| Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2016
Based on the availability of new prescription medications and the Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions were made to the Blue Cross and Blue Shield of Texas (BCBSTX) standard drug list and generics plus drug list effective Jan. 1, 2016. Brand Medications Added to the Standard and Generics Plus Drug Lists, Effective Jan. 1, 2016 Preferred Brand1 | Drug Class/Condition Used for | Actimmune | Osteoporosis | Daklinza | Hepatitis C | Ixinity | Hemophilia | Noxafil | Fungal Infections |
Brand Medications Moved to a Higher Out-of-pocket Payment Level on the Generics Plus Drug List, Effective Jan. 1, 2016 Non-preferred Brand1,2 | Condition Used for | Generic Preferred Alternative(s)2 | Preferred Brand Alternative(s)1,2 | Synarel | Endometriosis | N/A | N/A | Olysio | Hepatitis C | N/A | Harvoni | Mestinon | Neuromuscular Disorders | pyridostigmine | N/A | Mestinon Timespan | Neuromuscular Disorders | pyridostigmine | N/A | Tobradex Oph Oint | Topical Antibiotic | Tobramycin/Dexamethasone ophthalmic suspension | Zylet | Brand Medications Moved to a Higher Out-of-pocket Payment Level on the Standard Drug List, Effective Jan. 1, 2016 Non-preferred Brand1,2 | Condition Used for | Generic Preferred Alternative(s)2 | Preferred Brand Alternative(s)1,2 | Baraclude | Hepatitis B | entecavir | N/A | Celebrex | Pain | celecoxib | N/A | Cellcept | Transplant Rejection Prophylaxis | mycophenolate mofetil | N/A | Differin | Acne | adapalene | N/A | Epivir | HIV | lamivudine | Emtriva, Truvada, Epzicom | Intuniv | ADHD | guanfacine | Vyvanse | Nexium | GERD | esomeprazole magnesium | N/A | Protopic | Atopic Dermatitis/Eczema | tacrolimus | Zyclara, Elidel | Rapamune | Transplant Rejection Prophylaxis | sirolimus | N/A | Stromectol | Various Infections | ivermectin | Albenza, Biltricide | Synarel | Endometriosis | N/A | N/A | Olysio | Hepatitis C | N/A | Harvoni | Mestinon | Neuromuscular Disorders | pyridostigmine | N/A | Mestinon Timespan | Neuromuscular Disorders | pyridostigmine | N/A | Tobradex Oph Oint | Topical Antibiotic | Tobramycin/Dexamethasone ophthalmic suspension | Zylet | Valcyte | CMV Disease | valganciclovir | N/A | Zyvox | Bacterial Infection | linezolid | N/A | Dispensing Limit Changes
The BCBSTX standard and generics plus 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, 2016, dispensing limits for the following drugs were added to the standard and generics plus list: Drug Class and Medication1 | Product Strength(s) | Dispensing Limit | Afrezza | Afrezza (insulin human) inhalation powder | 4 units/cartridge | 19 packs per 30 days (1 pack = 90 cartridges) | Afrezza (insulin human) inhalation powder | 4 units and 8 units/cartridge | 14 packs per 30 days (1 pack = 60 x 4 unit cartridges, 30 x 8 unit cartridges) | Afrezza (insulin human) inhalation powder | 4 units and 8 units/cartridge | 12 packs per 30 days (1 pack = 30 x 4 unit cartridges, 60 x 8 unit cartridges) | Antiretrovirals | Kaletra (lopinavir/ritonavir) | 100/25 mg | 180 tablets per 30 days | Selzentry (maraviroc) | 300 mg | 60 tablets per 30 days | Cerdelga | Cerdelga (eliglustat) | 84 mg capsule | 60 capsules per 30 days | Diabetes (GLP-1 Receptor Agonists) | Bydureon (exenatide) | 2 mg syringe | 4 syringes per 28 days | Fibrates | Antara (fenofibrate) | 30 mg, 43 mg micronized capsules | 60 capsules per 30 days | Antara (fenofibrate) | 90 mg, 130 mg micronized capsules | 30 capsules per 30 days | Fenoglide (fenofibrate) | 40 mg tablets | 60 tablets per 30 days | Fenoglide (fenofibrate) | 120 mg tablets | 30 tablets per 30 days | Fibricor (fenofibric acid) | 35 mg tablets | 60 tablets per 30 days | Fibricor (fenofibric acid) | 105 mg tablets | 30 tablets per 30 days | Lipofen (fenofibrate) | 50 mg capsules | 60 capsules per 30 days | Lipofen (fenofibrate) | 150 mg capsules | 30 capsules per 30 days | Lofibra (fenofibrate) | 54 mg tablets | 60 tablets per 30 days | Lofibra (fenofibrate) | 160 mg tablets | 30 tablets per 30 days | Lofibra (fenofibrate) | 67 mg, 134 mg, 200 mg micronized capsules | 30 capsules per 30 days | Tricor (fenofibrate) | 48 mg tablets | 60 tablets per 30 days | Tricor (fenofibrate) | 145 mg tablets | 30 tablets per 30 days | Triglide (fenofibrate) | 50 mg tablets | 60 tablets per 30 days | Triglide (fenofibrate) | 160 mg tablets | 