Blue Cross and Blue Shield of Illinois

 

October 18, 2013

Pharmacy Program Changes Effective Jan. 1, 2014

Standard Formulary Dispensing Limit Changes
Blue Cross and Blue Shield of Illinois’ (BCBSIL) 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 Jan. 1, 2014, dispensing limits will be added for the following drugs:

Drug Class and Medication*

Dispensing Limit

Birth Control

Nuvaring ring (etonogestrel/ethinyl estradiol)

1 ring/21 days

Cushing’s Disease

Signifor inj (pasireotide)

60 mL/30 days

Familial Hypercholesterolemia

Juxtapid 5 mg, 10 mg  caps (lomitapide)

60 caps/30 days

Juxtapid 15 mg, 20 mg  caps (lomitapide)

90 caps/30 days

Kynamro inj (mipomersen)

4 injections (4 mL)/28 days

Mental Health Agents

Clozaril 25 mg, 50 mg tabs (clozapine)

90 tabs/30 days

Clozaril 100 mg tabs (clozapine)

270 tabs/30 days

Clozaril 200 mg tabs (clozapine)

120 tabs/30 days

Fanapt tabs (iloperidone)

60 tabs/30 days

Fanapt Titration Pak (iloperidone)

1 pack (8 tabs)/4 days

Fazaclo 12.5 mg, 100 mg tabs (clozapine)

90 tabs/30 days

Fazaclo 25 mg tabs (clozapine)

270 tabs/30 days

Fazaclo 150 mg tabs (clozapine)

180 tabs/30 days

Fazaclo 200 mg tabs (clozapine)

120 tabs/30 days

Geodon caps (ziprasidone)

60 caps/30 days

Invega 1.5 mg, 3 mg, 9 mg tabs (paliperidone)

30 tabs/30 days

Invega 6 mg tabs (paliperidone)

60 tabs/30 days

Risperdal 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg tabs (risperidone)

120 tabs/30 days

Risperdal 3 mg tabs (risperidone)

60 tabs/30 days

Risperdal 1 mg/mL soln (risperidone)

480 mL/30 days

Risperdal M-Tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg tabs (risperidone ODT)

60 tabs/30 days

Risperdal M-Tab 4 mg tabs (risperidone ODT)

120 tabs/30 days

Saphris tabs (asenapine sublingual)

60 tabs/30 days

Seroquel 25 mg, 50 mg tabs (quetiapine)

180 tabs/30 days

Seroquel 100 mg tabs (quetiapine)

120 tabs/30 days

Seroquel 200 mg tabs (quetiapine)

90 tabs/30 days

Seroquel 300 mg, 400 mg tabs (quetiapine)

60 tabs/30 days

Seroquel XR 50 mg, 300 mg, 400 mg tabs (quetiapine ext-release)

60 tabs/30 days

Seroquel XR 150 mg, 200 mg tabs (quetiapine ext-release)

30 tabs/30 days

Zyprexa 2.5 mg, 5 mg, 7.5 mg, 10 mg tabs (olanzapine)

60 tabs/30 days

Zyprexa 15 mg, 20 mg tabs (olanzapine)

30 tabs/30 days

Zyprexa Zydis tabs (olanzapine ODT)

30 tabs/30 days

Nausea and Vomiting

Emend 40 mg caps (aprepitant)

2 caps/30 days

Emend 80 mg caps (aprepitant)

6 caps/30 days

Emend 125 mg caps (aprepitant)

3 caps/30 days

Zofran 24 mg tabs (ondansetron)

4 tabs/30 days

Pain

ConZip caps (tramadol ext-release)

30 caps/30 days

Embeda caps (morphine/naltrexone)

60 caps/30 days

Exalgo (hydromorphone ext-release)

30 tabs/30 days

Kadian (morphine ext-release)

60 caps/30 days

MS Contin tabs (morphine ext-release)

90 tabs/30 days

Opana ER tabs (oxymorphone ext-release)

60 tabs/30 days

Oramorph SR tabs (morphine ext-release)

90 tabs/30 days

Rybix ODT tabs (tramadol ODT)

240 tabs/30 days

Respiratory Agents

Alvesco inhaler (ciclesonide)

1 inhaler/Rx

Flovent Diskus 50 mcg/inhalation,
100 mcg/inhalation inhaler (fluticasone)

1 inhaler/Rx

Flovent HFA 44 mcg/actuation,
110 mcg/actuation inhaler (fluticasone)

1 inhaler/Rx

Pulmicort Respules 0.25 mg/2 mL, 0.5 mg/2 mL inhal susp (budesonide)

120 mL/Rx

Pulmicort Respules 1 mg/2 mL inhal susp (budesonide)

60 mL/Rx

Xopenex 0.31 mg/3 mL, 0.63 mg/3 mL,
1.25 mg/3 mL  inhal soln (levalbuterol)

4 boxes (288 mL)/Rx

Various Skin Conditions

Picato 0.015% gel (ingenol)

3 tubes/90 days

Picato 0.05% gel (ingenol)

2 tubes/90 days

Zyclara 2.5%, 3.75% crm (imiquimod)

7.5 g/Rx; 15 g/6 months

Zyclara 3.75% packets (imiquimod)

28 packets/Rx; 56 packets/
6 months

* 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
Effective Jan. 1, 2014, the drug categories listed in the table below will be added to the prior
authorization (PA) program for all standard benefit plans upon renewal.

Drug Category

Targeted Medications*

Cushing’s Disease

Signifor

Familial Hypercholesterolemia

Juxtapid, Kynamro

Short Bowel Syndrome

Gattex

Urea Cycle Disorders

Buphenyl, Ravicti

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

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

 


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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.