Print

Medicare Part D Formulary Updates 1st Quarter 2012

May 9, 2012

A summary of recent Blue Cross and Blue Shield of Texas (BCBSTX) Medicare Part D formulary changes can be found below. The BlueMedicareRx formulary is updated monthly by our pharmacy provider, Prime Therapeutics. For a complete formulary listing and for future inquiries regarding prior authorizations, step therapy, coverage determinations/RE-determinations, transition plan benefits, and appointment of representative for your BCBSTX members please follow the following instructions: 

Utilize https://www.myprime.com to access the Prime Therapeutics’ Medicare Part D member website:

a) Click on ‘Find Drugs & Estimates’,

b) Follow directions to

  • ‘Select your Health Plan’ click on ‘BCBS Texas’,
  • ‘Medicare Part D Member?’ Click ‘YES’,
  • ‘Select Your Health plan type’  Click ‘Blue MedicareRx’

c) From this page you will be able to determine the formulary status and applicable utilization management programs for individual drugs or access any of the important databases outlined above.  

 

Generic name

(TRADE NAME)

BRAND Generic Product

Effective Date

Nature of Change

Comments

ANDRODERM (testosterone) transdermal patch, 2 mg/24hr,
4 mg/24 hr

Brand

1/1/12

Addition

Tier 2.

atorvastatin tabs, 10 mg, 20 mg,
40 mg, 80 mg

Generic

1/1/12

Cost Share Reduction

Change to Tier 1 (was 3).  Quantity Limits continue to apply.

atovaquone/proguanil
tabs, 250-100 mg

Generic

1/1/12

Addition

Tier 1.  First generic for this strength of Malarone.

BRILINTA (ticagrelor) tabs, 90 mg

Brand

1/1/12

Addition

Tier 3.

calcium acetate tabs, 667 mg

Generic

1/1/12

Addition

Tier 1.  First generic for this strength of Eliphos.

camrese (levonorgestrel/ethinyl estradiol and ethinyl estradiol)
tabs, 0.15-0.03 mg and 0.01 mg

Generic

1/1/12

Addition

Tier 1.  First generic for Seasonique.

cromolyn sodium oral soln,
100 mg/5 mL

Generic

1/1/12

Addition

Tier 1.  First generic for Gastrocrom.

DIFICID (fidaxomicin) tabs, 200 mg

Brand

1/1/12

Addition

Tier 4.

diltiazem ER caps, 360 mg

Generic

1/1/12

Addition

Tier 1.  First generic for this strength of Cardizem CD.

eprosartan tabs, 600 mg

Generic

1/1/12

Addition

Tier 1.  First generic for Teveten.  Quantity Limits apply.

felbamate susp, 600 mg/5 mL

Generic

1/1/12

Addition

Tier 1.  First generic for Felbatol suspension.

felbamate tabs, 400 mg, 600 mg

Generic

1/1/12

Addition

Tier 1.  First generic for Felbatol.

flucytosine caps, 250 mg, 500 mg

Generic

1/1/12

Addition

Tier 1.  First generic for Ancobon.

GEMCITABINE inj, 200 mg/5.26 mL, 1g/26.3 mL, 2 g/52.6 mL

Brand

1/1/12

Addition

Tier 4.

PROMACTA (eltrombopag olamine)
tab, 12.5 mg

Brand

1/22/12

Addition

Tier 4. Prior authorization applies.

JUVISYNC (sitagliptin-simvastatin)
tab, 100-10 mg,
100-20 mg,
100-40 mg

Brand

 

 

 

2/1/12

 

 

 

Addition

 

 

 

Tier 2. Step therapy and quantity limits apply.

 

 

caffeine citrate
oral soln,

60 mg/3 mL

 

Generic

 

 

 

2/1/12

 

 

 

Addition

 

 

 

Tier 1.

 

 

 

NICOTROL INHALER (nicotine)
inhaler, 10 mg

 

 

Brand

 

 

 

2/1/12

 

 

 

Addition

 

 

 

Tier 3.

 

 

 

NUEDEXTA (dextromethorphan hbr-quinidine sulfate)

cap, 20-10 mg

 

Brand

 

 

 

2/1/12

 

 

 

Addition

 

 

 

Tier 3.

 

 

 

NUCYNTA ER (tapentadol hcl)
tab, 50 mg, 100 mg, 150 mg, 200 mg,
250 mg

 

Brand

 

 

 

2/1/12

 

 

 

Addition

 

 

 

Tier 2. Quantity limits apply.

 

 

 

VIREAD (tenofovir disoproxil fumarate) tab, 150 mg,

200 mg, 250 mg, and 40 mg/gm powder for susp

Brand

 

 

 

1/29/12

 

 

 

Addition

 

 

 

Tier 3.

 

 

 

LATUDA (lurasidone hydrochloride)

tab, 20 mg

 

 

Brand

 

 

 

1/29/12

 

 

 

Addition

 

 

 

Tier 3. Step therapy and quantity limits apply.

 

 

SANDIMMUNE (cyclosporine)

oral soln,

100 mg/mL

Brand

2/13/12

Addition

Tier 3. May be covered by Medicare Part B or Medicare Part D depending on circumstances.

INLYTA (axitinib) tabs, 1 mg, 5 mg

Brand

2/14/12

Addition

Tier 4. Prior authorization and quantity limits apply.

RELISTOR (methynaltrexone) inj, 8 mg/0.4 mL

Brand

2/13/12

Addition

Tier 3. Prior authorization applies.