April 2024
Pharmacy Program Quarterly Update Changes Effective April 1, 2024 – Part 2
Contents
Drug List Changes
Drug List Additions – Effective April 1, 2024
Balanced Drug List Additions
Performance Drug List Additions
Performance Select Drug List Additions
Basic, Basic Multi-Tier, Enhanced, and Enhanced Multi-Tier Drug Lists Revisions
Other Drug List Additions
Balanced Drug List Additions
Performance Drug List Additions
Performance Select Drug List Additions
Basic, Basic Multi-Tier, Enhanced, and Enhanced Multi-Tier Drug Lists Revisions
Drug Tier Changes – As of April 1, 2024
Performance Drug List
Other Drug Tier Changes
Balanced Drug List Tier Changes
Performance Drug List Tier Changes
Performance Select Drug List Tier Changes
Utilization Management Program Changes
Dispensing Limit Changes
Basic, Enhanced, Balanced, Performance, Performance Select and Health Insurance Marketplace Drug Lists
Standard Utilization Management Program Updates
Change in Benefit Coverage for Select High-Cost Products
Reminder: The Quarterly Pharmacy Changes are published as articles in two parts. This part-2 article is a continuation of the April Quarterly Pharmacy Changes Part 1, which included changes that require member notification — drug list revisions/exclusions, dispensing limits, utilization management changes and general information on pharmacy benefit program updates. This article contains 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 drug lists. Additions effective April 1, 2024, and prior updates are outlined below.
Drug List Additions – Effective April 1, 2024
|
Balanced Drug List Additions |
Drug1 |
Condition |
CIBINQO (abrocitinib tab 50 mg, 100 mg, 200 mg) |
Atopic Dermatitis |
KALYDECO (ivacaftor packet 5.8 mg) |
Cystic fibrosis |
LODOCO (colchicine (cardiovascular) tab 0.5 mg) |
Cardiovascular Event Risk Reduction |
LUMRYZ (sodium oxybate pack for oral er susp 4.5 gm, 6 gm, 7.5 gm, 9 gm) |
Cataplexy |
OPZELURA (ruxolitinib phosphate cream 1.5%) |
Atopic Dermatitis, Vitiligo |
ORLADEYO (berotralstat hcl cap 110 mg, 150 mg) |
Hereditary Angioedema |
ROZLYTREK (entrectinib pellet pack 50 mg) |
Cancer |
SOHONOS (palovarotene cap 1 mg, 1.5 mg, 2.5 mg, 5 mg, 10 mg) |
Fibrodysplasia Ossificans Progressiva |
TIBSOVO (ivosidenib tab 250 mg) |
Cancer |
XALKORI (crizotinib cap sprinkle 20 mg, 50 mg, 150 mg) |
Cancer |
XDEMVY (lotilaner ophth soln 0.25%) |
Demodex Blepharitis |
ZEPBOUND (tirzepatide) 2.5 mg/0.5 ml, 5 mg/0.5 ml, 7.5 mg/0.5 ml, 10 mg/0.5 ml, 12.5 mg/0.5 ml, 15 mg/0.5 ml |
Weight Loss |
| Performance Drug List Additions |
Drug1 |
Condition |
CIBINQO (abrocitinib tab 50 mg, 100 mg, 200 mg) |
Atopic Dermatitis |
KALYDECO (ivacaftor packet 5.8 mg) |
Cystic fibrosis |
LUMRYZ (sodium oxybate pack for oral er susp 4.5 gm, 6 gm, 7.5 gm, 9 gm) |
Cataplexy |
ORLADEYO (berotralstat hcl cap 110 mg, 150 mg) |
Hereditary Angioedema |
ROZLYTREK (entrectinib pellet pack 50 mg) |
Cancer |
SOHONOS (palovarotene cap 1 mg, 1.5 mg, 2.5 mg, 5 mg, 10 mg) |
Fibrodysplasia Ossificans Progressiva |
vancomycin hcl for oral soln 50 mg/ml (base equivalent) |
C. Difficile Infection, Staphylococcal Enterocolitis |
XALKORI (crizotinib cap sprinkle 20 mg, 50 mg, 150 mg) |
Cancer |
ZEPBOUND (tirzepatide) 2.5 mg/0.5 ml, 5 mg/0.5 ml, 7.5 mg/0.5 ml, 10 mg/0.5 ml, 12.5 mg/0.5 ml, 15 mg/0.5 ml |
Weight Loss |
| Performance Select Drug List Additions |
Drug1 |
Condition |
CIBINQO (abrocitinib tab 50 mg, 100 mg, 200 mg) |
Atopic Dermatitis |
KALYDECO (ivacaftor packet 5.8 mg) |
Cystic fibrosis |
