Pharmacy Program Quarterly Update Changes Effective <strong>Jan. 1, 2024</strong>

January 2024

Pharmacy Program Quarterly Update Changes Effective Jan. 1, 2024 – Part 1

Pharmacy Benefit Reminders
Drug List Changes
Drug List Exclusions/Revisions – Effective Jan. 1, 2024
Balanced Drug List Exclusions
Performance Drug List Exclusions
Performance Select Drug List Exclusions
Health Insurance Marketplace (HIM) Drug List Exclusions
Basic and Enhanced Revisions
Multi‑Tier Basic and Multi‑Tier Enhanced Revisions
Multi‑Tier Basic Annual and Multi‑Tier Enhanced Annual Revisions
Drug Tier Changes
Balanced Drug List Tier Changes
Performance Drug List Tier Changes
Performance Select Drug List Tier Changes
Health Insurance Marketplace (HIM) Drug List Tier Changes
Tier 1 to Tier 2 Changes – Effective Jan. 1, 2024
Performance Drug List Tier 1 to Tier 2 Changes
Utilization Management Program Changes
Standard Program Additions – Effective Jan. 1, 2024
Basic and Enhanced Drug Lists
Other Standard Program Additions – Effective Jan. 1, 2024
Basic Annual, Enhanced Annual, Health Insurance Marketplace (HIM)
New Standard Programs
Basic, Enhanced, Balanced, Performance, Performance Select, Health Insurance Marketplace (HIM) Drug Lists
Basic, Enhanced, Performance, Health Insurance Marketplace (HIM) Drug Lists
Dispensing Limit Changes – Effective Jan. 1, 2024
Basic, Enhanced, Balanced, Performance, Performance Select, Health Insurance Marketplace (HIM) Drug Lists
Basic, Enhanced, Balanced, Performance, Performance Select, Health Insurance Marketplace (HIM) Drug Lists
Other Dispensing Limit Changes
Basic, Enhanced, Balanced, Performance, Performance Select, Health Insurance Marketplace (HIM) Drug Lists
Change in Benefit Coverage for Select High-Cost Products
Pharmacy Benefits Updates
HDHP-HSA Preventive Drug Program Updates
ASO/Custom Fully Insured (CFI) Groups
ASO-Only Groups
Blue Balance Funded Plans
Small Group (SG) Plans
Symbicort and Spiriva Positive Tier Changes

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 Jan. 1, 2024 effective date.

Pharmacy Benefit Reminders
A new year often welcomes new members to Blue Cross and Blue Shield of OK (BCBSOK) or updates to benefits for our current members. Discussing your patient’s pharmacy benefits can help with this transition.

As you visit with your patients, also consider the following:

Your patient’s pharmacy benefits may be new to them or apply to an updated drug list. The preview drug lists are available on our member website to help both you and your patients when prescribing medication. The final drug lists will be available closer to the Jan. 1, 2024 effective date.
Review the prescription drug list before prescribing medications. Some drugs may have been excluded from coverage or have a new utilization management program requirement. If your patients need a coverage exception or prior authorization request, visit the Prior Authorization/Step Therapy Programs section of our provider website where you can find forms and more information.
Some members’ plans may experience changes to the pharmacy network, such as moving to a new pharmacy network or changes to pharmacies participating within the network. Members that are impacted by these changes will receive letters from BCBSOK to alert them they will pay more if continue to use a pharmacy no longer in network. In most cases, no action is required on your part for these pharmacy network changes. Members can easily transfer prescriptions to an in-network pharmacy. You may want to ask which pharmacy is their preferred choice if your office stores pharmacy information on patient records.

If you or your patients are concerned about a particular drug benefit change, call the number on their ID card to confirm any new or updated pharmacy benefits. Treatment decisions are always between you and your patients. Coverage is subject to the terms and limits of your patients’ benefit plans. Please advise them to review their benefit materials for details.

Drug List Changes
Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) will be made to the Blue Cross and Blue Shield of BCBSOK (BCBSOK) drug lists, effective on or after Jan. 1, 2024. Your patient(s) may ask you about therapeutic or lower cost alternatives if their medication is affected by one of these changes. Drug-list changes are listed on the charts below.

You can view a preview of the January drug lists on our member website. The final lists will be available closer to the January 1 effective date.

