March 2023

Drug List Changes
Dispensing Limit Changes
Utilization Management Program Changes
Change in Benefit Coverage for Select High Cost Products Pharmacy Reminders

New Dosages of Statin Drug to be Covered Without Cost Sharing
Pharmacies Added to Specialty Pharmacy Networks
Split Fill Program Category Expansion

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2023 – Part 1

DRUG LIST CHANGES
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 revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) will be made to the Blue Cross and Blue Shield of Oklahoma (BCBSOK) drug lists. Your patient(s) may ask you about therapeutic or lower cost alternatives if their medication is affected by one of these changes.Changes effective on or after April 1, 2023 are outlined below.

The April Quarterly Pharmacy Changes Part 2 article with more recent coverage additions will be published closer to the April 1 effective date.

Drug List Updates (Revisions) – As of April 1, 2023

Non-Preferred Brand¹	Drug Class/ Condition Used For	Preferred Generic Alternative(s)²	Preferred Brand Alternative(s)^{1, 2}
Basic, Multi-Tier Basic, Enhanced and Multi-Tier Enhanced Drug Lists Revisions
GILENYA - (fingolimod hcl cap 0.5 mg (base equivalent))	Multiple Sclerosis	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

Multi-Tier Basic and Multi-Tier Enhanced Drug Lists Revisions
ISOSORB MONO - (isosorbide mononitrate tab 10 mg)	Angina	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
ISOSORB MONO - (isosorbide mononitrate tab 20 mg)	Angina	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
NP THYROID 15 (thyroid tab 15 mg (1/4 grain))	Hypothyroidism	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
NP THYROID 30 (thyroid tab 30 mg (1/2 grain))	Hypothyroidism	Please talk to your doctor or pharmacist about other medication(s) available for your condition.

Drug1	Drug Class/ Condition Used For	Generic Alternatives^1,2	Brand Alternatives^1,2
Balanced, Performance and Performance Select Drug Lists Revisions
ISOSORBIDE MONONITRATE (isosorbide mononitrate tab 10 mg, 20 mg)	Angina	isosorbide mononitrate ER tablet, isosorbide dinitrate tablet
PHENELZINE SULFATE (phenelzine sulfate tab 15 mg) (authorized generic for NARDIL)	Depression	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
VELIVET (desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025 mg-mg)	Contraception	Please talk to your doctor or pharmacist about medication(s) available for your condition.

Balanced Drug List Revisions
LANSOPRAZOLE/ AMOXICILLIN/ CLARITHROMYCIN (amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack)	Helicobacter Pylori Infection	amoxicillin tablet, clarithromycin tablet, omeprazole capsule, pantoprazole tablet, Talicia
ZYCLARA PUMP (imiquimod cream 2.5%)	Actinic Keratosis	imiquimod cream 5%

Health Insurance Marketplace (HIM) Drug List Revisions
ISOSORB MONO - (isosorbide mononitrate tab 10 mg, 20 mg)	Angina	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
NP THYROID - (thyroid tab 15 mg (1/4 grain), 30 mg (1/2 grain), 60 mg (1 grain), 90 mg (1 1/2 grain), 120 mg (2 grain))	Hypothyroidism	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
PREDNISOLONE - (prednisolone soln 15 mg/5 ml)	Inflammatory conditions	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
PREDNISOLONE - (prednisolone syrup 15 mg/5 ml (usp solution equivalent))	Inflammatory conditions	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
VELIVET - (desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025 mg-mg)	Contraception	Please talk to your doctor or pharmacist about other medication(s) available for your condition.

