Quarterly Pharmacy Program Update Changes Effective October 1, 2023

November 2023

Quarterly Pharmacy Program Update Changes Effective October 1, 2023 – Part 2

Contents

Drug List Changes
Drug List Additions – Effective October 1, 2023
Balanced Drug List
Performance Drug List
Performance Select Drug List
Basic, Enhanced, Multi-Tier Basic and Multi-Tier Enhanced Drug Lists
Other Drug List Additions
Balanced Drug List
Performance Drug List
Performance Select Drug List
Basic, Basic Multi-Tier, Enhanced, Enhanced Multi-Tier Drug Lists
Drug List Tier Changes
Balanced Drug List
Performance Drug List
Performance Select Drug List
Other Drug List Tier Changes
Balanced Drug List
Performance Drug List
Performance Select Drug List
Utilization Management Program Changes
Dispensing Limit Changes
Basic, Enhanced, Balanced, Performance, Performance Select and Health Insurance Marketplace (HIM) Drug Lists
Standard Utilization Management Program Updates
Pharmacy Benefits Updates
Update: RSV Vaccine Coverage

Update: This article is a continuation of the previously published October Quarterly Pharmacy Changes Part 1. 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.

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 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 October 1, 2023, and previous updates are outlined below.

Drug List Additions – Effective October 1, 2023

Balanced Drug List
Drug¹	Condition
AUSTEDO XR (deutetrabenazine tab er 24hr 6 mg, 12 mg, 24 mg)	Huntington Disease Associated Chorea, Tardive Dyskinesia
AUSTEDO XR PATIENT TITRATION KIT (deutetrabenazine tab er titration pack 6 mg, 12 mg, 24 mg)	Huntington Disease Associated Chorea, Tardive Dyskinesia
AZSTARYS (serdexmethylphenidate-dexmethylphenidate cap 26.1-5.2 mg, 39.2-7.8 mg, 52.3-10.4 mg)	ADHD
DAYBUE (trofinetide oral soln 200 mg/ml)	Rett Syndrome
FILSPARI (sparsentan tab 200 mg, 400 mg)	IgA Nephropathy, primary
glatiramer acetate soln prefilled syringe 20 mg/ml, 40 mg/ml	Multiple Sclerosis
JAYPIRCA (pirtobrutinib tab 50 mg, 100 mg)	Cancer
KONVOMEP (omeprazole-sodium bicarbonate for oral susp 2-84 mg/ml)	Gastric Ulcer, Upper GI Bleeding Prophylaxis
ORSERDU (elacestrant hydrochloride tab 86 mg, 345 mg)	Cancer
OVIDREL (choriogonadotropin alfa inj 250 mcg/0.5 ml)	Infertility
PRADAXA (dabigatran etexilate mesylate pellet pack 20 mg, 30 mg, 40 mg, 50 mg, 110 mg, 150 mg)	Thromboembolism/stroke prophylaxis, DVT/PE Treatment, DVT/PE Prophylaxis
SKYCLARYS (omaveloxolone cap 50 mg)	Friedreich Ataxia

Performance Drug List
Drug¹	Condition
AUSTEDO XR (deutetrabenazine tab er 24hr 6 mg, 12 mg, 24 mg)	Huntington Disease Associated Chorea, Tardive Dyskinesia
AUSTEDO XR PATIENT TITRATION KIT (deutetrabenazine tab er titration pack 6 mg, 12 mg, 24 mg)	Huntington Disease Associated Chorea, Tardive Dyskinesia
DAYBUE (trofinetide oral soln 200 mg/ml)	Rett Syndrome
FILSPARI (sparsentan tab 200 mg, 400 mg)	IgA Nephropathy, primary
glatiramer acetate soln prefilled syringe 20 mg/ml, 40 mg/ml	Multiple Sclerosis
hydroxychloroquine sulfate tab 100 mg, 300 mg, 400 mg	Malaria, Lupus, Rheumatoid Arthritis
JAYPIRCA (pirtobrutinib tab 50 mg, 100 mg)	Cancer
ORSERDU (elacestrant hydrochloride tab 86 mg, 345 mg)	Cancer
OVIDREL (choriogonadotropin alfa inj 250 mcg/0.5 ml)	Infertility
PRADAXA (dabigatran etexilate mesylate pellet pack 20 mg, 30 mg, 40 mg, 50 mg, 110 mg, 150 mg)	Thromboembolism/stroke prophylaxis, DVT/PE Treatment, DVT/PE Prophylaxis
SKYCLARYS (omaveloxolone cap 50 mg)	Friedreich Ataxia

