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1 oct, 2021

BCBSRI formulary changes effective 1 de octubre de 2021

The formulary changes noted below are effective as of 1 de octubre de 2021 and apply to all commercial BCBSRI products, including all large group, small group, and exchange (individual) plans. These changes do not apply to BlueCHiP for Medicare plans. Any changes to this list are the result of a comprehensive review of relevant clinical information by the BCBSRI Pharmacy and Therapeutics Committee.

 

Large group and small group markets formulary

 

Brand name drugs available with generic equivalents (Excluded from coverage)

 

For application across all commercial formularies, the following brand name drugs are now available with generic equivalents. As a result, the brand name will be excluded from coverage, effective 1 de octubre de 2021. The generic equivalent will continue to be covered.

 

 

AZOPT

BEPREVE

BROVANA NEB

INTELENCE

KALETRA

LOTEMAX

MIACALCIN

NAFTIFINE CREAM 2%

NORTHERA

PERFOROMIST NEB

THIOLA

TRUVADA

VELETRI

 

 

For the Traditional Formulary, these brand products will continue to be covered with non-preferred or specialty copay.

 

Brand name and generic drugs with available alternatives (Excluded from coverage)

The following generic and brand name drugs with preferred alternatives will be excluded from coverage, effective 1 de octubre de 2021. Request for coverage will require documented medical necessity.

 

For the Traditional Formulary, these brand products will continue to be covered with non-preferred or specialty copay.

 

 

ADDYI TAB

ALLZITAL

ALVESCO

BASAGLAR KWIKPEN

BINOSTO

CLENPIQ

CLINDAMYCIN PHOSPHATE FOAM

CLINDAMYCIN PHOSPHATE/TRETINOIN GEL

DOXEPIN HCL 3MG/6MG

DULOXETINE HCL 40MG

EMVERM

EPINEPHRINE INJ (AVKARE/AMNEAL)

ESTRADIOL VAG TAB

FEMRING VAG RING

FLUNISOLIDE

FORFIVO XL

FOSAMAX PLUS D

FULPHILA

KEVEYIS

LEVALBUTEROL TARTRATE HFA

MITIGARE CAP

MOMETASONE FUROATE

NIVESTYM

NYVEPRIA

OSMOPREP

PANCREAZE

PERTZYE

PREPOPIK

QUAZEPAM

QUILLICHEW ER

QUILLIVANT XR

RESTASIS OPTH

RESTASIS MULTIDOSE

SEEBRI NEOHALER

SUBSYS

TEMAZEPAM

TENCON TAB

TRETINOIN GEL

TRETINOIN MICROSPHERE GEL

TRETINOIN MICROSPHERE PUMP

TUDORZA PRESSAIR

TWIRLA

VISTOGARD

VTOL LQ

XOPENEX HFA

XURIDEN

YUVAFEM

ZIEXTENZO

 

 

For the Traditional Formulary, these brand products will continue to be covered with non-preferred or specialty copay.

 

Prior authorization

The following drugs will now require prior authorization for coverage, effective 1 de octubre de 2021.

 

 

AUBAGIO *#

GILENYA *#

KESIMPTA *#

 

RINVOQ *

SUPPRELIN LA *

ZEPOSIA *#

 

 

*Specialty drug

#Step Therapy for new starts only

 

Drugs that will be designated for coverage under the medical benefit*

The following drug will be covered under the medical benefit, effective 1 de octubre de 2021.

 

MYOBLOC*

 

*Specialty drug

 

Tier changes

The following products have been moved to a higher copay tier, effective 1 de octubre de 2021.

