamivudine)

30 tabs/30 days

Epzicom (lamivudine/abacavir)

30 tabs/30 days

Fuzeon (enfuvirtide)

60 vials/30 days

Intelence 25 mg (etravirine)

120 tabs/30 days

Intelence 100 mg, 200 mg (etravirine)

60 tabs/30 days

Invirase 200 mg (saquinavir)

300 caps/30 days

Invirase 500 mg (saquinavir)

120 tabs/30 days

Isentress 25 mg, 100 mg chewable (raltegravir)

180 tabs/30 days

Isentress 400 mg (raltegravir)

60 tabs/30 days

Kaletra 80 mg/20 mg/mL oral solution (lopinavir/ritonavir)

320 mL/30 days

Kaletra 100mg/25 mg (lopinavir/ritonavir)

300 tabs/30 days

Kaletra 200 mg/50 mg (lopinavir/ritonavir)

120 tabs/30 days

Lexiva 50 mg/mL oral suspension (fosamprenavir)

1,800 mL/30 days

Lexiva 700 mg (fosamprenavir)

120 tabs/30 days

Norvir 80 mg/mL oral solution (ritonavir)

480 mL/30 days

Norvir 100 mg (ritonavir)

360 caps/30 days

Norvir 100 mg (ritonavir)

360 tabs/30 days

Prezista 75 mg (darunavir)

300 tabs/30 days

Prezista 150 mg (darunavir)

180 tabs/30 days

Prezista 400 mg, 600 mg (darunavir)

60 tabs/30 days

Prezista 800 mg (darunavir)

30 tabs/30 days

Rescriptor 100 mg (delavirdine)

90 tabs/30 days

Rescriptor 200 mg (delavirdine)

180 tabs/30 days

Reyataz 100 mg, 150 mg, 300 mg (atazanavir)

30 caps/30 days

Reyataz 200 mg (atazanavir)

60 caps/30 days

Selzentry 150 mg (maraviroc)

60 tabs/30 days

Selzentry 300 mg (maraviroc)

120 tabs/30 days

Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir)

30 tabs/30 days

Sustiva 50 mg (efavirenz)

90 caps/30 days

Sustiva 200 mg (efavirenz)

60 caps/30 days

Sustiva 600 mg (efavirenz)

30 tabs/30 days

Trizivir (abacavir/lamivudine/zidovudine)

60 tabs/30 days

Truvada (emtricitabine/tenofovir)

30 tabs/30 days

Videx 10 mg/mL oral suspension (didanosine)

1,200 mL/30 days

Videx 125 mg, 200 mg, 250 mg, 400 mg (didanosine)

30 caps/30 days

Viracept 250 mg (nelfinavir)

270 tabs/30 days

Viracept 625 mg (nelfinavir)

120 tabs/30 days

Viramune 50 mg/5 mL oral suspension (nevirapine)

1,200 mL/30 days

Viramune 200 mg (nevirapine)

60 tabs/30 days

Viramune XR (nevirapine extended-release)

30 tabs/30 days

Viread 40 mg/1 g oral powder for suspension (tenofovir)

240 g/30 days

Viread 150 mg, 200 mg, 250 mg, 300 mg (tenofovir)

30 tabs/30 days

Zerit 1 mg/mL oral solution (stavudine)

2,400 mL/30 days

Zerit 15 mg, 20 mg, 30 mg, 40 mg (stavudine)

60 caps/30 days

Ziagen 20 mg/mL oral solution (abacavir)

960 mL/30 days

Ziagen 300 mg (abacavir)

60 tabs/30 days

zidovudine 50 mg/5 mL syrup

1,920 mL/30 days

zidovudine 100 mg

180 caps/30 days

zidovudine 300 mg

60 tabs/30 days

* Third-party brand names are the property of their respective owners.

For the most up-to-date list of drug dispensing limits, visit bcbsil.com.
 
Targeted mailings were sent to members affected by changes in dispensing limits per our usual process of notifying members at least 60 days prior to implementation. 

If you have questions regarding these changes, please contact your BCBSIL representative.

 


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an Independent Licensee of the Blue Cross and Blue Shield Association.