Performance Select Drug List
Drug¹	Condition
AUSTEDO XR (deutetrabenazine tab er 24hr 6 mg, 12 mg, 24 mg)	Huntington Disease Associated Chorea, Tardive Dyskinesia
AUSTEDO XR PATIENT TITRATION KIT (deutetrabenazine tab er titration pack 6 mg, 12 mg, 24 mg)	Huntington Disease Associated Chorea, Tardive Dyskinesia
AZSTARYS (serdexmethylphenidate-dexmethylphenidate cap 26.1-5.2 mg, 39.2-7.8 mg, 52.3-10.4 mg)	ADHD
DAYBUE (trofinetide oral soln 200 mg/ml)	Rett Syndrome
FILSPARI (sparsentan tab 200 mg, 400 mg)	IgA Nephropathy, primary
glatiramer acetate soln prefilled syringe 20 mg/ml, 40 mg/ml	Multiple Sclerosis
hydroxychloroquine sulfate tab 100 mg, 300 mg, 400 mg	Malaria, Lupus, Rheumatoid Arthritis
JAYPIRCA (pirtobrutinib tab 50 mg, 100 mg)	Cancer
ORSERDU (elacestrant hydrochloride tab 86 mg, 345 mg)	Cancer
OVIDREL (choriogonadotropin alfa inj 250 mcg/0.5 ml)	Infertility
PRADAXA (dabigatran etexilate mesylate pellet pack 20 mg, 30 mg, 40 mg, 50 mg, 110 mg, 150 mg)	Thromboembolism/stroke prophylaxis, DVT/PE Treatment, DVT/PE Prophylaxis
SKYCLARYS (omaveloxolone cap 50 mg)	Friedreich Ataxia

Basic, Enhanced, Multi-Tier Basic and Multi-Tier Enhanced Drug Lists
Drug¹	Condition
OVIDREL (choriogonadotropin alfa inj 250 mcg/0.5 ml)	Infertility
PREGNYL W/DILUENT BENZYLALCOHOL/NACL (chorionic gonadotropin for im inj 10,000 unit)	Hypogonadotrophic hypogonadism, Prepubertal cryptorchidism, Infertility
REXULTI (brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3, mg, 4 mg)	Depression, Schizophrenia, Dementia-associated agitation in Alzheimer dz

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 then added to the list.
Those drugs are listed below.