 

 

ABACAV/LAMIV TAB /ZIDOVUD

ADDERALL XR CAP 5MG

ADDERALL XR CAP 10MG

ADDERALL XR CAP 15MG

ADDERALL XR CAP 20MG

ADDERALL XR CAP 25MG

ADDERALL XR CAP 30MG

 

ALBUTEROL NEB 0.083% *

ALENDRONATE SOL 70/75ML

ALPRAZOLAM TAB 0.5MG ER *

ALPRAZOLAM TAB 0.5MG XR *

ALPRAZOLAM TAB 3MG ER *

ALPRAZOLAM TAB 3MG XR *

AMIODARONE TAB 200MG *

AMITRIPTYLIN TAB 10MG *

AMITRIPTYLIN TAB 25MG *

AMITRIPTYLIN TAB 50MG *

AMOX/K CLAV TAB 500-125 *

AMOX/K CLAV TAB 875-125 *

ANAGRELIDE CAP 0.5MG

APREPITANT CAP 40MG

ATOVAQ/PROGU TAB 62.5-25

AVITA CRE 0.025%

AVITA GEL 0.025%

BACLOFEN TAB 10MG *

BENZONATATE CAP 100MG *

BENZONATATE CAP 200MG *

BRIMONIDINE SOL 0.2% OP *

BUPREN/NALOX SUB 2-0.5MG

BUPRENORPHIN DIS 7.5/HR

BUPROPION TAB 150MG SR *

BUSPIRONE TAB 10MG *

BUSPIRONE TAB 15MG *

BUSPIRONE TAB 5MG *

BUT/APAP/CAF CAP

BUT/APAP/CAF CAP CODEINE

BUTAL/APAP TAB 50-325MG

CARBAMAZEPIN CAP 100MG ER

CARBAMAZEPIN CAP 200MG ER

CARBAMAZEPIN CAP 300MG ER

CARBAMAZEPIN TAB 100MG ER

CARBAMAZEPIN TAB 200MG ER

CARBAMAZEPIN TAB 400MG ER

CEPHALEXIN CAP 250MG *

CEPHALEXIN CAP 500MG *

CHLORPROMAZ TAB 10MG

CHLORZOXAZON TAB 500MG

CHLORZOXAZON TAB 750MG

CIMETIDINE TAB 200MG *

CIMETIDINE TAB 300MG *

CIPROFLOXACN SOL 0.3% OP *

CLINDAMYCIN CAP 150MG *

CLINDAMYCIN CAP 300MG *

CLINDAMYCIN SOL 75MG/5ML

CLORAZ DIPOT TAB 15MG

CLORAZ DIPOT TAB 3.75MG

CLORAZ DIPOT TAB 7.5MG

CLOTRIM/BETA LOT DIPROP

CLOZAPINE TAB 100MG

CLOZAPINE TAB 25MG

CLOZAPINE TAB 50MG

COMPRO SUP 25MG *

CROMOLYN SOD SOL 4% OP *

CYCLOBENZAPR TAB 10MG *

CYCLOBENZAPR TAB 5MG *

CYCLOPENTOL SOL 1% OP *

CYCLOPHOSPH CAP 25MG

CYCLOPHOSPH CAP 50MG

CYCLOSPORINE CAP 25MG MOD

CYCLOSPORINE CAP 50MG MOD

DESMOPRESSIN SPR 0.01%

DESOXIMETAS CRE 0.25%

DEXTROAMPHET CAP 5MG ER

DEXTROAMPHET SOL 5MG/5ML

DICLOFENAC SOL 1.5%

DICLOFENAC TAB 50MG DR *

DICLOFENAC TAB 75MG DR *

DILTIAZEM TAB 30MG *

DILTIAZEM TAB 60MG *

DILTIAZEM TAB 90MG *

DIPHENHYDRAM INJ 50MG/ML *

DISOPYRAMIDE CAP 100MG

DONEPEZIL TAB ODT 10MG *

DONEPEZIL TAB 10MG *

DONEPEZIL TAB 10MG ODT *

DONEPEZIL TAB 5MG *

DONEPEZIL TAB 5MG ODT *

DONEPEZIL TAB ODT 5MG *

DOXEPIN HCL CON 10MG/ML *

DOXYCYC MONO CAP 100MG

DOXYCYC MONO CAP 50MG

DOXYCYCL HYC TAB 100MG *

EC-NAPROXEN TAB 375MG *

EMTRICITABIN CAP 200MG

ENDOCET TAB 5-325MG *

ESTRAD VAL INJ 200MG/5

ESTRAD VAL INJ 40MG/ML

ETHOSUXIMIDE CAP 250MG

ETODOLAC ER TAB 400MG

ETODOLAC ER TAB 500MG