Drug List Updates (Exclusions) – As of April 1, 2023

Non-Preferred Brand¹	Drug Class/ Condition Used For	Preferred Generic Alternative(s)²	Preferred Brand Alternative(s)^1,2
Balanced, Performance and Performance Select Drug Lists Exclusions
DALIRESP (roflumilast tab 250 mcg, 500 mcg)	Chronic Obstructive Pulmonary Disease (COPD)	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
GILENYA (fingolimod hcl cap 0.5 mg (base equivalent))	Multiple Sclerosis	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
PRADAXA (dabigatran etexilate mesylate cap 150 mg (etexilate base equivalent))	Thromboembolism/stroke prophylaxis, DVT/PE Treatment, DVT/PE Prophylaxis	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
TRIMETHOPRIM (trimethoprim tab 100 mg)	Bacterial Infections	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

Performance and Performance Select Drug Lists Exclusions
ALPRAZOLAM INTENSOL (alprazolam conc 1 mg/ml)	Anxiety	alprazolam tablet, diazepam oral solution, diazepam concentrate oral solution, lorazepam concentrate oral solution
alprazolam orally disintegrating tab 0.25 mg, 0.5 mg, 1 mg, 2 mg	Anxiety	alprazolam tablet, diazepam oral solution, diazepam concentrate oral solution, lorazepam concentrate oral solution
dantrolene sodium cap 25 mg, 50 mg, 100 mg	Muscle Spasms	baclofen tablet
OXYMORPHONE HYDROCHLORIDE ER (oxymorphone hcl tab er 12hr 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg, 30 mg, 40 mg)	Pain	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
SUMATRIPTAN SUCCINATE REFILL (sumatriptan succinate solution cartridge 4 mg/0.5 ml, 6 mg/0.5 ml)	Migraine	sumatriptan succinate solution auto injector

Balanced Drug Lists Exclusions
NAPRELAN (naproxen sodium tab er 24hr 750 mg (base equivalent))	Pain/ Inflammation	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
TIMOPTIC OCUDOSE (timolol maleate preservative free ophth soln 0.25%)	Elevated Intra-ocular Pressure	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

Performance Select Drug List Exclusions
HYDROCODONE BITARTRATE ER (hydrocodone bitartrate cap er 12hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg)	Pain	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
ZYCLARA PUMP (imiquimod cream 2.5%)	Actinic Keratosis	imiquimod cream 5%

Health Insurance Marketplace (HIM) Drug List Exclusions
DALIRESP - (roflumilast tab 250 mcg, 500 mcg)	Chronic Obstructive Pulmonary Disease	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
GILENYA - (fingolimod hcl cap 0.5 mg (base equivalent))	Multiple Sclerosis	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
PRADAXA - (dabigatran etexilate mesylate cap 150 mg (etexilate base equivalent))	Thromboembolism/stroke prophylaxis, DVT/PE Treatment, DVT/PE Prophylaxis	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
SUMATRIPTAN - (sumatriptan succinate solution catridge 4 mg/0.5 ml, 6 mg/0.5 ml))	Migraine	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
TRIMETHOPRIM - (trimethoprim tab 100 mg)	Bacterial Infections	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

1 Third-party brand names are the property of their respective owner.
2 This list is not all inclusive. Other medicines may be available in this drug class.

DISPENSING LIMIT CHANGES

The BCBSOK 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. Changes by drug list are listed on the chart below.

BCBSOK letters all members with a claim for a drug included in the Dispensing Limit Program, regardless of the prescribed dosage. This means members may receive a letter even though their prescribed dosage doesn’t meet or exceed the dispensing limit.

Effective April 1, 2023:

Drug Class and Medication(s)¹	Dispensing Limit(s)
Basic, Enhanced, Balanced, Performance, Performance Select and Health Insurance Marketplace (HIM) Drug Lists
Miscellaneous QL
Metronidazole 1% gel	60 grams per 30 days

Basic, Enhanced and Balanced Drug Lists
Radicava PAQL
Radicava ORS (edaravone oral suspension) 105 mg/5 mL	50 mLs per 28 days
Radicava ORS Starter Kit (edaravone oral suspension) 105 mg/5 mL	70 mLs per 180 days

Basic and Enhanced Drug Lists
Antifungals PAQL
Vivjoa (oteseconazole) cap therapy pack 150 mg	18 capsules per 180 days
Hyftor PAQL
Hyftor (sirolimus) gel 0.2%	7 tubes per 84 days

1Third-party brand names are the property of their respective owner.
* Not all members may have been notified due to limited utilization.

