January 2015 Florida Blue Utilization Management Update

January 2015
Commercial and Other Pharmacy Program Updates
Effective Jan. 1, 2015
Several changes to Florida Blue’s Pharmacy Programs will be implemented Jan. 1, 2015. The
modifications affect medications that require prior authorization, the Responsible Steps Program, the
Responsible Quantity Program and the pharmacy coverage exclusions list. The changes are included
below.
Pharmacy Coverage Exclusion Addition
Effective Jan. 1, 2015, Florida Blue commercial pharmacy plans will no longer cover the brand name
drugs listed in the table below. However, Florida Blue will cover many of their generic alternatives. This
exclusion list only applies to members in plans that allow pharmacy coverage exclusions.
Drugs Not Covered
Covered Alternatives
Active Prep Kit
Oral generic versions of the components
Apidra, Humalog, Humalog Mix50/50, Humalog
Mix75/25, Humulin R U-100, Humulin 70/30,
Humulin N
Novolog, Novolog Mix 70/30, Novolin R, Novolin N
Novolin 70/30, Lantus, Levemir, Humulin R U-500
Deprizine fusepaq
ranitidine
Jublia
Ciclopirox nail lacquer
Natesto, Vogelxo,
Androderm, Androgel
NP #2 Drug preparation kit
Oral generic versions of the components
Panoxyl
Benzoyl Peroxide (Rx only)
Sitavig
Acyclovir
Synapryn fusepak
Tramadol generic
Tramadol ER brand
Tramadol ER generic
Responsible Steps Additions
Beginning Jan. 1, 2015, Florida Blue will add the following list of drugs to the Responsible Steps Program
for members enrolled in our under 65 products. This only applies to members enrolled in health plans that
are part of the Responsible Steps Program.
Program
New Target
Diabetes Step
Trulicity
900-524-1114
Medications Requiring Prior Authorization
Prior authorization requirements for the following list of medications will changeunder the member’s
pharmacy benefit effective Jan. 1, 2015. This only applies to members enrolled in plans that are part of
the Prior Authorization Program.
Drugs Added to the Prior Authorization Program
Drug
Coverage Criteria*
Apidra, Humalog, Humalog Mix
Trial and failure or contraindication to a therapeutically
products, Humulin R U-100,
equivalent product from the following list: Novolog, Novolog
Humulin 70/30, Humulin N**
Mix 70/30, Novolin R, Novolin N, Novolin 70/30 or Levemir,
Non-preferred glucose test strips
Concurrent use of an insulin pump that does not integrate with
(all strips except Bayer strips)
Bayer meters
Beleodaq
Relapsed or refractory T cell Lymphoma
Bunavail
Treatment of opioid dependence
Cerdelga
Treatment of Gaucher’s disease
Esbriet
Treatment of idiopathic pulmonary fibrosis
Harvoni
Treatment of Hepatitis C infection
Jublia
Treatment of fungal infection
Kerydin
Treatment of fungal infection
Keytruda
Treatment of melanoma
Natesto
Treatment of male hypogonadism
Ofev
Treatment of idiopathic pulmonary fibrosis
Plegridy
Prevention of Multiple Sclerosis exacerbations
Ruconest
Treatment of acute attacks of hereditary angioedema
Sivextro
Treatment of resistant gram positive infections
Terbinex
Treatment of fungal infection
Testosterone Pump
Treatment of male hypogonadism
Zydelig
Treatment of Leukemia or Lymphoma
*Summary of criteria, see http://mcgs.bcbsfl.com for complete criteria information.
**Prior authorization for non-preferred insulins only apply to members in plans that allow Prior Authorization but do
not allow Coverage Exclusion.
Responsible Quantity Additions
The following list of drugs and drug dispensing limits will be added to the Responsible Quantity Program,
Oct. 1, 2014. This only applies to members enrolled in in health plans that are part of the Responsible
Quantity Program. Please note: Responsible Quantity Program limits apply to generic drugs where
applicable and to members enrolled in health plans that are part of the Responsible Quantity Program.
900-524-1114
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Brand/Generic Name
Strength
Dispensing Limit Per Month
(unless otherwise noted)
New Drugs to the Program
Bunavail
2.1/03mg, 4.2/0.7mg
30 films
Bunavail
6.3/1mg
60 films
Buphenyl
powder
600 gm
Buphenyl
500 mg tablet
1200 tablets
7.5 mcg/hr
4 patches / 28 days
Butrans
Cerdelga
60 caps
Esbriet
270 caps
Myalept
30 vials
Ofev
60 caps
Plegridy
Plegridy
2 pens / 28 days
Starter kit
Ravicti
Revatio
1 kit / 180 days
525 ml
10mg / ml suspension
Sivextro
224 ml
6 tabs
Testosterone Pump
2 pumps
Triumeq
30 tabs
Trulicity
4 pens/28 days
Tybost
30 tabs
Xarelto
1 kit
Zydelig
60 tabs
Authorization Request forms
Authorization request forms are available at www.floridablue.com. Click on the Providers box, and then
click Pharmacy. A listing of the programs and authorization forms can be found there.
Pharmacy Preferred Drug List Changes and Current Listing
Changes to our preferred drug lists as well as a current listing is available at www.floridablue.com. Click
on the Providers tab, Pharmacy Information and Resources, and then the Medication Guides link. To
request a written copy of materials posted to our website, please contact our Provider Contact Center at
(800) 727-2227.
900-524-1114
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