Balanced Drug List
Drug¹	Condition	Date Added
ABRYSVO (rsv pre-fusion f a&b vac recomb for im soln 120 mcg/0.5 ml)	RSV Vaccine	9/1/23
AFLURIA QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/16/23
AFLURIA QUADRIVALENT 2023-2024 (influenza virus vaccine split quadrivalent im inj)	Flu vaccine	7/16/23
alendronate sodium oral soln 70 mg/75 ml	Osteoporosis, Paget Bone dz	5/21/23
AMJEVITA (adalimumab-atto soln prefilled syringe 10 mg/0.2 ml, 20 mg/0.4 ml, 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
AMJEVITA (adalimumab-atto soln auto-injector 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
AREXVY (rsvpref3 vaccine recomb adjuvanted for im susp 120 mcg/0.5 ml)	RSV Vaccine	9/1/23
baclofen susp 25 mg/5 ml	Multiple Sclerosis and Spinal Cord Lesions	6/25/23
COSENTYX UNOREADY (secukinumab subcutaneous soln auto-injector 300 mg/2 ml)	Psoriasis/Psoriatic arthritis	7/30/23
CYLTEZO (adalimumab-adbm auto-injector kit 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
CYLTEZO (adalimumab-adbm prefilled syringe kit 10 mg/0.2 ml, 20 mg/0.4 ml, 40 mg/0.8 ml))	Autoimmune Disease	7/1/23
CYLTEZO STARTER PACKAGE FOR CROHNS DISEASE/UC/HS (adalimumab-adbm auto-injector kit 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
CYLTEZO STARTER PACKAGE FOR PSORIASIS (adalimumab-adbm auto-injector kit 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
darunavir tab 600 mg, 800 mg (generic for PREZISTA)	HIV	6/4/23
FLUAD QUADRIVALENT 2023-2024 (influenza vac type a & b surface ant adj quad pref syr 0.5 ml)	Flu Vaccine	7/16/23
FLUARIX QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu Vaccine	7/9/23
FLUBLOK QUADRIVALENT 2023-2024 (influenza vac recomb ha quad pf soln pref syr 0.5 ml)	Flu vaccine	7/23/23
FLUCELVAX QUADRIVALENT 2023-2024 (influenza vac tiss-cult subunit quad susp pref syr 0.5 ml)	Flu vaccine	7/16/23
FLUCELVAX QUADRIVALENT 2023-2024 (influenza vac tissue-cultured subunit quadrivalent im susp)	Flu vaccine	7/16/23
FLULAVAL QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/9/23
FLUZONE HIGH-DOSE PF 2023-2024 (influenza vac split high-dose quad pf susp pref syr 0.7 ml)	Flu vaccine	7/23/23
FLUZONE QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/23/23
FLUZONE QUADRIVALENT 2023-2024 (influenza virus vaccine split quadrivalent im inj)	Flu vaccine	7/23/23
MECLIZINE HYDROCHLORIDE (meclizine hcl tab 50 mg)	Vertigo, Motion Sickness	7/16/23
NIVA THYROID (thyroid tab 15 mg (¼ grain), 30 mg (½ grain), 60 mg (1 grain), 90 mg (1 ½ grain), 120 mg (2 grain))	Hypothyroidism	8/13/23
SUNLENCA (lenacapavir sodium tab therapy pack 4 x 300 mg, 5 x 300 mg)	HIV	8/1/23
TALZENNA (talazoparib tosylate cap 0.1 mg, 0.35 mg (base equivalent))	Cancer	7/2/23
THYROID (15 mg (¼ grain), 30 mg (½ grain), 60 mg (1 grain), 90 mg (1 ½ grain), 120 mg (2 grain))	Hypothyroidism	7/2/23
TOLMETIN SODIUM (tolmetin sodium cap 400 mg)	Arthritis	8/6/23
vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent) (generic for FIRVANQ)	C. Difficile Infection, Staphylococcal Enterocolitis	7/2/23
ZEJULA (niraparib tosylate tab 100 mg, 200 mg, 300 mg (base equivalent))	Cancer	6/25/23
ZEPOSIA STARTER KIT (ozanimod cap pack 4 x 0.23 mg & 3 x 0.46 mg & 21 x 0.92 mg)	Multiple Sclerosis, Ulcerative Colitis	6/11/23

