docBCN Custom and Custom Select Drug List Updates
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BCN Custom and Custom Select Drug List Updates
BCN Drug List Updates – February 2015 This page shows monthly updates to our BCBSM/BCN Custom Drug List, and BCBSM/BCN Custom Select Drug List. These changes are incorporated in the Drug Lists when it is updated every January and July. New generic and brand-name drugs The table below shows drugs that are now available as generics and can be dispensed at the lowest copayment. The brand-name version of the drug will no longer be covered unless your physician requests coverage based on medical necessity and BCN approves the request. If a dispense-as-written prescription is not authorized, you must pay the difference in cost between the brand-name product and the generic drug, in addition to the required copayment for a brand-name medication. The table also includes new FDA-approved drugs that BCN has reviewed for the Drug List. New drugs that have not been reviewed are not covered. Brand Name Generic Name Category New generics ® Clobex 0.05% spray (g) ® Lamictal ODT(g) Drug List Status Effective Tier 5-Tier 6-Tier Custom Select Tier clobetasol propionate Dermatology 1 1 1B 1B 1/2015 lamotrigine Central nervous system 1 1 1B 1B 2/2015 morphine sulfate/naltrexone Central nervous system 3 3 3 3 1/2015 ledipasvir/sofosbuvir Anti-infectives 2 4 4 4 2/2015 beclomethasone dipropionate Otic and nasal preparations 3 3 3 Excluded 12/2014 (ombitasvir/paritaprevir/ ritonavir; dasabuvir) Anti-infectives 2 4 4 4 2/2015 New brand-name drugs ® Embeda * ® Harvoni * <s> ® Qnasl Childrens ™ Viekira Pak * <s> New drugs pending review Afrezza ® Akynzeo ® Belsomra Blincyto ® ™ ™ Cerdelga <s> ® Contrave ER insulin human inhalation powder Endocrinology netupitant/palonosetron hcl Gastrointestinal agents suvorexant Central nervous system blinatumomab Antineoplastics and immunosuppressants eliglustat Antineoplastics and immunosuppressants 10/2014 Not covered Pending review for drug list placement naltrexone hcl/bupropion hcl Lifestyle modification (g) Generic dispensed <s> Specialty drug 8/2014 * Step therapy or prior authorization required. Clinical criteria must be met. 11/2014 12/2014 8/2014 10/2014 ** Depending on member’s drug rider. BCN Drug List Updates – February 2015 Brand Name Generic Name Category Drug List Status Effective New drugs pending review (Cont.) ® Esbriet <s> pirfenidone Respiratory, cough and cold 9/2014 HPV 9-valent vaccine Immunology and hematology 10/2014 HyQvia <s> IGG/hyaluronidase,recombi Immunology and hematology nant 9/2014 Hysingla ER™ ® Gardasil 9 ™ hydrocodone bitartrate Central nervous system 1/2015 ® miltefosine Anti-infectives 3/2014 ® Keytruda <s> pembrolizumab Antineoplastics and immunossuppresants 9/2014 Lemtrada™<s> alemtuzumab Antineoplastics and immunossuppresants 11/2014 Lynparza™ olaparib Antineoplastics and immunossuppresants 1/2015 methoxy peg-epoetin beta Immunology and hematology 12/2014 Monovisc <s> hyaluronic acid derivative Rheumatology and musculoskeletal 3/2014 Movantik™ naloxegol Gastrointestinal 10/2014 Obredon™ Impavido <s> Mircera ® ® guaifenesin/hydrocodone Respiratory, cough and cold ® Ofev <s> nintedanib esylate Respiratory, cough and cold Onexton™ clindamycin phos/ benzoyl perox Dermatology 12/2014 nivolumab Antineoplastics and immunossuppresants 12/2014 Plegridy™ <s> peginterferon beta-1a Immunology and hematology 10/2014 Rapivab™ peramivir Anti-infectives 12/2014 Rytary™ carbidopa/levodopa Central nervous system 1/2015 edoxaban tosylate Cardiovascular, hypertension, cholesterol 1/2015 ivermectin Dermatology 1/2015 dulaglutide Endocrinology 10/2014 meningococcal group B vaccine Immunology and hematology 12/2014 Xigduo XR™ dapagliflozin/metformin Endocrinology 10/2014 Zerbaxa™ ceftolozane/tazobactam Anti-infectives 12/2014 Opdivo ® Savaysa™ Soolantra ® Trulicity™ Trumenba ® (g) Generic dispensed <s> Specialty drug Not covered Pending review for drug list placement * Step therapy or prior authorization required. Clinical criteria must be met. 1/2015 10/2014 ** Depending on member’s drug rider. BCN Drug List Updates – February 2015 Other changes BCN monitors the use of certain medications to ensure that our members receive the most appropriate and cost-effective drug therapy. This table reflects new or changed prior authorization requirements based on current medical information and the recommendations of BCN’s Pharmacy and Therapeutics Committee. Brand Name Generic Name Category Drug List Status Effective New prior authorization/step therapy criteria ® Harvoni * <s> ledipasvir/sofosbuvir Anti-infectives ™ Viekira Pak * <s> 2/2015 (ombitasvir/ Anti-infectives paritaprevir/ritonavir; dasabuvir) Coverage is provided for the treatment of chronic hepatitis C (HCV) genotype 1 in members 18 years or older with compensated liver disease, who have abstained from alcohol consumption for at least 6 months prior to therapy initiation and who have attested to compliance with the treatment regimen. Coverage is provided for the treatment of chronic hepatitis C (HCV) genotype 1 in members 18 years or older with compensated liver disease who meet clinical criteria. ledipasvir/sofosbuvir Anti-infectives 1 tablet per day 2/2015 (ombitasvir/ Anti-infectives paritaprevir/ritonavir; dasabuvir) 4 tablets per day 2/2015 mometasone furoate Respiratory, cough and cold Tier changed to Tier 1/1A for members with the Custom Drug List, and tier 2 for members with the Custom Select Drug List 1/2015 boceprevir 2/2015 1/2015 2/2015 2/2015 Quantity Limits ® Harvoni * <s> ™ Viekira Pak * <s> Miscellaneous Asmanex HFA ® ® Victrelis * <s> Prevacid(g) capsules lansoprazole Gastrointestinal agents Tier changed to Tier 3 for 3-Tier benefits and Tier 5 for 5 or 6-Tier benefits Step therapy removed Aciphex(g) tablets Zanaflex(g) tablets Gastrointestinal agents Central nervous system Step therapy removed Step therapy removed rabeprazole tizanidine (g) Generic dispensed <s> Specialty drug Anti-infectives * Step therapy or prior authorization required. Clinical criteria must be met. 1/2015 ** Depending on member’s drug rider.