LUMRYZ (sodium oxybate pack for oral er susp 4.5 gm, 6 gm, 7.5 gm, 9 gm) |
Cataplexy |
OPZELURA (ruxolitinib phosphate cream 1.5%) |
Atopic Dermatitis, Vitiligo |
ORLADEYO (berotralstat hcl cap 110 mg, 150 mg) |
Hereditary Angioedema |
ROZLYTREK (entrectinib pellet pack 50 mg) |
Cancer |
SOHONOS (palovarotene cap 1 mg, 1.5 mg, 2.5 mg, 5 mg, 10 mg) |
Fibrodysplasia Ossificans Progressiva |
TIBSOVO (ivosidenib tab 250 mg) |
Cancer |
vancomycin hcl for oral soln 50 mg/ml (base equivalent) |
C. Difficile Infection, Staphylococcal Enterocolitis |
XALKORI (crizotinib cap sprinkle 20 mg, 50 mg, 150 mg) |
Cancer |
XYOSTED (testosterone enanthate solution auto-injector 50 mg/0.5 ml, 75 mg/0.5 ml, 100 mg/0.5 ml) |
Primary hypogonadism, hypogonadotrophic hypogonadism |
ZEPBOUND (tirzepatide) 2.5 mg/0.5 ml, 5 mg/0.5 ml, 7.5 mg/0.5 ml, 10 mg/0.5 ml, 12.5 mg/0.5 ml, 15 mg/0.5 ml |
Weight Loss |
| Basic, Basic Multi-Tier, Enhanced, and Enhanced Multi-Tier Drug Lists Revisions |
Drug1 |
Drug Class/Condition |
BREO ELLIPTA (fluticasone furoate-vilanterol aero powd ba 50-25 mcg/act) |
Asthma |
CIBINQO (abrocitinib tab 50 mg, 100 mg, 200 mg) |
Atopic Dermatitis |
INSULIN GLARGINE-YFGN (insulin glargine-yfgn inj 100 unit/ml) |
Diabetes |
KALYDECO (ivacaftor packet 5.8 mg) |
Cystic fibrosis |
ROZLYTREK (entrectinib pellet pack 50 mg) |
Cancer |
TIBSOVO (ivosidenib tab 250 mg) |
Cancer |
XALKORI (crizotinib cap sprinkle 20 mg, 50 mg, 150 mg) |
Cancer |
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 Additions |
Drug1 |
Condition |
Effective Date |
ADTHYZA (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 |
1/7/2024 |
ANALPRAM-HC (hydrocortisone acetate w/ pramoxine perianal cream 1-1%) |
Pruritus, Dermatoses |
1/21/2024 |
bromfenac sodium ophth soln 0.075% (base equivalent) |
Inflammation-Ophthalmic |
2/11/2024 |
CLONIDINE HYDROCHLORIDE ER (clonidine hcl tab er 24 hr 0.17 mg (base equivalent)) |
Hypertension |
1/14/2024 |
dabigatran etexilate mesylate cap 110 mg (etexilate base eq) |
Thromboembolism/Stroke Prevention, DVT/PE Prevention and Treatment |
2/11/2024 |
deflazacort tab 6 mg, 18 mg, 30 mg, 36 mg |
Duchenne Muscular Dystrophy |
2/11/2024 |
gabapentin (once-daily) tab 300 mg, 600 mg |
Post-herpetic Neuralgia |
1/28/2024 |
GLOPERBA (colchicine oral soln 0.6 mg/5 ml) |
Gout prevention |
1/22/2024 |
HEMLIBRA (emicizumab-kxwh subcutaneous soln 300 mg/2 ml (150 mg/ml)) |
Hemophilia A |
1/14/2024 |
indomethacin susp 25 mg/5 ml |
Inflammatory Conditions |
1/21/2024 |
JYNNEOS (smallpox & monkeypox vac, live, non-replicating inj 0.5 ml) |
Smallpox and Monkeypox Vaccine |
2/1/2024 |
LOCOID LIPOCREAM (hydrocortisone butyrate hydrophilic lipo base cream 0.1%) |
Dermatitis, Dermatoses |
1/21/2024 |
loteprednol etabonate ophth susp 0.2% |
Ocular Inflammation/Pain |
2/11/2024 |
METHYLPHENIDATE ER TABLETS 24 HR 18 mg |
attention deficit-hyperactivity disorder (ADHD) |
3/1/2024 |
methylphenidate er tablets 27 mg, 36 mg and 54 mg |
attention deficit-hyperactivity disorder (ADHD) |
3/1/2024 |
mifepristone tab 300 mg |
Cushing’s Syndrome |
1/28/2024 |
OMNIPOD 5 G7 INTRO KIT (G EN 5) (insulin infusion disposable pump kit) |
Diabetes |
2/4/2024 |
OMNIPOD 5 G7 PODS (GEN 5) (insulin infusion disposable pump reservoir) |
Diabetes |
2/4/2024 |
teriparatide (recombinant) soln pen-inj 600 mcg/2.4 ml |
Osteoporosis |
1/7/2024 |
TRAMADOL HYDROCHLORIDE (tramadol hcl tab 25 mg) |
Pain |
1/7/2024 |
VANFLYTA (quizartinib dihydrochloride tab 17.7 mg, 26.5 mg) |
Cancer |
3/1/2024 |
| Performance Drug List Additions |
Drug1 |
Condition |
Date Added |
ADTHYZA (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 |
1/7/2024 |
ANALPRAM-HC (hydrocortisone acetate w/ pramoxine perianal cream 1-1%) |
Pruritus, Dermatoses |
1/21/2024 |
dabigatran etexilate mesylate cap 110 mg (etexilate base eq) |
Thromboembolism/Stroke Prevention, DVT/PE Prevention and Treatment |
2/11/2024 |
HEMLIBRA (emicizumab-kxwh subcutaneous soln 300 mg/2 ml (150 mg/ml)) |
Hemophilia A |
1/14/2024 |
JYNNEOS (smallpox & monkeypox vac, live, non-replicating inj 0.5 ml) |
Smallpox and Monkeypox Vaccine |
2/1/2024 |
loteprednol etabonate ophth susp 0.2% |
Ocular Inflammation/Pain |
2/11/2024 |
METHYLPHENIDATE ER TABLETS 24 HR 18 mg |
attention deficit-hyperactivity disorder (ADHD) |
3/1/2024 |
methylphenidate er tablets 27 mg, 36 mg and 54 mg |
attention deficit-hyperactivity disorder (ADHD) |
3/1/2024 |
mifepristone tab 300 mg |
Cushing’s Syndrome |
1/28/2024 |
OMNIPOD 5 G7 INTRO KIT (G EN 5) (insulin infusion disposable pump kit) |
Diabetes |
2/4/2024 |
OMNIPOD 5 G7 PODS (GEN 5) (insulin infusion disposable pump reservoir) |
Diabetes |
2/4/2024 |
teriparatide (recombinant) soln pen-inj 600 mcg/2.4 ml |
Osteoporosis |
1/7/2024 |
VANFLYTA (quizartinib dihydrochloride tab 17.7 mg, 26.5 mg) |
Cancer |
3/1/2024 |
| Performance Select Drug List Additions |
Drug1 |
Condition |
Date Added |
ADTHYZA (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 |
1/7/2024 |
ANALPRAM-HC (hydrocortisone acetate with pramoxine perianal cream 1-1%) |
Pruritus, Dermatoses |
1/21/2024 |
bromfenac sodium ophth soln 0.075% (base equivalent) |
Inflammation-Ophthalmic |
2/11/2024 |
dabigatran etexilate mesylate cap 110 mg (etexilate base eq) |
Thromboembolism/ Stroke Prevention, DVT/PE Prevention and Treatment |
2/11/2024 |
gabapentin (once-daily) tab 300 mg, 600 mg |
Post-herpetic Neuralgia |
1/28/2024 |
HEMLIBRA (emicizumab-kxwh subcutaneous soln 300 mg/2 ml (150 mg/ml)) |
Hemophilia A |
1/14/2024 |
JYNNEOS (smallpox & monkeypox vac, live, non-replicating inj 0.5 ml) |
Smallpox and Monkeypox Vaccine |
2/1/2024 |
loteprednol etabonate ophth susp 0.2% |
Ocular Inflammation/Pain |
2/11/2024 |
METHYLPHENIDATE ER TABLETS 24 HR 18 mg |
attention deficit-hyperactivity disorder (ADHD) |
3/1/2024 |
methylphenidate er tablets 27 mg, 36 mg and 54 mg |
attention deficit-hyperactivity disorder (ADHD) |
3/1/2024 |
mifepristone tab 300 mg |
Cushing’s Syndrome |
1/28/2024 |
OMNIPOD 5 G7 INTRO KIT (GEN 5) (insulin infusion disposable pump kit) |
Diabetes |
2/4/2024 |
OMNIPOD 5 G7 PODS (GEN 5) (insulin infusion disposable pump reservoir) |
Diabetes |
2/4/2024 |
teriparatide (recombinant) soln pen-inj 600 mcg/2.4 ml |
Osteoporosis |
1/7/2024 |
VANFLYTA (quizartinib dihydrochloride tab 17.7 mg, 26.5 mg) |
Cancer |
3/1/2024 |
| Basic, Basic Multi-Tier, Enhanced, and Enhanced Multi-Tier Drug Lists Revisions |
Drug1 |
Condition |
Date Added |
HEMLIBRA (emicizumab-kxwh subcutaneous soln 300 mg/2 ml (150 mg/ml)) |
Hemophilia A |
1/14/2024 |
XOLAIR (omalizumab subcutaneous soln auto-injector 75 mg/0.5 ml, 300 mg/2 ml, 150 mg/ml) |
Moderate to severe asthma, Chronic rhinosinusitis with nasal polyps, Chronic spontaneous urticaria |
2/18/2024 |
XOLAIR (omalizumab subcutaneous soln prefilled syringe
300 mg/2 ml) |
Moderate to severe asthma,
Chronic rhinosinusitis with nasal polyps, Chronic spontaneous urticaria |
2/18/2024 |
Drug Tier Changes – As of April 1, 2024
The tier changes listed below apply to members on a managed drug list. Tier changes effective April 1, 2024 are listed below.
Other Drug 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 Tier Changes |
| Drug1 |
Condition |
New Lower Tier |
Effective Date |
| albuterol sulfate soln nebu 0.5% (5 mg/ml) |
Asthma |
Non-Preferred Generic |
2/11/2024 |
| VALSARTAN (valsartan oral soln 4 mg/ml) |
Heart failure, Hypertension,
Cardiovascular risk reduction
post-myocardial infarction |
Non-Preferred Generic |
1/7/2024 |
| Performance Drug List Tier Changes |
Drug1 |
Condition |
New Lower Tier |
Effective Date |
albuterol sulfate soln nebu 0.5% (5 mg/ml) |
Asthma |
Non-Preferred Generic |
2/11/2024 |
| Performance Select Drug List Tier Changes |
|
Drug1 |
Condition |
New Lower Tier |
Effective Date |
albuterol sulfate soln nebu 0.5% (5 mg/ml) |
Asthma |
Non-Preferred Generic |
2/11/2024 |
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, are based on U.S. Food and Drug Administration 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 Drug Lists |
Clinical Program |
Medication(s)1 |
New Dispensing Limit |
Effective Date |
Keveyis PAQL |
Keveyis (dichlorphenamide) 50 mg tab |
Program retired |
3/15/2024 |
Therapeutic Alternatives PAQL |
Metaxalone 400 mg tab |
Target retired |
4/15/2024 |
Standard Utilization Management Program Updates
Prior authorization and Step Therapy programs for standard-pharmacy benefit plans correlate to a member's drug list. Not all standard programs apply since updates are based on the member's current drug list. The prescription drugs tab on bcbsok.com lists the pharmacy programs per drug list, current drug lists and dispensing limits.
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 log in to Blue Access for MembersSM or MyPrime.com for a variety of online resources.
Program Changes
The following standard utilization management programs were updated on the dates indicated below.
- Androgens/Anabolic Steroids PAQL: removed generic testosterone cypionate from the program effective April 15, 2024.
- Dipeptidyl Peptidase-4 Inhibitors and Combinations STQL: program will no longer apply to the HIM Drug List effective April 15, 2024.
- Oral Pulmonary Hypertension Agents PAQL: this program has been renamed to Pulmonary Arterial Hypertension PAQL. This change was effective March 15, 2024.
- Therapeutic Alternatives PAQL: removed Metaxalone 400 mg tab from program effective April 15, 2024.
Program Retirements
The following standard utilization management programs have been retired on the dates indicated below.
- Erectile Dysfunction PA was retired March 15, 2024.
This program included the following medications: Caverject, Cialis/tadalafil, Edex, Levitra/vardenafil, Muse, Staxyn/vardenafil, Stendra and Viagra
- Human Fibrinogen Concentrate PAQL will retire April 15, 2024.
This program included the following medications: Fibryga, RiaSTAP
- Keveyis PAQL was retired March 15, 2024.
This program included the following medication: Keveyis
Please Note: The prior authorization 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 log in to Blue Access for MembersSM or MyPrime.com for a variety of online resources.
Change in Benefit Coverage for Select High-Cost Products
Several high-cost products with available lower cost alternatives will be excluded on the pharmacy benefit for select drug lists. This change impacts BCBSOK members who have prescription-drug benefits administered by Prime Therapeutics†. This change is part of an ongoing effort to ensure our members and employer groups have access to safe, cost-effective medications.
Please note: Members were not notified of this change because either there is no utilization, or the pharmacist can easily fill a member's prescription with the equivalent without needing a new prescription from the doctor. The following drugs are excluded on select drug lists.
|
Product(s) No Longer Covered1 |
Condition |
Covered Alternative(s)1,2 |
KETOPROFEN 25 mg capsules |
Pain |
meloxicam, ibuprofen, naproxen |