Performance Drug List
Drug¹	Condition	Date Added
ABRYSVO (rsv pre-fusion f a&b vac recomb for im soln 120 mcg/0.5 ml)	RSV Vaccine	9/1/23
AFLURIA QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/16/23
AFLURIA QUADRIVALENT 2023-2024 (influenza virus vaccine split quadrivalent im inj)	Flu vaccine	7/16/23
AMJEVITA (adalimumab-atto soln auto-injector 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
AMJEVITA (adalimumab-atto soln prefilled syringe 10 mg/0.2 ml, 20 mg/0.4 ml, 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
AREXVY (rsvpref3 vaccine recomb adjuvanted for im susp 120 mcg/0.5 ml)	RSV Vaccine	9/1/23
COSENTYX UNOREADY (secukinumab subcutaneous soln auto-injector 300 mg/2 ml)	Psoriasis/Psoriatic arthritis	7/30/23
darunavir tab 600 mg, 800 mg	HIV	6/4/23
FLUAD QUADRIVALENT 2023-2024 (influenza vac type a&b surface ant adj quad pref syr 0.5 ml)	Flu Vaccine	7/16/23
FLUARIX QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu Vaccine	7/9/23
FLUBLOK QUADRIVALENT 2023-2024 (influenza vac recomb ha quad pf soln pref syr 0.5 ml)	Flu vaccine	7/23/23
FLUCELVAX QUADRIVALENT 2023-2024 (influenza vac tiss-cult subunt quad susp pref syr 0.5 ml)	Flu vaccine	7/16/23
FLUCELVAX QUADRIVALENT 2023-2024 (influenza vac tissue-cultured subunit quadrivalent im susp)	Flu vaccine	7/16/23
FLULAVAL QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/9/23
FLUZONE HIGH-DOSE PF 2023-2024 (influenza vac split high-dose quad pf susp pref syr 0.7 ml)	Flu vaccine	7/23/23
FLUZONE QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/23/23
FLUZONE QUADRIVALENT 2023-2024 (influenza virus vaccine split quadrivalent im inj)	Flu vaccine	7/23/23
HADLIMA (adalimumab-bwwd soln prefilled syringe 40 mg/0.4 ml, 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
HADLIMA PUSHTOUCH (adalimumab-bwwd soln auto-injector 40 mg/0.4 ml, 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
NIVA THYROID (thyroid tab 15 mg (¼ grain), 30 mg (½ grain), 60 mg (1 grain), 90 mg (1 ½ grain), 120 mg (2 grain))	Hypothyroidism	8/13/23
SUNLENCA (lenacapavir sodium tab therapy pack 4 x 300 mg, 5 x 300 mg)	HIV	8/1/23
TALZENNA (talazoparib tosylate cap 0.1 mg, 0.35 mg (base equivalent))	Cancer	7/2/23
THYROID (15 mg (¼ grain), 30 mg (½ grain), 60 mg (1 grain), 90 mg (1 ½ grain), 120 mg (2 grain))	Hypothyroidism	7/2/23
vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent) (generic for FIRVANQ)	C. Difficile Infection, Staphylococcal Enterocolitis	7/31/23
ZEJULA (niraparib tosylate tab 100 mg, 200 mg, 300 mg (base equivalent))	Cancer	6/25/23
ZEPOSIA STARTER KIT (ozanimod cap pack 4 x 0.23 mg & 3 x 0.46 mg & 21 x 0.92 mg)	Multiple Sclerosis, Ulcerative Colitis	6/11/23

Performance Select Drug List
Drug¹	Condition	Date Added
ABRYSVO (rsv pre-fusion f a&b vac recomb for im soln 120 mcg/0.5 ml)	RSV Vaccine	9/1/23
AFLURIA QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/16/23
AFLURIA QUADRIVALENT 2023-2024 (influenza virus vaccine split quadrivalent im inj)	Flu vaccine	7/16/23
AMJEVITA (adalimumab-atto soln auto-injector 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
AMJEVITA (adalimumab-atto soln prefilled syringe 10 mg/0.2 ml, 20 mg/0.4 ml, 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
AREXVY (rsvpref3 vaccine recomb adjuvanted for im susp 120 mcg/0.5 ml)	RSV Vaccine	9/1/23
COSENTYX UNOREADY (secukinumab subcutaneous soln auto-injector 300 mg/2 ml)	Psoriasis/Psoriatic arthritis	7/30/23
CYLTEZO (adalimumab-adbm auto-injector kit 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
CYLTEZO (adalimumab-adbm prefilled syringe kit 10 mg/0.2 ml, 20 mg/0.4 ml, 40 mg/0.8 ml))	Autoimmune Disease	7/1/23
CYLTEZO STARTER PACKAGE FOR CROHNS DISEASE/UC/HS (adalimumab-adbm auto-injector kit 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
CYLTEZO STARTER PACKAGE FOR PSORIASIS (adalimumab-adbm auto-injector kit 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
darunavir tab 600 mg, 800 mg	HIV	6/4/23
FLUAD QUADRIVALENT 2023-2024 (influenza vac type a&b surface ant adj quad pref syr 0.5 ml)	Flu Vaccine	7/16/23
FLUARIX QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu Vaccine	7/9/23
FLUBLOK QUADRIVALENT 2023-2024 (influenza vac recomb ha quad pf soln pref syr 0.5 ml)	Flu vaccine	7/23/23
FLUCELVAX QUADRIVALENT 2023-2024 (influenza vac tiss-cult subunit quad susp pref syr 0.5 ml)	Flu vaccine	7/16/23
FLUCELVAX QUADRIVALENT 2023-2024 (influenza vac tissue-cultured subunit quadrivalent im susp)	Flu vaccine	7/16/23
FLULAVAL QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/9/23
FLUZONE HIGH-DOSE PF 2023-2024 (influenza vac split high-dose quad pf susp pref syr 0.7 ml)	Flu vaccine	7/23/23
FLUZONE QUADRIVALENT 2023-2024 (influenza virus vac split quadrivalent susp pref syr 0.5 ml)	Flu vaccine	7/23/23
FLUZONE QUADRIVALENT 2023-2024 (influenza virus vaccine split quadrivalent im inj)	Flu vaccine	7/23/23
NIVA THYROID (thyroid tab 15 mg (¼ grain), 30 mg (½ grain), 60 mg (1 grain), 90 mg (1 ½ grain), 120 mg (2 grain))	Hypothyroidism	8/13/23
SUNLENCA (lenacapavir sodium tab therapy pack 4 x 300 mg, 5 x 300 mg)	HIV	8/1/23
TALZENNA (talazoparib tosylate cap 0.1 mg, 0.35 mg (base equivalent))	Cancer	7/2/23
THYROID (15 mg (¼ grain), 30 mg (½ grain), 60 mg (1 grain), 90 mg (1 ½ grain), 120 mg (2 grain))	Hypothyroidism	7/2/23
vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent) (generic for FIRVANQ)	C. Difficile Infection, Staphylococcal Enterocolitis	7/31/23
ZEJULA (niraparib tosylate tab 100 mg, 200 mg, 300 mg (base equivalent))	Cancer	6/25/23
ZEPOSIA STARTER KIT (ozanimod cap pack 4 x 0.23 mg & 3 x 0.46 mg & 21 x 0.92 mg)	Multiple Sclerosis, Ulcerative Colitis	6/11/23

