June 14, 2013 Pharmacy Program Changes Effective July 1, 2013 Standard Formulary Changes Based on Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions are being made to the standard Blue Cross and Blue Shield of Illinois (BCBSIL) formulary effective July 1, 2013. Standard Formulary Additions Brand Medications Being Added to the Formulary Effective July 1, 2013 Formulary Brand* | Drug Class/ Condition Used For | Advate | Hemophilia | Alphanate | Hemophilia | AlphaNine SD | Hemophilia | Bebulin | Hemophilia | Bebulin VH | Hemophilia | BeneFIX | Hemophilia | Corifact | Hemophilia | FEIBA NF | Hemophilia | FEIBA VH | Hemophilia | Helixate FS | Hemophilia | Hemophil M | Hemophilia | Humate-P | Hemophilia | Koate-DVI | Hemophilia | Kogenate FS | Hemophilia | Kogenate FS with BIO-SET | Hemophilia | Letairis | Pulmonary Arterial Hypertension | Monoclate-P | Hemophilia | Mononine | Hemophilia | NovoSeven RT | Hemophilia | Potassium Citrate | Kidney Function | Profilnine SD | Hemophilia | Recombinate | Hemophilia | Wilate | Hemophilia | Xarelto | Anticoagulant | Xyntha | Hemophilia | Xyntha Solofuse | Hemophilia | *Third-party brand names are the property of their respective owner. Standard Formulary Deletions Brand Medications Moving to a Higher Out-of-Pocket Payment Level July 1, 2013 Non-Formulary Brand* | Condition Used For | Generic Formulary Alternative(s) | Formulary Brand Alternative(s)* | Prevpac | Ulcer | N/A | N/A | Pylera | Ulcer | N/A | N/A | *Third-party brand names are the property of their respective owner. N/A = Not available 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 July 1, 2013, dispensing limits will be added for the following drugs: Drug Class and Medications*
| Dispensing Limit | Blood Modifying Drugs | Eliquis (apixaban) | 60 tabs/30 days | Opioid Dependence | Suboxone (buprenorphine/naloxone) | 60 films or tabs/30 days | Subutex (buprenorphine) | 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. Standard Utilization Management Program Package Changes Prior Authorization (PA) Addition Effective July 1, 2013, the drug category listed in the table below will be added to the PA program for all standard benefit plans upon renewal. Drug Category | Targeted Medications* | Opioid Dependence | Suboxone, Subutex | *Third-party brand names are the property of their respective owners. Targeted mailings were sent to members affected by this change per our usual process of notifying members at least 60 days prior to implementation. |