ETODOLAC ER TAB 600MG *

FELBAMATE TAB 600MG

FENOFIBRATE TAB 145MG

FENOFIBRATE TAB 160MG

FENOFIBRATE TAB 48MG

FENOFIBRATE TAB 54MG

FENTANYL DIS 12MCG/HR

FENTANYL DIS 25MCG/HR

FENTANYL DIS 50MCG/HR

FENTANYL DIS 62.5MCG *

FENTANYL DIS 75MCG/HR

FENTANYL DIS 87.5MCG *

FLUCONAZOLE TAB 150MG *

FLUPHENAZINE TAB 10MG *

FLUPHENAZINE TAB 1MG

FLUPHENAZINE TAB 2.5MG

FONDAPARINUX INJ 2.5/0.5

GABAPENTIN TAB 600MG*

GENGRAF CAP 25MG

HALOPERIDOL TAB 0.5MG *

HALOPERIDOL TAB 1MG *

HC BUTYRATE CRE 0.1%

HC/ACET ACID SOL OTIC *

HEPARIN SOD INJ 1000/ML *

HEPARIN SOD INJ 10000/M

HEPARIN SOD INJ 5000/0.5

HEPARIN SOD INJ 5000/ML

HYDROCO/APAP TAB 5-325MG *

HYDROCOD/IBU TAB 5-200MG

HYDROCOD/IBU TAB 7.5-200

HYDROMORPHON TAB 12MG ER

HYDROMORPHON TAB 2MG *

HYDROMORPHON TAB 4MG *

IMIQUIMOD CRE 3.75%

IMIQUIMOD CRE 3.75%PMP

IMIQUIMOD CRE 5%

LAMIVUDINE TAB 100M

LAMOTRIG ODT TAB 100MG

LAMOTRIGINE KIT START 49

LAMOTRIGINE TAB 100MG

LAMOTRIGINE TAB 100MG ER

LAMOTRIGINE TAB 200MG

LAMOTRIGINE TAB 200MG ER

LAMOTRIGINE TAB 250MG ER

LAMOTRIGINE TAB 25MG ER

LAMOTRIGINE TAB 25MG ODT *

LAMOTRIGINE TAB 300MG ER

LAMOTRIGINE TAB 50MG ER

LAMOTRIGINE TAB 50MG

LANSOPRAZOLE CAP 30MG DR *

LEUCOVOR CA TAB 10MG

LEUCOVOR CA TAB 15MG

LEUCOVOR CA TAB 25MG

LEUCOVOR CA TAB 5MG

LEVETIRACETA TAB 250MG *

LEVETIRACETA TAB 500MG *

LEVORPHANOL TAB 2MG

LIDOCAINE PAD 5%

LORCET TAB 5-325MG *

LORZONE TAB 750MG

LORZONE TAB 375MG *

MEPROBAMATE TAB 200MG

METAXALL TAB 800MG

METAXALONE TAB 400MG

METAXALONE TAB 800MG

METFORMIN TAB 500MG E

METFORMIN TAB 750MG ER

METHOTREXATE TAB 2.5MG

METHYLPRED TAB 32MG *

METRONIDAZOL GEL 0.75%

MIRTAZAPINE TAB 15MG *

MIRTAZAPINE TAB 30MG *

MIRTAZAPINE TAB 45MG *

MONDOXYNE NL CAP 100MG

MORPHINE SUL TAB 15MG ER *

MUPIROCIN CRE 2%

NAPROXEN DR TAB 375MG *

NIFEDIPINE TAB 30MG ER *

NIZATIDINE CAP 150MG *

NIZATIDINE CAP 300MG *

OLM MED/AMLO TAB /HCTZ

OLM MED/HCTZ TAB 20-12.5 *

OLM MED/HCTZ TAB 40-12.5 *

OLM MED/HCTZ TAB 40-25MG *

OXANDROLONE TAB 2.5MG

OXCARBAZEPIN SUS 300MG/5M

OXCARBAZEPIN TAB 150MG *

OXYCOD/APAP TAB 5-325MG *

OXYCODONE TAB 5MG *

PACERONE TAB 200MG *

PHENOBARB TAB 100MG *

PHENOBARB TAB 30MG *

PHRENILIN CAP FORTE

PILOCARPINE SOL 1% OP

PREDNISOLONE SOL 15MG/5ML *

PREDNISOLONE TAB 10MG

PREDNISOLONE TAB 15MG

PREGABALIN SOL 20MG/ML

PROCENTRA SOL 5MG/5ML

PROCHLORPER SUP 25MG *

PROCHLORPER TAB 10MG *

PROCHLORPER TAB 5MG *