Drug List Exclusions/Revisions – Effective Jan. 1, 2024

Balanced Drug List Exclusions
Drug¹	Drug Class/Condition	Alternatives^{1, 2}
ADVAIR DISKUS (fluticasone‑salmeterol aer powder ba 100‑50 mcg/act, 250‑50 mcg/act, 500‑50 mcg/act)	Asthma, Chronic Obstructive Pulmonary Disease (COPD)	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
APO‑VARENICLINE (varenicline tartrate tab 0.5 mg, 1 mg (base equivalent))	Smoking cessation	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
EDARBI (azilsartan medoxomil tab 40 mg, 80 mg)	Hypertension	candesartan, irbesartan, losartan, olmesartan, telimisartan, valsartan
EDARBYCLOR (azilsartan medoxomil‑chlorthalidone tab 40‑12.5 mg, 40‑25 mg)	Hypertension	candesartan, irbesartan, losartan, olmesartan, telimisartan, valsartan
FLEQSUVY (baclofen susp 25 mg/5 ml)	Spasticity associated with Multiple Sclerosis and Spinal Cord Lesions	baclofen tablet 10 mg, 20 mg
FLOVENT DISKUS (fluticasone propionate aer pow ba 50 mcg/act, 100 mcg/act, 250 mcg/act) (manufacturer to discontinue product in early 2024)	Asthma	ARNUITY, A^SMANEX, QVAR
FLOVENT HFA (fluticasone propionate hfa inhal aero 44 mcg/act (50/valve),110 mcg/act (125/valve), 220 mcg/act (250/valve)) (manufacturer to discontinue product in early 2024)	Asthma	ARNUITY, A^SMANEX, QVAR
lidocaine hcl urethral/mucosal gel prefilled syringe 2%	Urethritis Pain	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
OBSTETRIX DHA (prenat w/fe carbonyl‑fa tab 29‑1 mg & dha cap 350 mg pak)	Prenatal Vitamin	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
PREZISTA (darunavir tab 600 mg, 800 mg)	HIV	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
SYMBICORT (budesonide‑formoterol fumarate aerosol, 80‑4.5 mcg/act 160‑4.5 mcg/act)	Asthma, Chronic Obstructive Pulmonary Disease (COPD)	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
VICTOZA (liraglutide soln pen‑injector 18 mg/3 ml (6 mg/ml))	Diabetes	MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY

Performance Drug List Exclusions
Drug	Drug Class/Condition	Alternatives^{1, 2}
ADVAIR DISKUS (fluticasone‑salmeterol aer powder ba 100‑50 mcg/act, 250‑50 mcg/act, 500‑50 mcg/act)	Asthma, Chronic Obstructive Pulmonary Disease (COPD)	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
APO‑VARENICLINE (varenicline tartrate tab 0.5 mg, 1 mg (base equivalent))	Smoking cessation	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
FIRVANQ (vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent))	C. Difficile Infection, Staphylococcal Enterocolitis	vancomycin solution 50 mg/mL
FLOVENT DISKUS (fluticasone propionate aer pow ba 50 mcg/act, 100 mcg/act, 250 mcg/act) (manufacturer to discontinue product in early 2024)	Asthma	ARNUITY, A^SMANEX, QVAR
FLOVENT HFA (fluticasone propionate hfa inhal aero 44 mcg/act (50/valve),110 mcg/act (125/valve), 220 mcg/act (250/valve)) (manufacturer to discontinue product in early 2024)	Asthma	ARNUITY, A^SMANEX, QVAR
lamotrigine tab disint 21 x 25 mg & 7 x 50 mg, 42 x 50 mg & 14 x 100 mg titration kit	Bipolar disorder, Seizures	Please talk to your doctor or pharmacist about other medication(s) available for your condition.
PREZISTA (darunavir tab 600 mg, 800 mg)	HIV	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
risedronate sodium tab delayed release 35 mg	Osteoporosis treatment	risedronate tablet 35 mg
VICTOZA (liraglutide soln pen‑injector 18 mg/3 ml (6 mg/ml))	Diabetes	MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY

Performance Select Drug List Exclusions
Drug¹	Drug Class/Condition	Alternatives^{1, 2}
ADVAIR DISKUS (fluticasone‑salmeterol aer powder ba 100‑50 mcg/act, 250‑50 mcg/act, 500‑50 mcg/act)	Asthma, Chronic Obstructive Pulmonary Disease (COPD)	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
APO‑VARENICLINE (varenicline tartrate tab 0.5 mg, 1 mg (base equivalent))	Smoking cessation	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
EDARBI (azilsartan medoxomil tab 40 mg, 80 mg)	Hypertension	candesartan, irbesartan, losartan, olmesartan, telimisartan, valsartan
EDARBYCLOR (azilsartan medoxomil‑chlorthalidone tab 40‑12.5 mg, 40‑25 mg)	Hypertension	candesartan, irbesartan, losartan, olmesartan, telimisartan, valsartan
FIRVANQ (vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent))	C. Difficile Infection, Staphylococcal Enterocolitis	vancomycin solution 50 mg/mL
FLOVENT DISKUS (fluticasone propionate aer pow ba 50 mcg/act, 100 mcg/act, 250 mcg/act) (manufacturer to discontinue product in early 2024)	Asthma	ARNUITY, A^SMANEX, QVAR
FLOVENT HFA (fluticasone propionate hfa inhal aero 44 mcg/act (50/valve),110 mcg/act (125/valve), 220 mcg/act (250/valve)) (manufacturer to discontinue product in early 2024)	Asthma	ARNUITY, A^SMANEX, QVAR
isotretinoin cap 25 mg, 35 mg	Acne	isotretinoin capsule 20 mg, 30 mg
lamotrigine tab disint 21 x 25 mg & 7 x 50 mg, 42 x 50 mg & 14 x 100 mg titration kit	Bipolar disorder, Seizures	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
MOXIFLOXACIN HYDROCHLORID E (moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily))	Ocular Infections	moxifloxacin ophthamic solution 0.5% (3 times daily)
NEOMYCIN/POLYMYXIN/ HYDROCORTISONE (neomycin‑polymyxin‑hc ophth susp)	Inflammatory Ocular Conditions w/ Infection	neomycin/polymyxin/dexamethasone ointment, neomycin/polymyxin/dexamethasone suspension
PREZISTA (darunavir tab 600 mg, 800 mg)	HIV	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
risedronate sodium tab delayed release 35 mg	Osteoporosis treatment	risedronate tablet 35 mg
SYMBICORT (budesonide‑formoterol fumarate aerosol, 80‑4.5 mcg/act 160‑4.5 mcg/act)	Asthma, Chronic Obstructive Pulmonary Disease (COPD)	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
VICTOZA (liraglutide soln pen‑injector 18 mg/3 ml (6 mg/ml))	Diabetes	MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY

Health Insurance Marketplace (HIM) Drug List Exclusions
Drug¹	Drug Class/Condition	Alternatives^{1, 2}
ADVAIR DISKUS (fluticasone‑salmeterol aer powder ba 100‑50 mcg/act, 250‑50 mcg/act, 500‑50 mcg/act)	Asthma, Chronic Obstructive Pulmonary Disease (COPD)	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
APO‑VARENICLINE (varenicline tartrate tab 0.5 mg, 1 mg (base equivalent))	Smoking cessation	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
CELONTIN (methsuximide cap 300 mg)	Absence Seizure	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
FIRVANQ (vancomycin hcl for oral soln 25 mg/ml, 50 mg/ml (base equivalent))	C. Difficile Infection, Staphylococcal Enterocolitis	vancomycin solution 50 mg/mL
FLOVENT DISKUS (fluticasone propionate aer pow ba 50 mcg/act, 100 mcg/act, 250 mcg/act) (manufacturer to discontinue product in early 2024)	Asthma	ARNUITY, A^SMANEX, QVAR
FLOVENT HFA (fluticasone propionate hfa inhal aero 44 mcg/act (50/valve),110 mcg/act (125/valve), 220 mcg/act (250/valve)) (manufacturer to discontinue product in early 2024)	Asthma	ARNUITY, A^SMANEX, QVAR
ORFADIN (nitisinone cap 20 mg)	Hereditary Tyrosinemia	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
PREZISTA (darunavir tab 600 mg, 800 mg)	HIV	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

Basic and Enhanced Revisions
Drug¹	Drug Class/Condition	Preferred Alternatives^{1, 2}
ADVAIR DISKUS (fluticasone‑salmeterol aer powder ba 100‑50 mcg/act, 250‑50 mcg/act, 500‑50 mcg/act)	Asthma, Chronic Obstructive Pulmonary Disease (COPD)	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
APO‑VARENICLINE ‑ (varenicline tartrate tab 0.5 mg, 1 mg (base equivalent))	Smoking cessation	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
FLOVENT DISKUS (fluticasone propionate aer pow ba 50 mcg/act, 100 mcg/act, 250 mcg/act)	Asthma	ARNUITY, A^SMANEX, QVAR
FLOVENT HFA (fluticasone propionate hfa inhal aero 44 mcg/act (50/valve),110 mcg/act (125/valve), 220 mcg/act (250/valve))	Asthma	ARNUITY, A^SMANEX, QVAR

FLOVENT HFA (fluticasone propionate hfa inhal aero 44 mcg/act (50/valve),110 mcg/act (125/valve), 220 mcg/act (250/valve))	Asthma	ARNUITY, A^SMANEX, QVAR
haloperidol lactate oral conc 2 mg/ml	Psychosis, Tourette Syndrome, Behavioral Disorders	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
ORFADIN (nitisinone cap 20 mg)	Hereditary Tyrosinemia	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
PREZISTA (darunavir tab 600 mg, 800 mg)	HIV	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
sotalol hcl (afib/afl) tab 120 mg, 160 mg	Atrial Fibrillation/Atrial Flutter	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
VICTOZA (liraglutide soln pen‑injector 18 mg/3ml (6 mg/ml))	Diabetes	MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY

Multi-Tier Basic and Multi-Tier Enhanced Revisions
Drug¹	Drug Class/Condition	Preferred Alternatives^{1, 2}
dexamethasone tab 0.5 mg, 0.75 mg	inflammatory Conditions	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
haloperidol lactate oral conc 2 mg/ml	Psychosis, Tourette Syndrome, Behavioral Disorders	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
sotalol hcl (afib/afl) tab 120 mg, 160 mg	Atrial Fibrillation/Atrial Flutter	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

Multi-Tier Basic Annual and Multi-Tier Enhanced Annual Revisions
Drug¹	Drug Class/Condition	Preferred Alternatives^{1, 2}
dexamethasone tab 0.5 mg, 0.75 mg	inflammatory Conditions	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
haloperidol lactate oral conc 2 mg/ml	Psychosis, Tourette Syndrome, Behavioral Disorders	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.
sotalol hcl (afib/afl) tab 120 mg, 160 mg	Atrial Fibrillation/Atrial Flutter	There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

Drug Tier Changes
The tier changes listed below apply to members on a managed drug list. Members may pay more for these drugs after Jan. 1, 2024.

Balanced Drug List Tier Changes
Drug¹	Drug Class/Condition	Alternatives^{1, 2}	New Tier
MESALAMINE DR (mesalamine tab delayed release 800 mg)	Ulcerative Colitis	mesalamine tab delayed release 400 mg	Non‑Preferred Brand
NAFRINSE DROPS (sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf))	Dental Caries Prophylaxis	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
OXANDROLONE (oxandrolone tab, 2.5 mg 10 mg)	Promotes Weight Gain	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
PODOFILOX (podofilox soln 0.5%)	Warts	imiquimod cream 5%	Non‑Preferred Brand
TELMISARTAN/AMLODIPINE (telmisartan‑amlodipine tab 40‑5 mg, 40‑10 mg, 80‑5 mg, 80‑10 mg)	Hypertension	telmisartan tab 40 mg, amlodipine tab 10 mg, amlodipine‑valsartan, amlodipine‑olmesartan	Non‑Preferred Brand

Performance Drug List Tier Changes
Drug¹	Drug Class/ Condition	Alternatives^{1, 2}	New Tier
MESALAMINE DR (mesalamine tab delayed release 800 mg)	Ulcerative Colitis	mesalamine tab delayed release 400 mg	Non‑Preferred Brand
NAFRINSE DROPS (sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf))	Dental Caries Prophylaxis	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
OXANDROLONE (oxandrolone tab, 2.5 mg 10 mg)	Promotes Weight Gain	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
PODOFILOX (podofilox soln 0.5%)	Warts	imiquimod cream 5%	Non‑Preferred Brand
TELMISARTAN/AMLODIPINE (telmisartan‑amlodipine tab 40‑5 mg, 40‑10 mg, 80‑5 mg, 80‑10 mg)	Hypertension	telmisartan tab 40 mg, amlodipine tab 10 mg, amlodipine‑valsartan, amlodipine‑olmesartan	Non‑Preferred Brand

