Blue Review - Blue Cross and Blue Shield of Oklahoma

Jan. 14, 2016

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2016

DRUG LIST (FORMULARY) CHANGES
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 Oklahoma's (BCBSOK) 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 Brand^1,2	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

DISPENSING LIMIT CHANGES
The BCBSOK 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 January 1, 2016, dispensing limits for the following drugs were added to the standard list:

Drug Class and Medication¹	Product Strength(s)	Dispensing Limit
Antiretrovirals
Kaletra (lopinavir/ritonavir)	100/25 mg	180 tablets per 30 days
Selzentry (maraviroc)	300 mg	60 tablets per 30 days
Hypercholesterolemia (HoFH)
Juxtapid (lomitapide)	20 mg capsule	30 capsules per 30 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
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

Targeted drugs added to current pharmacy ST standard programs, effective Jan. 1, 20163

Drug Category	Targeted Medication(s)^1,2
Diabetes (GLP-1 Receptor Agonists)	Bydureon

Targeted mailings were sent to members affected by formulary change and prior authorization program 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 our website at bcbsok.com/provider.

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. BCBSOK contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSOK, 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 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 and their health care provider.

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