Provider Newsletter 1st Quarter 2013 Medicare Part D Formulary Updates

A summary of recent Blue Cross and Blue Shield of Texas (BCBSTX) Medicare Part D formulary changes can be found below. The Blue MedicareRx 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 the following link (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.  

 

TRADE NAME
(generic name)
or
generic name

Brand/
Generic
Product

Effective Date

Description of Change

Comments

abacavir
tabs, 300 mg

Generic

1/1/13

Addition

Tier 2. Quantity limits apply. First generic for ZIAGEN.

ANDROGEL (testosterone)
gel packet, 1.62%

Brand

1/1/13

Addition

Tier 3. Prior authorization and quantity limits apply. 

BACITRACIN
ophth oint,
500 units/g

Brand

1/1/13

Addition

Tier 4.

BOSULIF (bosutinib) tabs, 100 mg,
500 mg

 

Brand

1/1/13

Addition

Tier 5. Prior authorization and quantity limits apply.

calcipotriene
cream, 0.005%

 

Generic

1/1/13

Addition

Tier 2. First generic for DOVONEX cream.

candesartan/
hydrochlorothiazide tabs, 16-12.5 mg,
32-12.5 mg,
32-25 mg

 

Generic

1/1/13

Addition

Tier 2. Quantity limits apply. First generic for ATACAND HCT.

cidofovir
IV inj, 75 mg/mL

Generic

1/1/13

Addition

Tier 2. First generic for VISTIDE.

cisplatin
inj, 200 mg/200 mL

Generic

1/1/13

Cost Share Reduction

Change to Tier 2
(was 4).

COMBIVENT RESPIMAT (ipratropium/
albuterol) inhal soln,
20-100 mcg/actuation

Brand

1/1/13

Addition

Tier 4. Quantity limits apply.

diclofenac/
misoprostol
tabs, 50-0.2 mg,
75-0.2 mg

Generic

1/1/13

Addition

Tier 2. First generic for ARTHROTEC.

ELELYSO (taliglucerase alfa)
for inj, 200 units

Brand

1/1/13

Addition

Tier 5. 

fenofibrate
tabs, 48 mg, 145 mg

Generic

1/1/13

Addition

Tier 2. Quantity limits apply. First generic for TRICOR.

griseofulvin ultramicrosize
tabs, 125 mg,
250 mg

Generic

1/1/13

Addition

Tier 2. First generic for GRIS-PEG.

ICLUSIG

tabs, 15 mg, 45 mg

Brand

1/1/13

Addition

Tier 5. Prior authorization and quantity limits apply. 

ILEVRO
ophth susp, 0.3%

Brand

1/1/13

Addition

Tier 4.

JUVISYNC (sitagliptin/
simvastatin)
tabs, 50-10 mg,
50-20 mg, 50-40 mg

Brand

1/1/13

Addition

Tier 3. Step therapy and quantity limits apply. 

LATUDA (lurasidone) tabs, 120 mg

Brand

1/1/13

Addition

Tier 4. Prior authorization and quantity limits apply.

leucovorin calcium
for inj, 50 mg

Generic

1/1/13

Cost Share Reduction

Change to Tier 2
(was 4).

LOTEMAX
ophth gel, 0.5%

Brand

1/1/13

Addition

Tier 3.

modafinil
tabs, 100 mg,
200 mg

Generic

1/1/13

Addition

Tier 2. Prior authorization and quantity limits apply. First generic for PROVIGIL.

montelukast
chew tabs, 4 mg,
5 mg; tabs, 10 mg

Generic

1/1/13

Addition

Tier 2. First generic for SINGULAIR.

montelukast
oral granules
packet, 4 mg

Generic

1/1/13

Addition

Tier 2. First generic for SINGULAIR.

phenobarbital
elixir, 20 mg/5 mL

Generic

1/1/13

Addition

Tier 2.

phenobarbital
inj, 65 mg/mL,
130 mg/mL

Generic

1/1/13

Addition

Tier 2.

phenobarbital
tabs, 15 mg, 60 mg, 100 mg

Generic

1/1/13

Addition

Tier 2.

phenytoin
chew tabs, 50 mg

Generic

1/1/13

Addition

Tier 2. First generic for DILANTIN chew tabs.

pioglitazone
tabs, 15 mg, 30 mg,
45 mg

Generic

1/1/13

Addition

Tier 2. Quantity limits apply. First generic for ACTOS.

prednisone
dose-pack, 5 mg,
10 mg

Generic

1/1/13

Cost Share Reduction

Change to Tier 1
(was 2).

PREZISTA
tabs, 800 mg

Brand

1/1/13

Addition

Tier 4. Quantity limits apply.

sildenafil
tabs, 20 mg

Generic

1/1/13

Addition

Tier 5. Prior authorization and quantity limits apply. First generic for REVATIO.

SOLTAMOX

soln 10 mg/5 mL

Brand

1/1/13

Addition

Tier 4.

STIVARGA (regorafenib)
tabs, 40 mg

Brand

1/1/13

Addition

Tier 5. Prior authorization and quantity limits apply.

STRIBILD (elvitegravir/
cobicistat/ emtricitabine/ tenofovir disoproxil fumarate) tabs,
150-150-200-300 mg

Brand

1/1/13

Addition

Tier 4. Quantity limits apply. 

SUBOXONE
film, 4-1 mg,
12-3 mg

Brand

1/1/13

Addition

Tier 4. