September 2023
Pharmacy Program Quarterly Update Changes Effective October 1, 2023 – Part 1
Contents
Drug List Changes
Drug List Updates (Revisions/Exclusions) – As of October 1, 2023
Basic, Multi-Tier Basic, Enhanced and Multi-Tier Enhanced Drug Lists Revisions
Balanced Drug List Exclusions
Performance Drug List Exclusions
Performance Select Drug List Exclusions
Health Insurance Marketplace (HIM) Drug List Exclusions
Balanced Drug List Tier Changes
Drug List Updates (Tier Changes) – As of October 1, 2023
Performance Drug List Tier Changes
Performance Select Drug List Tier Changes
Health Insurance Marketplace (HIM) Drug List Tier Changes
Utilization Management Program Changes
Additions to Standard Prior Authorization Programs – Effective October 1, 2023
Balanced, Basic, Enhanced, Multi-Tier Basic, Multi-Tier Enhanced, Performance, and Performance Select Drug Lists Health Insurance Marketplace (HIM) Drug List
Balanced and Performance Select Drug Lists
Pharmacy Prior Authorization (PA) or Step Therapy (ST) Standard Program Updates – Effective October 1, 2023
Dispensing Limit Changes – Effective October 1, 2023
Humira Biosimilars Added to Select Drug Lists
Reminder: The Quarterly Pharmacy Changes awareness article is published in two parts. This part 1 article includes changes that require member notification – drug list revisions/exclusions, dispensing limits, utilization management changes and general information on pharmacy benefit program updates. Our intention is to alert you of these changes as our members are receiving letters on changes to their drug list and/or pharmacy benefit. The part 2 article will be published closer to the October 1 effective date.
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 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 October 1, 2023, are outlined below.
The October Quarterly Pharmacy Changes Part 2 article with more recent coverage additions will also be published closer to the October 1 effective date.
| Drug List Updates (Revisions/Exclusions) – As of October 1, 2023 | ||
| Basic, Multi-Tier Basic, Enhanced and Multi-Tier Enhanced Drug Lists Revisions | ||
Non-Preferred Brand1 |
Preferred Alternatives1,2 |
Drug Class/Condition |
AUBAGIO (teriflunomide tab 7 mg, 14 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Multiple Sclerosis |
DIVIGEL (estradiol td gel 0.25 mg/0.25 gm, 0.5 mg/0.5 gm 0.75 mg/0.75 gm, 1 mg/gm, 1.25 mg/1.25 gm) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Vasomotor symptoms due to menopause |
LATUDA (lurasidone hcl tab 20 mg, 40 mg, 60 mg, 80 mg, 120 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bipolar major depression, schizophrenia |
NOXAFIL (posaconazole susp 40 mg/ml) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Oropharyngeal candidiasis, prophylaxis of invasive Aspergillus and Candida infections |
SUPREP BOWEL PREP KIT (sod sulfate-pot sulf-mg sulf oral sol 17.5-3.13-1.6 gm/177 ml) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bowel Prep |
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class.
| Balanced Drug List Exclusions | |||
Drug1 |
Alternatives1,2 |
Drug Class/Condition |
|
AUBAGIO (teriflunomide tab 7 mg, 14 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Multiple Sclerosis |
|
CARDIZEM LA (diltiazem hcl tab er 24hr 120 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Angina, Hypertension, Atrial Fibrillation/Flutter |
|
CELONTIN (methsuximide cap 300 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Refractory Absence Seizures |
|
CHORIONIC GONADOTROPIN (chorionic gonadotropin for im inj 10,000 unit) |
OVIDREL, PREGNYL |
Ovulation induction, Cryptorchidism, Hypogonadism |
|
DIVIGEL (estradiol td gel 0.25 mg/0.25 gm, 0.5 mg/0.5 gm 0.75 mg/0.75 gm, 1 mg/gm, 1.25 mg/1.25 gm) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Vasomotor symptoms due to menopause |
|
FARYDAK (panobinostat lactate cap 10 mg, 15 mg, 20 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cancer |
|
IRESSA (gefitinib tab 250 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cancer |
|
LAMICTAL ODT (lamotrigine tab disint 21 x 25 mg & 7 x 50 mg titration kit, 42 x 50 mg & 14 x 100 mg titration kit) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bipolar Disorder, Seizures |
|
NAFTIN (naftifine hcl gel 2%) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Fungal Infections (Topical) |
|
NOVAREL (chorionic gonadotropin for im inj 5,000 unit, 10,000 unit) |
OVIDREL, PREGNYL |
Ovulation induction, Cryptorchidism, Hypogonadism |
|
NOXAFIL (posaconazole susp 40 mg/ml) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Fungal Infections |
|
ORFADIN (nitisinone cap 20 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Type 1 Hereditary Tyrosinemia |
|
PRENATABS RX (prenatal vit w/ iron carbonyl-fa tab 29-1 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Prenatal Vitamin |
|
PRUDOXIN (doxepin hcl cream 5%) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Atopic Dermatitis-associated or Lichen Simplex Chronicus-associated Pruritus |
|
SUPREP BOWEL PREP KIT (sod sulfate-pot sulf-mg sulf oral sol 17.5-3.13-1.6 gm/177 ml) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bowel Prep |
|
TAZORAC (tazarotene gel 0.05%, 0.1%) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Plaque Psoriasis, Acne Vulgaris |
|
TROKENDI XR (topiramate cap er 24hr 200 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Epilepsy, Migraine |
|
UCERIS (budesonide rectal foam 2 mg/act) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Inflammatory Bowel Disease |
|
XYREM (sodium oxybate oral solution 500 mg/ml) |
sodium oxybate oral solution 500mg/ml, Xywav (calcium, mag, potassium, & sod oxybates oral soln) 500 mg/ml |
Cataplexy |
|
ZONALON (doxepin hcl cream 5%) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Atopic Dermatitis-associated or Lichen Simplex Chronicus-associated Pruritus |
|
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class.
| Performance Drug List Exclusions | ||
Drug1 |
Alternatives1,2 |
Drug Class/Condition |
AUBAGIO (teriflunomide tab 7 mg, 14 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Multiple Sclerosis |
CARDIZEM LA (diltiazem hcl tab er 24hr 120 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Angina, Hypertension, Atrial Fibrillation/Flutter |
CELONTIN (methsuximide cap 300 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Refractory Absence Seizures |
CHORIONIC GONADOTROPIN (chorionic gonadotropin for im inj 10,000 unit) |
OVIDREL, PREGNYL |
Ovulation induction, Cryptorchidism, Hypogonadism |
DIVIGEL (estradiol td gel 0.25 mg/0.25 gm, 0.5 mg/0.5 gm 0.75 mg/0.75 gm, 1 mg/gm, 1.25 mg/1.25 gm) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Vasomotor symptoms due to menopause |
dutasteride-tamsulosin hcl cap 0.5-0.4 mg |
dutasteride, tamsulosin |
Benign Prostatic Hyperplasia (BPH) |
FARYDAK (panobinostat lactate cap 10 mg, 15 mg, 20 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cancer |
IRESSA (gefitinib tab 250 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cancer |
LAMICTAL ODT (lamotrigine tab disint 21 x 25 mg & 7 x 50 mg titration kit, 42 x 50 mg & 14 x 100 mg titration kit) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bipolar Disorder, Seizures |
NOVAREL (chorionic gonadotropin for im inj 5,000 unit, 10,000 unit) |
OVIDREL, PREGNYL |
Ovulation induction, Cryptorchidism, Hypogonadism |
NOXAFIL (posaconazole susp 40 mg/ml) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Fungal Infections |
ORFADIN (nitisinone cap 20 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Type 1 Hereditary Tyrosinemia |
PRENATABS RX (prenatal vit w/ iron carbonyl-fa tab 29-1 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Prenatal Vitamin |
SUPREP BOWEL PREP KIT (sod sulfate-pot sulf-mg sulf oral sol 17.5-3.13-1.6 gm/177 ml) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bowel Prep |
TAZORAC (tazarotene gel 0.05%, 0.1%) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Plaque Psoriasis, Acne Vulgaris |
TROKENDI XR (topiramate cap er 24hr 200 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Epilepsy, Migraine |
UCERIS (budesonide rectal foam 2 mg/act) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Inflammatory Bowel Disease |
XYREM (sodium oxybate oral solution 500 mg/ml) |
sodium oxybate oral solution 500mg/ml, Xywav (calcium, mag, potassium, & sod oxybates oral soln) 500 mg/ml |
Cataplexy |
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class
| Performance SelectDrug List Exclusions | ||
Drug1 |
Alternatives1,2 |
Drug Class/Condition |
AUBAGIO (teriflunomide tab 7 mg, 14 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Multiple Sclerosis |
CARDIZEM LA (diltiazem hcl tab er 24hr 120 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Angina, Hypertension, Atrial Fibrillation/Flutter |
CELONTIN (methsuximide cap 300 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Refractory Absence Seizures |
CHORIONIC GONADOTROPIN (chorionic gonadotropin for im inj 10,000 unit) |
OVIDREL, PREGNYL |
Ovulation induction, Cryptorchidism, Hypogonadism |
DIVIGEL (estradiol td gel 0.25 mg/0.25 gm, 0.5 mg/0.5 gm 0.75 mg/0.75 gm, 1 mg/gm, 1.25 mg/1.25 gm) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Vasomotor symptoms due to menopause |
dutasteride-tamsulosin hcl cap 0.5-0.4 mg |
dutasteride, tamsulosin |
Benign Prostatic Hyperplasia (BPH) |
FARYDAK (panobinostat lactate cap 10 mg, 15 mg, 20 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cancer |
IRESSA (gefitinib tab 250 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cancer |
LAMICTAL ODT (lamotrigine tab disint 21 x 25 mg & 7 x 50 mg titration kit, 42 x 50 mg & 14 x 100 mg titration kit) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bipolar Disorder, Seizures |
NOVAREL (chorionic gonadotropin for im inj 5,000 unit, 10,000 unit) |
OVIDREL, PREGNYL |
Ovulation induction, Cryptorchidism, Hypogonadism |
NOXAFIL (posaconazole susp 40 mg/ml) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Fungal Infections |
ORFADIN (nitisinone cap 20 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Type 1 Hereditary Tyrosinemia |
PRENATABS RX (prenatal vit w/ iron carbonyl-fa tab 29-1 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Prenatal Vitamin |
SUPREP BOWEL PREP KIT (sod sulfate-pot sulf-mg sulf oral sol 17.5-3.13-1.6 gm/177 ml) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bowel Prep |
TAZORAC (tazarotene gel 0.05%, 0.1%) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Plaque Psoriasis, Acne Vulgaris |
TROKENDI XR (topiramate cap er 24hr 200 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Epilepsy, Migraine |
UCERIS (budesonide rectal foam 2 mg/act) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Inflammatory Bowel Disease |
XYREM (sodium oxybate oral solution 500 mg/ml) |
sodium oxybate oral solution 500mg/ml, Xywav (calcium, mag, potassium, & sod oxybates oral soln) 500 mg/ml |
Cataplexy |
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class.
| Health Insurance Marketplace (HIM) Drug List Exclusions | ||
Drug1 |
Alternatives1,2 |
Drug Class/Condition |
AUBAGIO (teriflunomide tab 7mg, 14 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Multiple Sclerosis |
AUBAGIO (teriflunomide tab 7mg, 14 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Multiple Sclerosis |
CARDIZEM LA (diltiazem hcl coated beads tab er 24hr 120 mg) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Angina, Hypertension, Atrial Fibrillation/Flutter |
DIVIGEL (estradiol td gel 0.25 mg/0.25 gm, 0.5 mg/0.5 gm 0.75 mg/0.75 gm, 1 mg/gm, 1.25 mg/1.25 gm) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Vasomotor symptoms due to menopause |
dutasteride/tamsulosin hcl cap |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Benign Prostatic Hyperplasia (BPH) |
FARYDAK (panobinostat lactate cap 10 mg, 15 mg, 20 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cancer |
IRESSA (gefitinib tab 250 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cancer |
SUPREP BOWEL SOL PREP KIT |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bowel Prep |
XYREM (sodium oxybate soln 500 mg/ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cataplexy |
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class.
| Balanced Drug List Tier Changes | |||
Drug1 |
Alternative(s)1,2 |
Drug Class/Condition |
|
ACETAMINOPHEN/CODEINE (acetaminophen w/ codeine soln 120-12 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Pain |
|
ALBUTEROL SULFATE (albuterol sulfate soln nebu 0.5% (5 mg/ml)) |
albuterol sulfate soln nebu 0.083% (2.5 mg/3 ml), albuterol sulfate soln nebu 0.63 mg/3 ml |
Asthma |
|
AMILORIDE/HYDROCHLOROTHIA ZIDE (amiloride & hydrochlorothiazide tab 5-50 mg) |
amiloride hcl tab 5 mg, hydrochlorothiazide tab 50 mg |
Hypertension |
|
APO-VARENICLINE (varenicline tartrate tab 0.5 mg, 1 mg (base equivalent)) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Smoking cessation |
|
APRACLONIDINE (apraclonidine hcl ophth soln 0.5% (base equivalent)) |
brimonidine tartrate ophth soln 0.2% |
Glaucoma, Post-surgical ocular hypertension |
|
BETAXOLOL HCL (betaxolol hcl ophth soln 0.5%) |
timolol maleate ophth soln 0.25%, timolol maleate ophth soln 0.5% |
Glaucoma |
|
CHLORPROMAZINE HYDROCHLOR IDE (chlorpromazine hcl conc 30 mg/ml, 100 mg/ml) |
Chlorpromazine Hcl Tab |
Behavioral Disorders, Nausea/Vomiting |
|
CIMETIDINE HCL (cimetidine hcl soln 300 mg/5 ml) |
Cimetidine Tab |
Gastroesophageal Reflux Disease (GERD) |
|
CROMOLYN SODIUM (cromolyn sodium ophth soln 4%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Keratitis, Conjunctivitis |
|
EFAVIRENZ (efavirenz cap 50 mg, 200 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
HIV |
|
HYDROCORTISONE/ACETIC ACI D (hydrocortisone w/ acetic acid otic soln 1-2%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Ear Infections |
|
LEVOFLOXACIN (levofloxacin ophth soln 0.5%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bacterial Infections |
|
LEVOFLOXACIN (levofloxacin oral soln 25 mg/ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bacterial Infections |
|
LEVORPHANOL TARTRATE (levorphanol tartrate tab 3 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Pain |
|
LOTEPREDNOL ETABONATE (loteprednol etabonate ophth gel 0.5%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Ocular Inflammation/Pain |
|
PERINDOPRIL ERBUMINE (perindopril erbumine tab 8 mg) |
perindopril erbumine tab 4 mg |
Hypertension |
|
PREDNISOLONE (prednisolone soln 15 mg/5 ml) |
prednisolone sod phosph oral soln 6.7 mg/5 ml (5 mg/5 ml base) |
Inflammatory conditions |
|
PROMETHAZINE VC (promethazine & phenylephrine syrup 6.25-5 mg/5 ml, 6.25-5-10 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Upper Respiratory Symptoms |
|
PROMETHAZINE VC/CODEINE (promethazine-phenylephrine-codeine syrup) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cough, Upper Respiratory Symptoms |
|
RIBAVIRIN (ribavirin cap 200 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Hepatitis C |
|
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class.
Drug List Updates (Tier Changes) – As of October 1, 2023
The drug changes listed below apply to members on a managed drug list. Members may pay more for these drugs after October 1, 2023.
| Performance Drug List Tier Changes | ||
Drug1 |
Alternative(s)1,2 |
Drug Class/Condition |
ACETAMINOPHEN/CODEINE (acetaminophen w/ codeine soln 120-12 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Pain |
ALBUTEROL SULFATE (albuterol sulfate soln nebu 0.5% (5 mg/ml)) |
albuterol sulfate soln nebu 0.083% (2.5 mg/3 ml), albuterol sulfate soln nebu 0.63 mg/3 ml |
Asthma |
AMILORIDE/HYDROCHLOROTHIAZIDE (amiloride & hydrochlorothiazide tab 5-50 mg) |
amiloride hcl tab 5 mg, hydrochlorothiazide tab 50 mg |
Hypertension |
APRACLONIDINE (apraclonidine hcl ophth soln 0.5% (base equivalent)) |
brimonidine tartrate ophth soln 0.2% |
Glaucoma, Post-surgical ocular hypertension |
BETAXOLOL HCL (betaxolol hcl ophth soln 0.5%) |
timolol maleate ophth soln 0.25%, timolol maleate ophth soln 0.5% |
Glaucoma |
CROMOLYN SODIUM (cromolyn sodium ophth soln 4%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Keratitis, Conjuctivitis |
EFAVIRENZ (efavirenz cap 50 mg, 200 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
HIV |
HYDROCORTISONE/ACETIC ACID (hydrocortisone w/ acetic acid otic soln |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Ear Infections |
LEVOFLOXACIN (levofloxacin ophth soln 0.5%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bacterial Infections |
LEVOFLOXACIN (levofloxacin oral soln 25 mg/ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bacterial Infections |
LOTEPREDNOL ETABONATE (loteprednol etabonate ophth gel 0.5%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Ocular Inflammation/Pain |
PERINDOPRIL ERBUMINE (perindopril erbumine tab 8 mg) |
perindopril erbumine tab 4 mg |
Hypertension |
PREDNISOLONE (prednisolone soln 15 mg/5 ml) |
prednisolone sod phosph oral soln 6.7 mg/5 ml (5 mg/5 ml base) |
Inflammatory conditions |
PROMETHAZINE VC (promethazine & phenylephrine syrup 6.25-5 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Upper Respiratory Symptoms |
PROMETHAZINE VC/CODEINE (promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cough, Upper Respiratory Symptoms |
RIBAVIRIN (ribavirin cap 200 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Hepatitis C |
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class.