Performance Select Drug List Tier Changes
Drug¹	Drug Class/ Condition	Alternatives^{1, 2}	New Tier
MESALAMINE DR (mesalamine tab delayed release 800 mg)	Ulcerative Colitis	mesalamine tab delayed release 400 mg	Non‑Preferred Brand
NAFRINSE DROPS (sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf))	Dental Caries Prophylaxis	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
OXANDROLONE (oxandrolone tab, 2.5 mg 10 mg)	Promotes Weight Gain	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
PODOFILOX (podofilox soln 0.5%)	Warts	imiquimod cream 5%	Non‑Preferred Brand
TELMISARTAN/AMLODIPINE (telmisartan‑amlodipine tab 40‑5 mg, 40‑10 mg, 80‑5 mg, 80‑10 mg)	Hypertension	telmisartan tab 40 mg, amlodipine tab 10 mg, amlodipine‑valsartan, amlodipine‑olmesartan	Non‑Preferred Brand

Health Insurance Marketplace (HIM) Drug List Tier Changes
Drug¹	Drug Class/ Condition	Alternatives^{1, 2}	New Tier
MELPHALAN (melphalan tab 2 mg)	Cancer	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand Specialty
MESALAMINE (mesalamine tab delayed release 800 mg)	Ulcerative Colitis	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
NAFRINSE (sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf))	Dental Caries	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
OXANDROLONE (oxandrolone tab 2.5 mg, 10 mg)	Weight Gain	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand
PODOFILOX (podofilox soln 0.5%)	Anogenital Warts	Please talk to your doctor or pharmacist about other medication(s) available for your condition.	Non‑Preferred Brand

Tier 1 to Tier 2 Changes – Effective Jan. 1, 2024
The following drugs are moving from a preferred generic (tier 1) to a non‑preferred generic (tier 2), effective Jan. 1, 2024. These changes only apply to members with a pharmacy benefit plan that includes different payment tiers for preferred generics and non‑preferred generic (e.g. 5‑tier or higher plan design with preferred generic and non‑preferred generic lower tiers). Members may pay more for these drugs.

Performance Drug List Tier 1 to Tier 2 Changes
Drug¹	Drug Class/Condition
bupropion hcl (smoking deterrent) tab er 12hr 150 mg	Smoking cessation
dexamethasone tab 0.5 mg, 0.75 mg	inflammatory Conditions
haloperidol lactate oral conc 2 mg/ml	Psychosis, Tourette Syndrome, Behavioral Disorders
sotalol hcl (afib/afl) tab 120 mg, 160 mg	Atrial Fibrillation/Atrial Flutter
stannous fluoride conc 0.63%	Dental Caries Prophylaxis

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.
Standard Program Additions – Effective Jan. 1, 2024

Several drug categories and/or targeted medications will be added to the Prior Authorization (PA) and Step Therapy (ST) 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.

The drug programs listed below have been added to the step therapy and dispensing limit programs.

Basic and Enhanced Drug Lists
Standard Program	Medication(s)¹ Added
Oral Inhaler STQL*	Advair Diskus (Fluticasone-Salmeterol Aer Powder BA), Alvesco (ciclesonide inhal aerosol), Flovent Diskus (fluticasone propionate aer pow ba), Flovent HFA (fluticasone propionate hfa inhal aer; fluticasone propionate hfa inhal aero)

*Members were lettered on this change.
Other Standard Program Additions – Effective Jan. 1, 2024
Members were notified about these changes.

Basic Annual, Enhanced Annual, Health Insurance Marketplace (HIM)
Standard Program	Medication(s)¹ Added
Factor VIII and von Willebrand Factor	Alphanate, Humate P, Vonvendi, Wilate
Multiple Sclerosis	Augagio 7 mg, 14 mg tab; Gilenya (fingolimod) 0.5 mg capsule
Radicava	Radicava ORS (edaravone oral suspension) 105 mg/5 ml, Radicava ORS Starter Kit (edaravone oral suspension) 105 mg/5 ml
Therapeutic Alternatives	Tobi Podhaler 28 mg (tobramycin inhal cap)

New Standard Programs
The drug programs listed below have been added to the dispensing limit and/or prior authorization programs. Members were not notified about these changes, unless otherwise noted.