PROMETHAZINE SOL 6.25/5ML *

PROMETHAZINE SUP 50MG *

PROMETHAZINE SYP 6.25/5ML *

PROMETHAZINE TAB 12.5MG *

PROMETHAZINE TAB 25MG *

PROMETHAZINE TAB 50MG *

PROPRANOLOL TAB 10MG *

RISPERIDONE TAB 0.5MG OD

RISPERIDONE TAB 1MG ODT

RISPERIDONE TAB 2MG ODT

RISPERIDONE TAB 3MG ODT

ROSADAN GEL 0.75%

ROWEEPRA TAB 500MG

SIROLIMUS SOL 1MG/ML

SUBVENITE KIT START 49

TACROLIMUS CAP 0.5MG

TACROLIMUS CAP 1MG

TEMAZEPAM CAP 30MG *

TIAGABINE TAB 12MG

TIAGABINE TAB 16MG *

TIAGABINE TAB 2MG *

TIMOLOL GEL SOL 0.25% OP

TIMOLOL GEL SOL 0.5% OP

TIMOLOL MAL SOL 0.25% OP *

TIMOLOL MAL SOL 0.5% OP *

TRAZODONE TAB 100MG *

TRAZODONE TAB 150MG *

TRAZODONE TAB 50MG *

TRETINOIN CRE 0.025%

TRETINOIN GEL 0.025%

TRIAMCINOLON OIN 0.025%

TRIAMCINOLON OIN 0.1%

TRIAMCINOLON OIN 0.5%

TRIAMTERENE CAP 100MG

TRIAMTERENE CAP 50MG *

VALSART/HCTZ TAB 160-12.5 *

VALSART/HCTZ TAB 160-25MG *

VALSART/HCTZ TAB 80-12.5 *

VERAPAMIL TAB 120MG ER *

VERAPAMIL TAB 180MG ER *

VERAPAMIL TAB 240MG ER *

XULANE DIS 150-35

ZONISAMIDE CAP 50MG *

 

 

 

* 5-tier generic formulary only

 

Individual market (direct pay/direct pay exchange) formulary

 

   Brand name drugs (Excluded from coverage)

 

The following brand name drugs are now available with generic equivalents. As a result, the brand name will be excluded from coverage effective 1 de octubre de 2021. The generic equivalent will continue to be covered.

 

 

GLUCAGON KIT 1MG

LOTEMAX GEL 0.5%

NAFTIFINE CRE HCL 2%

SAPHRIS SUB

TRUVADA TAB

VELTIN GEL

ZYTIGA TAB

 

 

Drugs (Excluded from coverage)

 

The following drugs are available with alternatives. As a result, they will be excluded from coverage effective 1 de octubre de 2021.

 

 

APAP-CAFFEIN CAP DIHYDROCODEINE

EX-NAPROXEN TAB

FEMRING

FENOFIBRATE CAP

FENOFIBRIC CAP

LIDOCAINE SOL 4%

NAPROXEN DR TAB

TRAZODONE TAB

TREZIX CAP

 

Tier changes

The following brand name drugs have been moved to a higher copay tier effective 1 de octubre de 2021.

 

CEFACLOR CAP                              SODIUM POLYSTYRENE SULFONATE ORAL SUSP

CEFADROXIL TAB                         VCF VAGINA GEL

CYCLOSERINE CAP

 

Prior authorization

The following drugs will now require prior authorization for coverage, effective 1 de octubre de 2021.

 

 

CODEINE

FIORINAL w/ CODEINE

NOVOSEVEN RT

QDOLO

SEVENFACT

TRAMADOL

TREZIX

TYLENOL w/ CODEINE

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