| Performance Select Drug List Tier Changes | |||
Drug1 |
Alternative(s)1,2 |
Drug Class/Condition |
|
ACETAMINOPHEN/CODEINE (acetaminophen w/ codeine soln 120-12 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Pain |
|
ALBUTEROL SULFATE (albuterol sulfate soln nebu 0.5% (5 mg/ml)) |
albuterol sulfate soln nebu 0.083% (2.5 mg/3 ml), albuterol sulfate soln nebu 0.63 mg/3 ml |
Asthma |
|
AMILORIDE/HYDROCHLOROTHIA ZIDE (amiloride & hydrochlorothiazide tab 5-50 mg) |
amiloride hcl tab 5 mg, hydrochlorothiazide tab 50 mg |
Hypertension |
|
APO-VARENICLINE (varenicline tartrate tab 0.5 mg, 1 mg (base equivalent)) |
There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Smoking cessation |
|
APRACLONIDINE (apraclonidine hcl ophth soln 0.5% (base equivalent)) |
brimonidine tartrate ophth soln 0.2% |
Glaucoma, Post-surgical ocular hypertension |
|
BETAXOLOL HCL (betaxolol hcl ophth soln 0.5%) |
timolol maleate ophth soln 0.25%, timolol maleate ophth soln 0.5% |
Glaucoma |
|
CROMOLYN SODIUM (cromolyn sodium ophth soln 4%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Keratitis, Conjuctivitis |
|
EFAVIRENZ (efavirenz cap 50 mg, 200 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
HIV |
|
HYDROCORTISONE/ACETIC ACI D (hydrocortisone w/ acetic acid otic soln 1-2%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Ear Infections |
|
LEVOFLOXACIN (levofloxacin ophth soln 0.5%, 25 mg/ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bacterial Infections |
|
LOTEPREDNOL ETABONATE (loteprednol etabonate ophth gel 0.5%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Ocular Inflammation/Pain |
|
PERINDOPRIL ERBUMINE (perindopril erbumine tab 8 mg, 15 mg/5m) |
perindopril erbumine tab 4 mg |
Hypertension |
|
PREDNISOLONE (prednisolone soln 15 mg/5 ml) |
prednisolone sod phosph oral soln 6.7 mg/5 ml (5 mg/5 ml base) |
Inflammatory conditions |
|
PROMETHAZINE VC (promethazine & phenylephrine syrup 6.25-5 mg/5 ml, 6.25-5-10 mg/5 m) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Upper Respiratory Symptoms |
|
PROMETHAZINE VC/CODEINE (promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Cough, Upper Respiratory Symptoms |
|
RIBAVIRIN (ribavirin cap 200 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Hepatitis C |
|
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class.
| Health Insurance Marketplace (HIM) Drug List Tier Changes | ||
Drug1 |
Alternatives1,2 |
Drug Class/Condition |
ALBUTEROL (albuterol sulfate soln nebu 0.5% (5 mg/ml)) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Asthma |
AMILOR/HCTZ (amiloride/hydrochlorothiazide tab 5-50 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Hypertension |
APAP/CODEINE (acetaminophen w/ codeine soln 120-12 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Pain |
APRACLONIDIN (apraclonidine hcl ophth soln 0.5% (base equivalent)) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Glaucoma, Post-Surgical Ocular Hypertension |
BETAXOLOL (betaxolol hcl ophth soln 0.5%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Glaucoma |
CIMETIDINE (cimetidine hcl soln 300 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Gastroesophageal Reflux Disease (GERD) |
CROMOLYN SOD (cromolyn sodium ophth soln 4%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Keratitis, Conjuctivitis |
EFAVIRENZ (EFAVIRENZ CAP 50 mg, 200 mg) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
HIV |
HC/ACET ACID (hydrocortisone w/ acetic acid otic soln 1-2%) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Ear Infections |
LEVOFLOXACIN (levofloxacin ophth soln 0.5, 25 mg/ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Bacterial Infections |
PERINDOPRIL |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Hypertension |
PREDNISOLONE (prednisolone soln 15 mg/5 ml) |
Please talk to your doctor or pharmacist about other medication(s) available for your condition. |
Inflammatory conditions |
1Third-party brand names are the property of their respective owner.