UTILIZATION MANAGEMENT PROGRAM CHANGES

Members were notified about the PA standard program changes listed in the tables below.

Drug categories or targets added to current pharmacy PA standard programs, effective April 1, 2023:

Drug Category	Targeted Medication(s)¹
Basic, Basic Multi-Tier, Enhanced, Enhanced Multi-Tier, Balanced, Performance, Performance Select and Health Insurance Marketplace (HIM) Drug Lists
Multiple Sclerosis	Gilenya (fingolimod) 0.5 mg capsule
Radicava	Radicava ORS (edaravone oral suspension) 105 mg/5 mL, Radicava ORS Starter Kit (edaravone oral suspension) 105 mg/5 mL

Drug Category		Targeted Medication(s)¹
Basic, Basic Multi-Tier, Enhanced, Enhanced Multi-Tier, Balanced, Performance and Performance Select Drug Lists
Antifungals	Vivjoa (oteseconazole) capsule therapy pack 150 mg
Hyftor	Hyftor (sirolimus) gel 0.2%
Zoryve	Zoryve (roflumilast) cream 0.3%

Drug Category	Targeted Medication(s)¹
Basic, Basic Multi-Tier, Enhanced, Enhanced Multi-Tier, Balanced, Performance and Performance Select Drug Lists
Factor VIII and von Willebrand Factor	Alphanate antihemophilic factor/vwf (human) for injection, Humate-P antihemophilic factor/vwf (human) for injection, Vonvendi von willebrand factor (recombinant) for injection, Wilate anithemophilic factor/vwf (human) for injection

Drug Category	Targeted Medication(s)¹
Basic, Basic Multi-Tier, Enhanced, Enhanced Multi-Tier, Balanced, Performance, Performance Select and Health Insurance Marketplace (HIM) Drug Lists
Therapeutic Alternatives	Prednisolone tab 5 mg

Drug Category		Targeted Medication(s)¹
Basic, Basic Multi-Tier, Enhanced, Enhanced Multi-Tier and Performance Drug Lists
Supplemental Therapeutic Alternatives	Winlevi (clascoterone) cream 1%

1Third-party brand names are the property of their respective owner.
* Not all members may have been notified due to limited utilization.

Other program changes being applied to pharmacy PA or Step Therapy (ST) standard programs include:

Effective Date	Program Name	Description of Change	Drug Lists	Program Type
Feb. 1, 2023	Lyrica CR PAQL	PA program retiring	Basic, Enhanced, 2022 Health Insurance Marketplace (HIM), 2023 HIM, Balanced, Performance, Performance Select	PA
Feb. 1, 2023	GLP-1 (Glucagon-like peptide-1) Agonists PA	New PA program with various target drugs.	2022 HIM, 2023 HIM	PA
March 1, 2023	Kerendia PAQL	New criteria requirements	Basic, Enhanced, 2022 HIM, 2023 HIM, Balanced, Performance, Performance Select	PA
April 1, 2023	Antifungals PAQL	Effective 4/1/23, the Antifungal Agents - Brexafemme (ibrexafungerp), Cresemba (isavuconazonium), Noxafil (posaconazole), Tolsura (itraconazole), Vfend (voriconazole), Vivjoa (oteseconazole) program will change its name to Antifungals.	Basic, Enhanced, 2022 HIM, 2023 HIM, Balanced, Performance, Performance Select	PA
April 1, 2023	Metformin PAQL	The program will change its name from Metformin ER to Metformin. Also, drug targets Riomet IR and metformin tab 625 mg are being moved to this program.	Basic, Enhanced, 2022 HIM, 2023 HIM, Balanced, Performance, Performance Select	PA
April 1, 2023	Multiple Sclerosis PAQL	New criteria requirements	Basic, Enhanced, 2022 HIM, 2023 HIM, Balanced, Performance, Performance Select	Specialty PA
April 1, 2023	Pancreatic Enzymes PAQL	New program with various target drugs. The targets have continuation of therapy in place and members with a drug regimen history will not be impacted.	Basic, Enhanced, Balanced, Performance, Performance Select	PA
April 1, 2023	Thrombopoietin Receptor Agonists and Tavalisse PAQL	Effective 4/1/23, the Thrombopoietin Receptor Agonists program will change its name to Thrombopoietin Receptor Agonists and Tavalisse.	Basic, Enhanced, 2022 HIM, 2023 HIM, Balanced, Performance, Performance Select	Specialty PA
April 1, 2023	Topical Non-Steroidal Anti-Inflammatory Drug STQL	New formularies added to existing ST program	Balanced, Performance Select	ST
April 1, 2023	Hyftor PAQL	New PA program with target Hyftor (sirolimus) gel 0.2%*	Basic, Enhanced, 2022 HIM, 2023 HIM, Balanced, Performance, Performance Select	PA
April 1, 2023	Zoryve PA	New PA program with target Zoryve (roflumilast) cream 0.3%*	Basic, Enhanced, 2022 HIM, 2023 HIM, Balanced, Performance, Performance Select	PA
April 1, 2023	Supplemental Therapeutic Alternatives PAQL	New target Winlevi (clascoterone) cream 1%*	Basic, Enhanced, 2022 HIM, 2023 HIM, Performance	PA
April 1, 2023	Therapeutic Alternatives PAQL	New target Prednisolone tab 5 mg*	Basic, Enhanced, 2022 HIM, 2023 HIM, Balanced, Performance, Performance Select	PA

