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Update: Changes to Your Drug Formulary
New Covered Drugs and Changes to Tier Status or Prior Authorization Program
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Effective July 1, 2007, there are several changes to the Capital BlueCross Drug Formulary which will affect you and your employees. These medications have been reviewed according to safety, efficacy and overall value to ensure the formulary remains responsive to your needs.
HOW THIS AFFECTS YOU AS AN EMPLOYEE
Please review the below tables to learn about the newest updates to your drug program. The information includes new drugs out on the market that are now available to you as well as those medications that may have changed tier status impacting the amount of out of pocket $ you are responsible for paying. In addition, we have included a list of updates to the Prior Authorization Program.
NEWLY MARKETED DRUGS |
QLL (Quantity Level Limits Apply) |
Bold lowercase print= generic |
Brand Name |
Formulary Status |
Tier |
Indication |
Preferred Alternatives |
ANGELIQUE |
Nonpreferred*/
Nonformulary** |
3 |
Menopause Symptoms |
Estradiol, YASMIN |
CESAMET (QLL) |
Nonpreferred*/
Nonformulary** |
3 |
Nausea |
Ondanestron (QLL), EMEND (QLL), KYTRIL (QLL) |
CHANTIX (only covered under benefit plans that include smoking cessation products) |
Preferred*/
Formulary** |
2 |
Smoking Cessation |
N/A |
DUETACT |
Preferred*/
Formulary** |
2 |
Diabetes |
N/A |
INVEGA (QLL) |
Non-Preferred*/
Non-Formulary** |
3 |
Schizophrenia |
RISPERDAL, ZYPREXA (QLL) |
JANUVIA |
Non-Preferred*/
Non-Formulary** |
3 |
Diabetes |
metformin , ACTOS, AVANDIA |
NOXAFIL |
Non-Preferred*/
Non-Formulary** |
3 |
Fungal Infections |
fluconazole |
OPANA/OPANA ER (QLL) |
Non-Preferred*/
Non-Formulary** |
3 |
Pain |
oxycodone, morphine sulfate , KADIAN (QLL) |
PREZISTA |
Preferred*/
Formulary** |
2 |
HIV |
N/A |
SPRYCEL |
Preferred*/
Formulary** |
2 |
Leukemia |
N/A |
SYNERA |
Non-Preferred*/
Non-Formulary** |
3 |
Local Anasthesia |
lidocane, LIDODERM (a preferred alternative for commercial formularies but is not a preferred alternative for Medicare formularies) |
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* Applies to Incentive-tiered Formulary- Provides access to both Preferred ( Tier 1 & 2) and Nonpreferred (Tier 3) medications regardless of tier designation. Coverage may vary based upon a member’s specific benefit plan design.
** Applies to Closed Formulary- Provides access to only products on the formulary (Tier 1 &2 ). Products with Nonpreferred/Nonformulary (Tier 3) status are off the formulary and are not covered unless approved via the Non-Formulary Consideration Process. Approvals will be member-and drug-specific, and each exception must be reviewed and approved separately. Coverage may vary based upon a member’s specific benefit plan design.
PRODUCTS CHANGING TIER STATUS
KEY
Tier Status 2= Brand
Tier Status 3= Nonformulary
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Brand Name |
Old Tier Status |
New Tier Status |
Comments |
ACTONEL (QLL) |
2 |
3 |
Effective July 1, 2007 for commercial products Effective January 1, 2007 for Medicare products |
BENICAR/ -HCT |
2 |
3 |
Effective July 1, 2007 for Medicare products |
ELMIRON |
3 |
2 |
Effective April 1, 2007 for commercial and Medicare products |
KADIAN (QLL) |
3 |
2 |
Effective January 1, 2007 for commercial and Medicare products |
MICARDIS/ -HCT |
3 |
2 |
Effective July 1, 2007 for Medicare products |
UPDATES TO THE PRIOR AUTHORIZATION PROGRAM
EPA= Enhanced Prior Authorization Required |
Drug Class/Drug |
Description |
Agents for Narcolepsy (PAR) (XYREM, PROVIGIL) |
Encourages appropriate use for treatment of narcolelpsy |
Updates to the Enhanced Prior Authorization (Step Therapy) Program |
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Non-Sedating Antihistamines (EPA) |
Encourages use of a generic non-sedating antihistamine before a brand-name product (e.g. CLARINEX) |
Transmucosal Fentanyl (EPA) |
Encourages use of a long-acting narcotic analgesic in combination with short-acting fentanyl products |
Osteoporosis Agents |
New clinical program encourages use of FDA-approved dosages: (1)ACTONEL 35 mg: 4 tablets per 28 days (2) ACTONEL + Calcium: 28 tablets per 28 days (3) BONIVA 150 mg: 1 tablet per 28 days (4) FOSAMAX 35 mg, 70mg; FOSAMAX+D: 4 tablets per 28 days
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Proton Pump Inhibitors, Sedative/Hypnotics, HMG CoA Reductase Inhibitors and SSRI Antidepressants |
Established quantity limits will be changed from “per dispensing (per prescription)” to “per 30 days’ supply” |
WHAT SHOULD I DO NEXT?
If you have any questions about this update to the Capital BlueCross drug formulary, or how these changes affect you, please call Corporate Synergies at 1.866.CSG.1719, or click HERE to contact us.
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