2This list is not all inclusive. Other medicines may be available in this drug class.
Utilization Management Program Changes
Additions to Standard Prior Authorization Programs – Effective October 1, 2023
Several drug categories and/or targeted medications will be added to the Prior Authorization (PA) programs for standard pharmacy benefit plans. This includes ASO groups with a standard UM package and/or subcategory selection with auto updates. For groups that have not selected the auto update, these programs will be available to be added to their benefit design as of the program effective date.
Remember: 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. Members were notified about the PA standard program changes listed in the table below.
| Balanced, Basic, Enhanced, Multi-Tier Basic, Multi-Tier Enhanced, Performance, and Performance Select Drug Lists Health Insurance Marketplace (HIM) Drug List | |
Drug Category |
Targeted Medication(s)1 |
Alternative Dosage Form |
Gimoti 15 mg/act spray |
Multiple Sclerosis |
Aubagio 7 mg, 14 mg tab |
Therapeutic Alternatives |
Fenofibrate 120 mg tab |
| Balanced and Performance Select Drug Lists | |
PCSK9 Inhibitors |
Repatha 140 mg/ml pre-filled syringe, 140 mg/ml pre-filled auto-injector, 42 0 mg/3.5 ml single-use Pushtronex system, Praluent 75 mg/ml, 150 mg/ml pre-filled pen |
Pharmacy Prior Authorization (PA) or Step Therapy (ST) Standard Program Updates – Effective October 1, 2023
| Effective Date | Program Name |
Description of Change |
Drug Lists |
Program Type |
10/1/2023 |
Daybue PAQL |
New Program |
Prior Authorization |
|
10/1/2023 |
Filspari PAQL |
New Program |
Balanced, Basic, Basic Annual, Enhanced, Enhanced Annual, HIM Quarterly, Jade, Performance Select, Topaz |
Prior Authorization |
10/1/2023 |
Infertility STQL |
Added Chorionic Gonadotropin and Novarel as drug targets and removed from HIM plans. |
Basic/Enhanced, Basic/Enhanced Annual |
Step Therapy |
10/1/2023 |
PCSK9 Inhibitors |
Added Repatha 140 mg/mL pre-filled syringe, 140 mg/mL |
Balanced, Performance Select |
Prior Authorization |
10/1/2023 |
Skyclarys PAQL |
New Program |
Balanced, Basic, Basic Annual, Enhanced, Enhanced Annual, HIM Quarterly, Jade, Performance Select, Topaz |
Prior Authorization |
Dispensing Limit Changes – Effective October 1, 2023
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.
BCBSOK may send letters to 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.
Changes by drug list are listed on the chart below. All changes are effective October 1, 2023. View the most up-to-date drug list and list of drug dispensing limits on www.bcbsok.com/rx-drugs/drug-lists/drug-lists.
Target Agent |
Dispensing Limit |
|
Daybue PAQL* |
Daybue (trofinetide)oral soln 200 mg/mL |
8 bottles per 30 days |
Filspari PAQL* |
Filspari (Sparsentan) 200 mg tab, 400 mg tab |
30 tabs per 30 days |
Skyclarys PAQL* |
Skyclarys (omaveloxolone) 50 mg caps |
90 caps per 30 days |
*This is a new program and coverage will begin October 1, 2023. Members were not lettered. |
||
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.
| TRADE NAME (generic) | Manufacturer |
Brand or |
Effective Date |
Description |
Drug Lists |
AMJEVITA (adalimumab-atto) |
Amgen |
Brand |
7/1/23 |
Preferred |
All* |
CYLTEZO |
Boehringer Ingelheim |
Brand |
7/1/23 |
Preferred |
Balanced, Performance Select |
HADLIMA |
Samsung/Organon |
Brand |
Upon Launch |
Preferred |
Basic, Enhanced, HIM, Performance |
HUMIRA (adalimumab) |
AbbVie |
Brand |
Current |
Preferred |
All |
*Preferred NDCs start with 55513. Non-preferred NDCs start with 72511.
†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 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.