Basic, Basic Multi-Tier, Enhanced, Enhanced Multi-Tier Drug Lists
Drug¹	Condition	Date Added
AMJEVITA (adalimumab-atto soln auto-injector 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
AMJEVITA (adalimumab-atto soln prefilled syringe 10 mg/0.2 ml, 20 mg/0.4 ml, 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
COSENTYX (secukinumab subcutaneous soln auto-injector 300 mg/2 ml)	Psoriasis/Psoriatic arthritis	7/30/23
HADLIMA (adalimumab-bwwd soln prefilled syringe 40 mg/0.4 ml, 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
HADLIMA PUSHTOUCH (adalimumab-bwwd soln auto-injector 40 mg/0.4 ml, 40 mg/0.8 ml)	Autoimmune Disease	7/1/23
HUMATIN (paromomycin sulfate cap 250 mg)	Intestinal Amebiasis, Hepatic Encephalopathy	7/2/23

Drug List Tier Changes
Tier changes effective October 1, 2023, are outlined below.

Balanced Drug List
Drug¹	Condition	New Lower Tier
REXULTI (brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg)	Depression, Schizophrenia, Dementia-associated agitation in Alzheimer dz	Preferred Brand
Performance Drug List
REXULTI (brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg)	Depression, Schizophrenia, Dementia-associated agitation in Alzheimer dz	Preferred Brand
Performance Select Drug List
REXULTI (brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg)	Depression, Schizophrenia, Dementia-associated agitation in Alzheimer dz	Preferred Brand

Other Drug List Tier Changes
Most tier changes become effective quarterly, however, some drugs are moved to a new tier as part of formulary maintenance or re-evaluated during the quarter. Those drugs are listed below with their addition date.

Balanced Drug List
Drug¹	Condition	New Lower Tier	Date Added
alendronate sodium oral soln 70 mg/75 ml	Osteoporosis, Paget Bone dz	Non-Preferred Generic	5/21/23
baclofen susp 25 mg/5 ml	Spasticity associated with Multiple Sclerosis and Spinal Cord Lesions	Non-Preferred Generic	7/2/23
clemastine fumarate syrup 0.67 mg/5 ml (0.5 mg/5 ml base equivalent)	Allergic Symptoms	Non-Preferred Generic	7/2/23
HUMATIN (paromomycin sulfate cap 250 mg)	Intestinal Amebiasis, Hepatic Encephalopathy	Preferred Brand	7/2/23
indomethacin suppos 50 mg	Inflammatory Conditions	Non-Preferred Generic	8/13/23
isoniazid syrup 50 mg/5 ml	Tuberculosis	Non-Preferred Generic	5/28/23
prednisolone sodium phosphate oral soln 25 mg/5 ml (base equivalent)	Inflammatory Conditions	Non-Preferred Generic	5/28/23
vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent)	C. Difficile Infection, Staphylococcal Enterocolitis	Non-Preferred Generic	7/31/23

