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1 abr, 2021

BCBSRI pharmacy program 1 de abril de 2021 formulary changes

The information below is effective as of 1 de abril de 2021 and applies to all commercial BCBSRI products, including all large group, small group and exchange (individual) markets. 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 abril de 2021. The generic equivalent will continue to be covered.

ALINIA

HYCODAN

SAPHRIS

ATRIPLA

JADENU SPRINKLE

SKLICE

BETHKIS

KERYDIN

SYMFI

CIPRODEX

K-TAB

SYMFI LO

DEMSER

KUVAN

TACLONEX

EMTRIVA

MONUROL

TECFIDERA

FERRIPROX

MOVIPREP

TYKERB

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)

ALKINDI SPRINKLE

MYNATAL PLUS

PRENA1 PEARL

ALOGLIPTIN

MYNATAL-Z

PRENATE

ALOGLIPTIN/METFORMIN HCL

NATACHEW

QTERN

ALOGLIPTIN/PIOGLITAZONE

NEEVO DHA

SEGLUROMET

CITRANATAL (all formulations)

NESINA

SELECT-OB+DHA

DUET DHA 400

NESTABS DHA

STEGLATRO

DUET DHA BALANCED

NESTABS ONE

STEGLUJAN

INVOKAMET

OB COMPLETE (all formulations)

TRADJENTA

INVOKAMET XR

ONGENTYS

TRI-TABS DHA

INVOKANA

ONGLYZA

VINATE DHA RF

JENTADUETO

OSENI

VITAFOL (all formulations)

JENTADUETO XR

PNV OB+DHA

VITAMEDMD (all formulations)

KAZANO

PRENA1 CHEW

VITAPEARL

KOMBIGLYZE XR

The following generic and brand name drugs with preferred alternatives will be excluded from coverage, effective 1 de abril 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.

Tier changes

The following product has been moved to a higher copay tier, effective 1 de abril de 2021.

           CONCERTA

Prior authorization

The following drug will now require prior authorization for coverage, effective 1 de abril de 2021.

SUPPRELIN LA*

Drugs that will be designated for coverage under medical*

The following drugs will be covered under the medical benefit, effective 1 de abril de 2021.

ACTEMRA IV

LUPRON DEPOT (3-MONTH)

RUXIENCE

BOTOX

LUPRON DEPOT (4-MONTH)

SIMPONI ARIA

DYSPORT

LUPRON DEPOT (6-MONTH)

TRELSTAR MIXJECT

ELIGARD

LUPRON DEPOT-PED (1-MONTH)

TYSABRI

EYLEA

LUPRON DEPOT-PED (3-MONTH)

XEOMIN

LUCENTIS

PROLIA

XGEVA

LUPRON DEPOT (1-MONTH)

RITUXAN

ZOLADEX

 

*Specialty drug

 

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 abril de 2021. The generic equivalent will continue to be covered.

CIPRODEX

MOVIPREP

SYMFI LO

CONCERTA

SYMFI

TIMOPTIC-XE

EMTRIVA

Drugs (Excluded from coverage)

 

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

BUTALBITAL/ACETAMINOPHEN/CAFFEINE

PRENATAL 19

CONDYLOX

RANITIDINE HCL

PHRENILIN FORTE

RANITIDINE HYDROCHLORIDE

Tier changes

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

NIZATIDINE

ISONIAZID

Prior authorization

The following drug will now require prior authorization for coverage, effective 1 de abril de 2021.

FLUOROURACIL CRE 5%   

TARGRETIN GEL 1%

 

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