May 2023
Pharmacy Program Quarterly Update, Part 2
Contents
Pharmacy Program Quarterly Update – Changes Effective April 1, 2023 — Part 2
Drug List Additions — As of April 1, 2023
Multi-Tier Basic and Multi-Tier Enhanced Drug Lists
Drug List Changes — Tier Changes (Effective April 1, 2023)
Balanced, Performance and Performance Select Drug Lists
Standard Utilization Management (UM) Program Package Changes
QL Increased on Initial Opioid Prescription for Members 19 Years Old and Younger
Genotropin® Added as a Preferred Brand to All Formularies
New Dosages of Statin Drug to be Covered without Cost Sharing
Pharmacies Added to Specialty Pharmacy Networks
Pharmacy Program Quarterly Update – Changes Effective April 1, 2023 — Part 2
Update: This article is a continuation of the previously published April 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.
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. Both additions effective April 1, 2023, and previous updates, are outlined below.
Drug List Additions — As of April 1, 2023
| Multi-Tier Basic and Multi-Tier Enhanced Drug Lists | |
|---|---|
| Drug1 | Drug Class/Condition Used For |
| ALECENSA (alectinib hcl cap 150 mg (base equivalent)) | Cancer |
| ALUNBRIG (brigatinib tab 30 mg, 90 mg, 180 mg) | Cancer |
| ALUNBRIG (brigatinib tab initiation therapy pack 90 mg & 180 mg) | Cancer |
| BRUKINSA (zanubrutinib cap 80 mg) | Cancer |
| CALQUENCE (acalabrutinib cap 100 mg) | Cancer |
| ALQUENCE (acalabrutinib maleate tab 100 mg) | Cancer |
| DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT (continuous blood glucose system sensor) | Diabetes |
| DEXCOM G5 RECEIVER KIT (continuous blood glucose system receiver) | Diabetes |
| DEXCOM G5 MOBILE RECEIVER KIT (continuous blood glucose system receiver) | Diabetes |
| DEXCOM G6 SENSOR (continuous blood glucose system sensor) | Diabetes |
| DEXCOM G6 TRANSMITTER (continuous blood glucose system transmitter) | Diabetes |
| DEXCOM G7 RECEIVER (continuous blood glucose system receiver) | Diabetes |
| DEXCOM G7 SENSOR (continuous blood glucose system sensor) | Diabetes |
| ETOPOSIDE (etoposide cap 50 mg) | Cancer |
| GENOTROPIN (somatropin for subcutaneous inj cartridge 12 mg (36 unit)) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature |
| GENOTROPIN (somatropin for subcutaneous inj cartridge 5 mg) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature |
| GENOTROPIN MINIQUICK (somatropin for subcutaneous inj prefilled syr 0.2 mg, 0.4 mg, 0.6 mg, 0.8 mg, 1 mg, 1.2 mg, 1.4 mg, 1.6 mg, 1.8 mg, 2 mg) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature |
| GLEOSTINE (lomustine cap 10 mg, 40 mg, 100 mg) | Cancer |
| MATULANE (procarbazine hcl cap 50 mg) | Cancer |
| MOUNJARO (tirzepatide soln pen-injector 2.5 mg/0.5ml, 5 mg/0.5ml, 7.5 mg/0.5ml, 10 mg/0.5ml, 12.5 mg/0.5ml, 15 mg/0.5ml) | Diabetes |
| TAGRISSO (osimertinib mesylate tab 40 mg, 80 mg (base equivalent)) | Cancer |
| Balanced Drug List | |
|---|---|
| Drug1 | Drug Class/Condition Used For |
| DEXCOM G7 RECEIVER (continuous blood glucose system receiver) | Diabetes |
| DEXCOM G7 SENSOR (continuous blood glucose system sensor) | Diabetes |
| ENTADFI (finasteride-tadalafil cap 5-5 mg) | Benign Prostatic Hyperplasia |
| HYFTOR (sirolimus gel 0.2%) | Facial Angiofibroma, tuberous sclerosis associated |
| KYZATREX (testosterone undecanoate cap 100 mg, 150 mg, 200 mg) | Testosterone Replacement - Males |
| MOUNJARO (tirzepatide soln pen-injector 10 mg/0.5 ml, 12.5 mg/0.5 ml, 15 mg/0.5 ml, 2.5 mg/0.5 ml, 5 mg/0.5 ml, 7.5 mg/0.5 ml) | Diabetes |
| RYALTRIS (olopatadine hcl-mometasone furoate nasal susp 665-25 mcg/act) | Seasonal Allergic Rhinitis |
| VIVJOA (oteseconazole cap therapy pack 150 mg (12 weeks)) | Vulvovaginal Candidiasis |
| Performance Drug List | |
|---|---|
| Drug1 | Drug Class/Condition Used For |
| DEXCOM G7 RECEIVER (continuous blood glucose system receiver) | Diabetes |
| DEXCOM G7 SENSOR (continuous blood glucose system sensor) | Diabetes |
| HYFTOR (sirolimus gel 0.2%) | Facial Angiofibroma, tuberous sclerosis associated |
| MOUNJARO (tirzepatide soln pen-injector 10 mg/0.5 ml, 12.5 mg/0.5 ml, 15 mg/0.5 ml, 2.5 mg/0.5 ml, 5 mg/0.5 ml, 7.5 mg/0.5 ml) | Diabetes |
| Performance Select Drug List | |
|---|---|
| Drug1 | Drug Class/Condition Used For |
| DEXCOM G7 RECEIVER (continuous blood glucose system receiver) | Diabetes |
| DEXCOM G7 SENSOR (continuous blood glucose system sensor) | Diabetes |
| HYFTOR (sirolimus gel 0.2%) | Facial Angiofibroma, tuberous sclerosis associated |
| MOUNJARO (tirzepatide soln pen-injector 10 mg/0.5 ml, 12.5 mg/0.5 ml, 15 mg/0.5 ml, 2.5 mg/0.5 ml, 5 mg/0.5 ml, 7.5 mg/0.5 ml) | Diabetes |