Performance Drug List
Drug¹	Condition	New Lower Tier	Date Added
alendronate sodium oral soln 70 mg/75 ml	Osteoporosis, Paget Bone dz	Non-Preferred Generic	5/21/23
HUMATIN (paromomycin sulfate cap 250 mg)	Intestinal Amebiasis, Hepatic Encephalopathy	Preferred Brand	7/2/23
isoniazid syrup 50 mg/5 ml	Tuberculosis	Non-Preferred Generic	5/28/23
prednisolone sodium phosphate oral soln 25 mg/5 ml (base equivalent)	Inflammatory Conditions	Non-Preferred Generic	5/28/23
vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent)	C. Difficile Infection, Staphylococcal Enterocolitis	Non-Preferred Generic	7/31/23

Performance Select Drug List
Drug¹	Condition	New Lower Tier	Date Added
alendronate sodium oral soln 70 mg/75 ml	Osteoporosis, Paget Bone dz	Non-Preferred Generic	5/21/23
HUMATIN (paromomycin sulfate cap 250 mg)	Intestinal Amebiasis, Hepatic Encephalopathy	Preferred Brand	7/2/23
indomethacin suppos 50 mg	Inflammatory Conditions	Non-Preferred Generic	8/13/23
isoniazid syrup 50 mg/5 ml	Tuberculosis	Non-Preferred Generic	5/28/23
prednisolone sodium phosphate oral soln 25 mg/5 ml (base equivalent)	Inflammatory Conditions	Non-Preferred Generic	5/28/23
vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent)	C. Difficile Infection, Staphylococcal Enterocolitis	Non-Preferred Generic	7/31/23

Utilization Management Program Changes
Utilization Management programs are implemented to regularly review the appropriateness of medications within drug-therapy programs, and as a result, may adjust dispensing limits, prior authorization or step therapy requirements. The following drug programs reflect those changes.
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.

Basic, Enhanced, Balanced, Performance, Performance Select and Health Insurance Marketplace (HIM) Drug Lists
Drug Class and Medication(s)¹	New Dispensing Limit	Effective Date
Rinvoq 45 mg tab	84 tabs every 365 days	9/15/23
Vuity (pilocarpine) 1.25% ophthalmic solution	5 mL (2 bottles) per 30 days	10/1/23
¹ Third-party Brand names are the property of their respective owner.

Standard Utilization Management Program Updates
The following programs have changes effective this quarter.

Multiple Sclerosis PAQL removed Glatopa as a target from Prior Authorization effective Oct. 1, 2023.
Phosphodiesterase Type 5 Inhibitors PAQL removed sildenafil as a target from Prior Authorization effective Oct. 15, 2023. Quantity limits remain in effect.

Please Note: The prior authorization (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.

Pharmacy Benefits Updates

Update: RSV Vaccine Coverage
Effective Sept. 1. 2023, BCBSOK covers the Respiratory Syncytial Virus (RSV) vaccine without cost sharing for adults, as recommended by the Advisory Committee on Immunization Practices (ACIP). This coverage is effective for all non-grandfathered ACA-compliant plans(group and Individual & Family) regardless of renewal date.
What you need to know: This year, the Food and Drug Administration (FDA) approved two new RSV vaccines, Abrysvo and Arexvy, for the prevention of lower respiratory tract disease caused by RSV in those age 60 and older.
We will cover both RSV vaccines without cost sharing when obtained at a doctor’s office (medical claim) or at a participating pharmacy (pharmacy claim) for groups that have Prime Therapeutics as their Pharmacy Benefits Manager (PBM).
Groups that have carved-out pharmacy benefits should check with their PBM to confirm their coverage and implementation of this update.
As with any preventive service, the vaccine must be obtained from an in-network provider to be covered without cost sharing.
Note: The RSV vaccine for infants, (Beyfortus), is a different drug, and it is covered only under the medical plan.

BLUE REVIEW^{^SM}

for Providers