Basic, Enhanced, Balanced, Performance, Performance Select, Health Insurance Marketplace (HIM) Drug Lists
Effective Date	New Program	Medication(s)	Program Type
11/1/2023	Joenja	Joenja	Prior Authorization and Dispensing Limits
1/1/2024	Miebo	Miebo	Prior Authorization and Dispensing Limits
1/1/2024	Neurokinin Receptor Antagonists	Veozah	Prior Authorization and Dispensing Limits
1/1/2024	Opioids	Oxycontin	Prior Authorization and Dispensing Limits
1/1/2024	Rezurock*	Rezurock	Prior Authorization and Dispensing Limits
1/1/2024	Vowst	Vowst	Prior Authorization and Dispensing Limits

*Members were lettered on this change. The change does not apply on the Health Insurance Drug List until on or after Jan. 1, 2025.

Basic, Enhanced, Performance, Health Insurance Marketplace (HIM) Drug Lists
Effective Date	New Program	Medication(s)	Program Type
1/1/2024	Winlevi*	Winlevi	Prior Authorization

*Not all members were lettered on this change due to limited utilization.

Dispensing Limit Changes – Effective Jan. 1, 2024
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.
Changes by drug list are listed on the chart below. Members were not notified about these changes due to limited utilization.

Basic, Enhanced, Balanced, Performance, Performance Select, Health Insurance Marketplace (HIM) Drug Lists
Program	Target Agent	Dispensing Limit
Miebo PAQL	Miebo (perflurohexylocatane) opth solution 1.338 gm/mL	4 bottles per 30 days
Neurokinin Receptor Antagonists PAQL	Veozah (fezolinetant) 45 mg tab	30 tabs per 30 days
Vowst PAQL	Vowst (fecal microbiota spores) live-brpk caps	12 caps per 12 months

If BCBSOK sends letters to members, it is 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. Members were notified about the dispensing limit program changes listed in the tables below.

Basic, Enhanced, Balanced, Performance, Performance Select, Health Insurance Marketplace (HIM) Drug Lists
Program	Target Agent	Dispensing Limit
Rezurock PAQL	Rezurock (belumosudil mesylate) 200 mg tab	60 tabs per 30 days

Other Dispensing Limit Changes

Basic, Enhanced, Balanced, Performance, Performance Select, Health Insurance Marketplace (HIM) Drug Lists
Effective Date	Program	Target Agent	Dispensing Limit
11/1/2023	Joenja PAQL*	Joenja (leniolisib phosphate) 70 mg tab	60 tabs per 30 days

*Members were not lettered.
Per our usual process, members affected by drug list revisions and/or exclusions, dispensing limit and prior authorization program changes will receive mailings prior to implementation.

Per our usual process of member notification prior to implementation, targeted mailings were sent to members affected by drug list revisions and/or exclusions and prior authorization program changes.

For the most up-to-date drug list and list of drug dispensing limits, visit the provider pharmacy webpage.

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 more 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 make sure 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 Covered^1*	Condition	Covered Alternative(s)^{1, 2}
AMCINONIDE OINTMENT 0.1%	Eczema, rash	Lower cost, Group 2 Potency Steroids (e.g., Betamethasone cream/ointment, Fluocinonide)
DICLOFENAC POTASSIUM 25 MG TABLETS		DICLOFENAC POT 50 MG, MELOXICAM, IBUPROFEN, NAPROXEN

Pharmacy Benefits Updates
HDHP-HSA Preventive Drug Program Updates
The HDHP-HSA Preventive Drug Program offers certain preventive medications at reduced out-of-pocket costs to members in select High Deductible Health Plans (HDHP), along with those using a Health Savings Account (HSA).

See below for the applicable categories and the 2024 updates for each market segment.

Some preventive medications have been removed from the 2024 HDHP preventive lists and will affect members’ out-of-pocket expense. Member costs (copay or coinsurance) may vary based on plan benefits and/or group selection.

Note: Affected members will receive letters alerting them of the preventive-drug changes. Impacted categories include the following: Contraceptives, High Blood Pressure, High Cholesterol, Respiratory, and Osteoporosis.

