Medicare Part D Formulary Updates 2nd Quarter 2012

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July 26, 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	Description of Change	Comments
doxorubicin liposomal inj, 2 mg/mL	Generic	2/26/12	Addition	Tier 1. May be covered by Medicare Part B or Medicare Part D depending on circumstances.
AFINITOR (everolimus) tab, 7.5 mg	Brand	3/4/12	Addition	Tier 4. Prior authorization and quantity limits apply.
ziprasidone cap, 20 mg, 40 mg, 60 mg, 80 mg	Generic	3/4/12	Addition	Tier 1. Quantity limits apply. Generic for GEODON.
ZYCLARA (imiquimod) pump cream, 3.75%	Brand	3/4/12	Addition	Tier 2. Prior authorization and quantity limits apply.
methotrexate for inj	Generic	3/25/12	Cost Share Reduction	Change to Tier 1 (was 3).
MENEST tab, 0.3 mg, 0.625 mg, 1.25 mg, 2.5 mg	Brand	3/30/12	Addition	Tier 3.
quetiapine tab, 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg	Generic	4/1/12	Addition	Tier 1. Quantity limits apply. First generic for Seroquel.
escitalopram oral soln, 5 mg/5 mL; tab, 5 mg, 10 mg, 20 mg	Generic	4/1/12	Addition	Tier 1. Quantity limits apply. First generic for Lexapro.
irbesartan tab, 75 mg, 150 mg, 300 mg	Generic	4/8/12	Addition	Tier 1. Quantity limits apply. First generic for Avapro.
irbesartan/ hydrochlorothiazide tab, 150-12.5 mg, 300-12.5 mg	Generic	4/8/12	Addition	Tier 1. Quantity limits apply. First generic for Avalide.
morphine sulfate oral soln, 10 mg/5 mL, 20 mg/5 mL	Generic	4/10/12	Cost Share Reduction	Change to Tier 1 (was 3).
REVLIMID (lenalidomide) cap, 2.5 mg	Brand	4/22/12	Addition	Tier 4. Quantity limits apply.
dextroamphetamine tab, 10 mg	Generic	4/22/12	Cost Share Reduction	Change to Tier 1 (was 3). Quantity Limits continue to apply.
ibandronate sodium tab, 150 mg	Generic	4/22/12	Addition	Tier 1. Quantity limits apply. May be covered by Medicare Part B or Medicare Part D depending on circumstances. First generic for Boniva.
vancomycin cap, 125 mg, 250 mg	Generic	4/29/12	Addition	Tier 4. First generic for Vancocin..
VIIBRYD (vilazodone) tab, starter kit containing 10 mg, 20 mg, and 40 mg	Brand	4/29/12	Addition	Tier 2. Step therapy and quantity limits apply.
JANUMET XR (sitagliptin-metformin) extended-release tab, 50-500 mg, 50-1000 mg, 100-1000 mg	Brand	5/1/12	Addition	Tier 2. Step therapy and quantity limits apply.
JENTADUETO (linagliptin-metformin) tab, 2.5-500 mg, 2.5-850 mg, 2.5-1000 mg	Brand	5/1/12	Addition	Tier 3. Step therapy and quantity limits apply.
KALYDECO (ivacaftor) tab, 150 mg	Brand	5/1/12	Addition	Tier 4. Prior authorization and quantity limits apply.
PROLIA (denosumab) inj, 60 mg/mL	Brand	5/1/12	Addition	Tier 4. Prior authorization applies.
TRADJENTA (linagliptin) tab, 5 mg	Brand	5/1/12	Addition	Tier 3. Step therapy and quantity limits apply.
INTELENCE (etravirine) tab, 25 mg	Brand	5/6/12	Addition	Tier 3.
clopidogrel tab, 75 mg	Generic	5/20/12	Addition	Tier 1. First generic for Plavix.