1 Third-party brand names are the property of their respective owner.
Other Drug-List Additions
Most additions to the drug list become effective quarterly, however, some drugs are added as part of formulary maintenance (e.g., new strength of covered drug) or re-evaluated during the quarter and are added to the list then. Those drugs are listed below.
| Balanced Drug List | ||
|---|---|---|
| Drug1 | Drug Class/Condition Used For | Effective Date |
| ADTHYZA (thyroid tab 16.25 mg, 32.5 mg, 65 mg, 97.5 mg, 130 mg) | Hypothyroidism | 2/19/23 |
| ATROPINE SULFATE (atropine sulfate ophth soln 1%) | Amblyopia/Cycloplegia | 1/22/23 |
| brimonidine tartrate gel 0.33% (base equivalent) | Rosacea | 1/8/23 |
| BUTALBITAL/ACETAMINOPHEN (butalbital-acetaminophen tab 25-325 mg) | Tension Headache | 1/1/23 |
| CORTISONE ACETATE (cortisone acetate tab 25 mg) | Anti-inflammatory | 1/29/23 |
| COVID-19 AT-HOME TEST KIT (covid-19 at home antigen test kit) | COVID-19 Test | 2/5/23 |
| dexlansoprazole cap delayed release 30 mg, 60 mg | Gastroesophageal Reflux Disease (GERD) | 1/29/23 |
| dichlorphenamide tab 50 mg | Primary Periodic Paralysis | 1/22/23 |
| DICLOFENAC EPOLAMINE (diclofenac epolamine patch 1.3%) | Pain | 1/1/23 |
| estradiol valerate IM in oil 10 mg/ml | Menopausal vasomotor symptoms | 1/22/23 |
| GENOTROPIN (somatropin for subcutaneous inj cartridge 12 mg (36 unit)) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature | 1/13/23 |
| GENOTROPIN (somatropin for subcutaneous inj cartridge 5 mg,) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature | 1/13/23 |
| lurasidone hcl tab 20 mg, 40 mg, 60 mg, 80 mg, 120 mg | Bipolar Major Depression/Schizophrenia | 1/29/23 |
| MENEST (esterified estrogens tab 2.5 mg) | Menopausal vasomotor symptoms | 1/31/23 |
| OXBRYTA (voxelotor tab 300 mg) | Sickle Cell Disease | 1/1/23 |
| pirfenidone cap 267 mg | Idiopathic Pulmonary Fibrosis | 1/15/23 |
| REBINYN (coagulation factor ix recomb glycopegylated for inj 3000 unit) | Hemophilia B | 2/19/23 |
| ROTARIX (rotavirus vaccine, live oral susp) | Rotavirus Vaccine | 2/5/23 |
| SODIUM OXYBATE (sodium oxybate oral solution 500 mg/ml) | Narcolepsy | 1/15/23 |
| TAKHZYRO (lanadelumab-flyo soln pref syringe 150 mg/ml) | Hereditary Angioedema | 2/19/23 |
| tasimelteon capsule 20 mg | Sleep Disorders | 1/1/23 |
| testosterone cypionate IM inj in oil 200 mg/ml | Hypogonadism | 1/1/23 |
| topiramate cap er 24hr 25 mg, 50 mg, 100 mg | Epilepsy, Migraine | 1/8/23 |
| TRAMADOL HYDROCHLORIDE (tramadol hcl oral soln 5 mg/ml) | Pain | 1/29/23 |
| VTAMA (tapinarof cream 1%) | Plaque Psoriasis | 2/1/23 |
| Performance Drug Lists | ||
|---|---|---|
| Drug1 | Drug Class/Condition Used For | Effective Date |
| ADTHYZA (thyroid tab 16.25 mg, 32.5 mg, 65 mg, 97.5 mg, 130 mg) | Hypothyroidism | 2/19/23 |
| brimonidine tartrate gel 0.33% (base equivalent) | Rosacea | 1/8/23 |
| COVID-19 AT-HOME TEST KIT (covid-19 at home antigen test kit) | Covid-19 Test | 2/5/23 |
| estradiol valerate IM in oil 10 mg/ml | Menopausal vasomotor symptoms | 1/22/23 |
| GENOTROPIN (somatropin for subcutaneous inj cartridge 12 mg (36 unit)) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature | 1/13/23 |
| GENOTROPIN (somatropin for subcutaneous inj cartridge 5 mg,) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature | 1/13/23 |
| GENOTROPIN MINIQUICK (somatropin for subcutaneous inj prefilled syr 0.2 mg, 0.4 mg, 0.6 mg, 0.8 mg, 1 mg, 1.2 mg, 1.4 mg, 1.6 mg, 1.8 mg, 2 mg) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature | 1/13/23 |