ASO/Custom Fully Insured (CFI) Groups
Effective Date	2024 Changes	Categories
1/1/2024	Standard categories from 2023 are unchanged with minor product differences. CFI groups can now select from all extended categories rather than only select categories and products.	Standard Anti-Coagulants / Anti-Platelets, Bowel Prep Medications, Breast Cancer Primary Prevention, Contraceptives, Depression, Diabetes Medications, Diabetic Supplies, Fluoride Supplements, High Blood Pressure, High Cholesterol Orals, Osteoporosis, Respiratory (asthma/COPD), Tobacco Cessation, Vaccines. Extended Antianginal, Anti-Coagulants Preferred Brands, Anti-Platelets Preferred Brands, Diabetic Medications Oral (DPP4, SGLT2, DPP4+SGLT2 combo) Preferred Brands, Diabetic Medications GLP1 Oral & Other Injectables Preferred Brands, Diabetic Supplies - Continuous Glucose Monitors (CGMs) and Associated Supplies, High Cholesterol Injectable PCSK-9s, Respiratory Devices and Supplies, Transplant (anti-rejection), Vitamins - Prenatal

ASO-Only Groups
Effective Date	2024 Changes	Custom Categories
1/1/2024	The migraine prophylaxis custom category was split into Migraine Prophylaxis DGRPs Injectable and Migraine Prophylaxis CGRPs Oral. Custom categories remain ASO only with the exception of Diabetic Supplies – Insulin Pumps and Associated Supplies, which is available for CFI groups.	Anaphylaxis Agents, Antiarrhythmics, Anticonvulsants, Anti-Malarials, Antipsychotics, Breast Cancer Secondary Prevention, Diabetic Supplies - Insulin Pumps and Associated Supplies*, Estrogen, Gastrointestinal Ulcer, Gout, Heparin/Low Molecular Weight Heparin, HIV/AIDS, Influenza Agents, Lipid Lowering – Other, Mental Health, Migraine Prophylaxis CGRPs Injectable, Migraine Prophylaxis CGRPs Oral, Substance Use Disorder, Thyroid Agents, Weight Loss *Optional coverage is also available to Custom Fully Insured groups

Blue Balance Funded Plans
Effective Date	2024 Changes	Categories
1/1/2024	Standard categories from 2023 are unchanged with minor product differences.	Anti-Coagulants / Anti-Platelets, Bowel Prep Medications, Breast Cancer Primary Prevention, Contraceptives, Depression, Diabetes Medications, Diabetic Supplies, Fluoride Supplements, High Blood Pressure, High Cholesterol Orals, Osteoporosis, (asthma/COPD), Tobacco Cessation, Vaccines

Small Group (SG) Plans
State/Market Segment	Effective Date	2024 Changes	Categories
QHP/Metallic SG Blue Preferred Gold PPO 418 Blue Advantage Gold PPO 119 Blue Advantage Silver PPO 121 Blue Preferred Silver PPO 419	1/1/24	The Quality Health Plan (QHP) categories from 2023 are unchanged with minor product differences.	Anti-Coagulants / Anti-Platelets, Depression, Diabetes Medications, Diabetic Supplies, High Blood Pressure, High Cholesterol Orals, Osteoporosis

Symbicort and Spiriva Positive Tier Changes
As markets change, BCBSOK is focused on reducing the rising cost of generic drugs for our members. In doing so, it has chosen to move the following brand-name drugs to lower payment tiers on select drug lists.

Symbicort was placed in the non-preferred generic tier on the Balanced and Performance Select drug lists until Jan. 1, 2024. The available alternatives – budesonide/formoterol fumarate dihydrate inhalation aerosol and Breyna – will no longer be covered during this time.
For all other quarterly drug lists – Basic, Enhanced, Performance and Health Insurance Marketplace – Symbicort will be move to the non-preferred generic tier and remain until multiple generics are available. This approach will not be adopted with annually updated drug lists. (Effective Oct. 15)
Spiriva HandiHaler was added to the non-preferred generic tier on all drug lists. The available generic – tiotropium bromide inhalation – will no longer be covered. (Effective Oct. 15)

BLUE REVIEW^SM

for Providers

Pharmacy Program Quarterly Update Changes Effective Jan. 1, 2024 – Part 1

BLUE REVIEWSM

for Providers

Pharmacy Program Quarterly Update Changes Effective Jan. 1, 2024 – Part 1

BLUE REVIEW^SM