August 2023

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2023

Contents
Drug List Additions – As of July 1, 2023
Balanced Drug List
Performance Drug List
Performance Select Drug List
Basic, Enhanced, Multi-Tier Basic and Multi-Tier Enhanced Drug Lists
Health Insurance Marketplace (HIM) Drug List
Dispensing Limit Changes
Basic, Enhanced, Balanced, Performance, Performance Select and Health Insurance Marketplace (HIM) Drug Lists
Standard Utilization Management (UM) Program Package Changes
Humira Biosimilars Added to Select Drug Lists
Change in Benefit Coverage for Select High-Cost Products
Federal COVID-19 Public Health Emergency Ends
Drugs Horizant and Gralise Removed from Maintenance List

Update: This article is a continuation of the previously published July Quarterly Pharmacy Changes Part 1 article. The Part 1 article included changes that require member notification — drug list revisions/exclusions, dispensing limits, utilization management changes and general information on pharmacy benefit program updates. This Part 2 article contains more recent coverage additions, utilization management updates and any other pharmacy-program updates.

Note: Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some additions (new to coverage) and/or some coverage tier changes (drugs moved to a lower out-of-pocket payment level) will be made to the Blue Cross and Blue Shield of Oklahoma (BCBSOK) drug lists.

Additions effective July 1, 2023, as well as previous updates, are outlined below.

Dispensing Limit Changes
BCBSOK’s prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits, or quantity limits (QLs), are based on U.S. Food and Drug Administration (FDA) approved dosage regimens and product labeling. New dispensing limits and effective dates are listed on the chart below.

• The Self-Administered Oncology Program has removed generic capecitabine as a target effective July 1, 2023.
• Welchol (colesevelam) packet for suspension has been removed as a target from the Alternative Dosage Form Prior Authorization Program effective May 15, 2023.
• The Fibrates Step Therapy/Quantity Limits Program has been retired effective July 1, 2023.
• The Inhaled Antibiotics-Cystic Fibrosis Quantity Limits Program has been retired effective July 1, 2023 and targets moved to Therapeutic Alternatives Prior Authorization Program.

Please Note: The PA programs for standard pharmacy benefit plans correlate to a member's drug list. Not all standard PA programs may apply, based on the member's current drug list. A list of PA programs per drug list is posted on the member pharmacy programs section of BCBSOK.com.

If your patients have any questions about their pharmacy benefits, please advise them to contact the number on their member ID card. Members may also visit BCBSOK.com and log in to Blue Access for Members^SM (BAM^SM) or MyPrime.com for a variety of online resources.

Humira Biosimilars Added to Select Drug Lists

Preferred Adalimumab Products
This list includes any existing preferred adalimumab products or biosimilar adalimumab additions to BCBSOK drug lists.

Change in Benefit Coverage for Select High-Cost Products
Several high-cost products with available lower cost alternatives will be excluded on the pharmacy benefit for select drug lists. This change impacts BCBSOK members who have prescription-drug benefits administered by Prime Therapeutics†. This change is part of an ongoing effort to make sure our members and employer groups have access to safe, cost-effective medications.

Please note: Members were not notified of this change because either there is no utilization or the pharmacist can easily fill a member's prescription with the equivalent without needing a new prescription from the doctor. The following drugs are excluded on select drug lists.

Federal COVID-19 Public Health Emergency Ends
The public health emergency (PHE) officially ended May 11, and members are experiencing changes in the over-the-counter (OTC) test kits and testing-related visits.

OTC Test Kits: Most BCBSOK commercial plan members no longer have coverage for OTC COVID-19 home test kits under their benefits. This includes members on an individual and family markets plan, as well as both fully insured and ASO group plans. Some ASO groups may have opted in to continue covering these OTC COVID-19 test kits under the pharmacy benefit. If a member’s plan no longer covers OTC test kits, they are no longer reimbursable.

Members with existing coverage can still purchase an OTC test kit at the pharmacy if needed. There is still a limit of up to 8 tests every 30 days per member. If for any reason the pharmacist is unable to process under their pharmacy benefit when coverage exists, the member can pay out of pocket at the pharmacy counter and submit a prescription drug claim form, along with the pharmacy receipt, to be reimbursed. Updated prescription drug claim forms are available have in the BCBSOK.com Form Finder section, in Blue Access for Members^SM and on MyPrime.com.

COVID-19 Anti-Viral Medications: Paxlovid and Lagevrio (molnupiravir) are oral, anti-viral prescription medicines that treat mild-to-moderate COVID-19. These medicines may be covered under the member’s pharmacy benefit. There is a limit of one course of treatment every 180 days per member. Member cost share is based on plan benefits.

Monovalent COVID-19 Vaccine: As of April 18, 2023, the monovalent COVID-19 vaccine is no longer authorized for use in the United States. The Moderna and Pfizer bivalent COVID-19 vaccines and the Johnson & Johnson or Novavax COVID-19 vaccines are not affected.

Verify Coverage: If members are unsure about what their plan covers, they can call the number on their ID card.

Drugs Horizant and Gralise Removed from Maintenance List
Gabapentin products, Gralise and Horizant, were removed from the maintenance drug list effective June 1, 2023. These drugs are typically prescribed to treat epilepsy and certain types of nerve pain, but a growing body of evidence suggests possible abuse.

For members whose plan benefits required these medications to be filled in a 90-day supply or at select pharmacies to receive coverage, they will no longer be subject to those specific requirements.

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSOK contracts with Prime to provide pharmacy benefit management and related other services. BCBSOK, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. MyPrime.com is an online resource offered by Prime Therapeutics.

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.