| lurasidone hcl tab 20 mg, 40 mg, 60 mg, 80 mg, 120 mg | Bipolar Major Depression/Schizophrenia | 1/29/23 |
| MENEST (esterified estrogens tab 2.5 mg) | Menopausal vasomotor symptoms | 1/31/23 |
| OXBRYTA (voxelotor tab 300 mg) | Sickle Cell Disease | 1/1/23 |
| pirfenidone cap 267 mg | Idiopathic Pulmonary Fibrosis | 1/15/23 |
| REBINYN (coagulation factor ix recomb glycopegylated for inj 3000 unit) | Hemophilia B | 2/19/23 |
| ROTARIX (rotavirus vaccine, live oral susp) | Rotavirus Vaccine | 2/5/23 |
| ROTARIX (rotavirus vaccine, live oral susp) | Rotavirus Vaccine | 2/5/23 |
| SODIUM OXYBATE (sodium oxybate oral solution 500 mg/ml) | Narcolepsy | 1/15/23 |
| TAKHZYRO (lanadelumab-flyo soln pref syringe 150 mg/ml) | Hereditary Angioedema | 2/19/23 |
| tasimelteon capsule 20 mg | Sleep Disorders | 1/1/23 |
| topiramate cap er 24hr 25 mg, 50 mg, 100 mg | Epilepsy, Migraine | 1/8/23 |
| Performance Select Drug Lists | ||
|---|---|---|
| Drug1 | Drug Class/Condition Used For | Effective Date |
| adapalene-benzoyl peroxide gel 0.3-2.5% | Acne | 1/1/23 |
| ADTHYZA (thyroid tab 16.25 mg, 32.5 mg, 65 mg, 97.5 mg, 130 mg) | Hypothyroidism | 2/19/23 |
| ATROPINE SULFATE (atropine sulfate ophth soln 1%) | Amblyopia/Cycloplegia | 1/22/23 |
| brimonidine tartrate gel 0.33% (base equivalent) | Rosacea | 1/8/23 |
| COVID-19 AT-HOME TEST KIT (covid-19 at home antigen test kit) | COVID-19 Test | 2/5/23 |
| dexlansoprazole cap delayed release 30 mg, 60 mg | Gastroesophageal Reflux Disease (GERD) | 1/29/23 |
| estradiol valerate IM in oil 10 mg/ml | Menopausal vasomotor symptoms | 1/22/23 |
| GENOTROPIN (somatropin for subcutaneous inj cartridge 12 mg (36 unit)) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature | 1/13/23 |
| GENOTROPIN (somatropin for subcutaneous inj cartridge 5 mg,) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature | 1/13/23 |
| GENOTROPIN MINIQUICK (somatropin for subcutaneous inj prefilled syr 0.2 mg, 0.4 mg, 0.6 mg, 0.8 mg, 1 mg, 1.2 mg, 1.4 mg, 1.6 mg, 1.8 mg, 2 mg) | Growth Hormone Deficiency, Prader-Willi syndrome, Small for Gestational Age, Turner syndrome, Idiopathic Short Stature | 1/13/23 |
| lurasidone hcl tab 20 mg, 40 mg, 60 mg, 80 mg, 120 mg | Bipolar Major Depression/Schizophrenia | 1/29/23 |
| MENEST (esterified estrogens tab 2.5 mg) | Menopausal vasomotor symptoms | 1/31/23 |
| OXBRYTA (voxelotor tab 300 mg) | Sickle Cell Disease | 1/1/23 |
| pirfenidone cap 267 mg | Idiopathic Pulmonary Fibrosis | 1/15/23 |
| REBINYN (coagulation factor ix recomb glycopegylated for inj 3000 unit) | Hemophilia B | 2/19/23 |
| ROTARIX (rotavirus vaccine, live oral susp) | Rotavirus Vaccine | 2/5/23 |
| SODIUM OXYBATE (sodium oxybate oral solution 500 mg/ml) | Narcolepsy | 1/15/23 |
| TAKHZYRO (lanadelumab-flyo soln pref syringe 150 mg/ml) | Hereditary Angioedema | 2/19/23 |
| tasimelteon capsule 20 mg | Sleep Disorders | 1/1/23 |
| testosterone cypionate IM inj in oil 200 mg/ml | Hypogonadism | 1/1/23 |
| topiramate cap er 24hr 25 mg, 50 mg, 100 mg | Epilepsy, Migraine | 1/8/23 |
| VTAMA (tapinarof cream 1%) | Plaque Psoriasis | 2/1/23 |
Drug List Changes — Tier Changes (Effective April 1, 2023)
| Balanced, Performance and Performance Select Drug Lists | ||
|---|---|---|
| Drug1 | New Lower Tier | Drug Class/Condition |
| BRUKINSA (zanubrutinib cap 80 mg) | Preferred Brand | Cancer |
| CALQUENCE (acalabrutinib cap 100 mg) | Preferred Brand | Cancer |