30 tablets per 30 days | Trilipix (fenofibric acid) | 45 mg delayed-release tablets | 60 tablets per 30 days | Trilipix (fenofibric acid) | 135 mg delayed-release tablets | 30 tablets per 30 days | Lopid (gemfibrozil) | 600 mg tablets | 60 tablets per 30 days | Fibromyalgia | Lyrica (pregabalin) | 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg capsule | 90 capsules per 30 days | Lyrica (pregabalin) | 225 mg, 300 mg capsule | 60 capsules per 30 days | Lyrica (pregabalin) | 20 mg/mL oral solution | 900 mL solution per 30 days | Hetlioz | Hetlioz (tasimelteon) | 20 mg capsule | 30 capsules per 30 days | Hypercholesterolemia (HoFH) | Juxtapid (lomitapide) | 5 mg, 10 mg, 20 mg capsule | 30 capsules per 30 days | Idiopathic Pulmonary Fibrosis (IPF) | Esbriet (pirfenidone) | 267 mg capsule | 270 capsules per 30 days | Ofev (nintedanib) | 100 mg capsule, 150 mg capsule | 60 capsules per 30 days | Korlym | Korlym (mifepristone) | 300 mg tablet | 60 tablets per 30 days | Ophthalmic Prostaglandins | Rescula (unoprostone) | 0.15% | 5 mL per 30 days | Opioid Dependence | Subutex (buprenorphine) | All strengths | 15 tabs per 90 days | Oral Immunotherapy | Grastek (timothy grass pollen allergen extract) | 2800 BAU SL tablet | 30 tablets per 30 days | Oralair (sweet vernal, orchard, perennial rye, timothy and Kentucky blue grass mixed pollens allergen extract) | 300 IR tablet | 30 tablets per 30 days | Ragwitek (short ragweed pollen allergen extract) | 12 Amb a 1-U SL tablet | 30 tablets per 30 days | Oral PAH | Tyvaso (treprostinil) starter kit | 0.6 mg/mL | 1 kit per 180 days | Tyvaso (treprostinil) institutional starter kit | 0.6 mg/mL | 1 kit per 180 days | Tyvaso (treprostinil) | 0.6 mg/mL, 4 pack carton | 7 packages per 28 days | Tyvaso (treprostinil) | 0.6 mg/mL refill kit | 1 package per 28 days | Ventavis (iloprost) | 10 mcg/mL, 20 mcg/mL | 270 ampules per 30 days | Thrombopoietin Receptor Agonists | Promacta (eltrombopag) | 25 mg | 30 tablets per 30 days | Promacta (eltrombopag) | 75 mg | 60 tablets per 30 days | Topical Cancer Treatment | Picato (ingenol mebutate) | 0.015% gel | 3 tubes per 90 days | Picato (ingenol mebutate) | 0.05% gel | 2 tubes per 90 days | Utilization Management Program Changes
Effective Jan. 1, 2016, several drug categories and/or targeted medications will be added to the current Prior Authorization (PA) and Step Therapy (ST) programs for standard pharmacy benefit plans. Drug categories added to the pharmacy PA standard programs, effective Jan. 1, 2016 Drug Category | Targeted Medication(s)1 | Afrezza | Afrezza | Cerdelga | Cerdelga | Hetlioz | Hetlioz | Idiopathic Pulmonary Fibrosis (IPF) | Esbriet, Ofev | Korlym | Korlym | Myalept | Myalept | Oral Immunotherapy | Grastek, Oralair, Ragwitek | Topical Antifungal | CNL8, Ciclopirox Kit, Ciclodan Kit, Jublia, Kerydin, Pedipirox, Penlac | Targeted drugs added to current pharmacy PA standard programs, effective Jan. 1, 2016 Drug Category | Targeted Medication(s)1 | Antifungal | Cresemba 186 mg | Doxycycline/Minocycline | Doxycycline 75 mg, Doxycycline 150 mg capsules, Doxycycline Monohydrate 150 mg tablets | Erythropoiesis Stimulating Agents (ESAs) | Mircera 50 mcg, 75 mcg, 100 mcg, 200 mcg | Pulmonary Arterial Hypertension (PAH) | Tyvaso, Ventavis | Targeted drugs added to current pharmacy ST standard programs, effective Jan. 1, 20163 Drug Category | Targeted Medication(s)1, 2 | Atopic Dermatitis | Elidel, Protopic | Diabetes (GLP-1 Receptor Agonists) | Bydureon | Fibrates | Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, Triglide, Trilipix | Ophthalamic Prostaglandins (Glaucoma) | Lumigan, Rescula, Travatan Z, Travaprost, Xalatan, Zioptan | Targeted mailings were sent to members/subscribers affected by formulary changes per our usual process of member notification prior to implementation. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of the BCBSTX provider website. 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.
3Members on a current drug regimen will be grandfathered from participation in the ST program. Prime Therapeutics LLC is a pharmacy benefit management company. BCBSTX contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSTX, 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/subscribers 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/subscriber and their health care provider. |