1Third-party brand names are the property of their respective owner.
* Not all members may have been notified due to limited utilization.

Per our usual process of member notification prior to implementation, targeted mailings were sent to members affected by drug list revisions and/or exclusions and prior authorization program changes. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of our Provider website.

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 or MyPrime.com for a variety of online resources.

Change in Benefit Coverage for Select High Cost Products
Several high cost product 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 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:

Product(s) No Longer Covered^1*

Condition Used For

Covered Alternative(s)^1,2

PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA CAP 0.9 MG (Vita-PAC)

Vitamins

PRENATAL 19, VINATE M, PRENATAL+FE TAB 29-1, TRINATE, SE-NATAL 19

1 All brand names are the property of their respective owners.

2 This list is not all-inclusive. Other products may be available.

* This chart applies to members on the Basic, Multi-Tier Basic, Enhanced and Multi-Tier Enhanced Drug Lists.

New Dosages of Statin Drug to be Covered Without Cost Sharing

The United States Preventive Services Task Force (USPSTF) updated its guidance around statin coverage for the prevention of cardiovascular disease. Previously the guidance recommended low-to-moderate doses of statin for preventive use, but the new guidance doesn’t specify dosage strength.

To align with the updated recommendation, two new dosage strengths of atorvastatin will be added to the list of statins covered at the preventive level on the Affordable Care Act (ACA) $0 Preventive Drug List, without member cost sharing:

40 mg atorvastatin
80 mg atorvastatin

This change will go into effect April 1, 2023, for all non-grandfathered ACA-compliant plans, regardless of renewal date.

Pharmacies Added to Specialty Pharmacy Networks

As of January 1, 2023, we have added several new specialty pharmacies into our networks, including those for oral oncology and hemophilia. Members also now have access to the IntegratedRx™ (IRX) oral oncology network.

Christus Specialty Pharmacy, University Medical Center and Red Chip were added to select pharmacy networks/plans effective Jan. 1, 2023.

Reminder of Split Fill Program Category Expansion

As of Jan. 1, 2023, the Split Fill Program has been expanded to include additional categories beyond oral oncology medications, such as multiple sclerosis and iron toxicity.

BCBSOK offers its members and groups a Split Fill Program to reduce waste and help avoid costs of select specialty medications that may go unused. Members new to therapy (or have not had claims history within the past 120 days for the drug) are provided partial, or “split,” prescription fills for up to three months.

The Split Fill Program applies to a specific list of drugs known to have early discontinuation or dose modification. You can view the current list of drugs and find more information on the Split Fill Program on our Provider website. A version of this document is also available on our member pharmacy programs section of bcbsok.com.

Please call the number on the member’s ID card to verify coverage, or for further assistance or clarification on your patient’s benefits.

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.