January 17, 2014 Group Markets Pharmacy Program Changes Effective April 1, 2014 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, 2014. Standard Formulary Deletions Brand Medication Moving to a Higher Out-of-Pocket Payment Level Effective April 1, 2014 Non-Formulary Brand* | Condition Used for | Generic Formulary Alternative(s)1 | Formulary Brand Alternative(s)*,1 | Solaraze | Actinic Keratosis | fluorouracil cream, imiquimod cream | Carac, Zyclara | *Third-party brand names are the property of their respective owner. 1This list is not all inclusive. Other medications may be included in this drug class. Targeted mailings were sent to members affected by this change 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, 2014, dispensing limits will be added for the following drugs: Drug Class and Medication* | Dispensing Limit | Antibiotics | Alinia tabs (nitazoxanide) | 6 tabs/30 days | Zithromax tabs (azithromycin) | 60 tabs/180 days | Diabetes | Invokana tabs (canagliflozin) | 30 tabs/30 days | Multiple Sclerosis | Tecfidera Starter Kit (dimethyl fumarate) | 60 caps/180 days | Tecfidera 120 mg caps (dimethyl fumarate) | 14 caps/180 days | *Third-party brand names are the property of their respective owner. 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 account representative. |