| CALQUENCE (acalabrutinib maleate tab 100 mg) | Preferred Brand | Cancer |
Dispensing Limit Changes
BCBSOK’s 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. New dispensing limits and effective dates are listed on the chart below.
| Basic, Enhanced, Balanced, Performance, Performance Select and Health Insurance Marketplace (HIM) Drug Lists | ||
|---|---|---|
| Drug Class and Medication(s)1 | New Dispensing Limit | Effective Date |
| D.H.E. 45 Dihydroergotamine Mesylate Inj 1 mg/ mL | 24 ampules for 28 days | 1/15/2023 |
| Dulera 50-5 mcg/act, 100-5 mcg/act, 200-5 mcg/act | 3 inhalers per 30 days | 4/15/2023 |
| Lucemyra 0.18mg tab | N/A - Termed | 3/15/2023 |
| Lyrica CR 82.5 mg tab, 165 mg tab, 330mg tab | N/A - Termed | 2/1/2023 |
| Sucraid Sacrosidase soln 8500 unit/mL | 300 mL per 30 days | 1/15/2023 |
| Symbicort 80 mcg/act, 160 mcg/act | 3 inhalers per 30 days | 4/15/2023 |
1 Third-party brand names are the property of their respective owner.
Standard Utilization Management (UM) Program Package Changes
The following programs have changes effective this quarter.
- Lyrica CR PAQL program was retired Feb. 1, 2023.
- Mounjaro was added as preferred drug to the GLP-1 Agonists PA program effective Jan. 1, 2023.
- Nizatidine and Riomet ER oral solution were removed from the Alternative Dosage PA program effective April 1, 2023. Riomet oral solution was moved to the Metformin PAQL program.
- The Growth Hormone program will include Genotropin as a co-preferred agent effective May 1, 2023.
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.
QL Increased on Initial Opioid Prescription for Members 19 Years Old and Younger
Effective Apr. 15, 2023, BCBSOK’s Appropriate Use of Opioids program is increasing quantity limits of immediate-release (IR) opioids for members 19 years and younger in response to updated CDC guidelines. This increase only applies to the first prescription and is for members who are “opioid naïve” — those who have not filled an IR opioid prescription within the past 60 days.
Prescribers can now issue a seven-day supply rather than the former three-day supply. This is reversing a previous change that went into effect Jan. 1, 2022
- Members with an oncology or sickle cell medication on hand in the past 90 days per pharmacy claims will not be subject to the day supply limit.
- All ages will have a 7-day supply limit on an initial fill of an immediate-release opioid medication.
Genotropin® Added as a Preferred Brand to All Formularies
Due to shortages of the preferred drug Norditropin®, Genotropin® has been added to the preferred brand formularies effective, 1/13/2023. Both Norditropin® and Genotropin® will be covered as preferred-brand options.
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, the following 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
We have added several new specialty pharmacies into our 2023 specialty pharmacy networks, including those for oral oncology and hemophilia. Members also now have access to the IntegratedRxTM (IRX) oral oncology and cystic fibrosis networks. IRX is a clinically integrated program that allows members to receive their oral oncology or cystic fibrosis prescriptions, as well as other select medications, in their health care provider’s clinic or hospital pharmacy.
Christus Specialty Pharmacy, University Medical Center and Red Chip were added to specialty pharmacy networks effective Jan. 1, 2023. Members can view the specialty vendor list on MyPrime.com.
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.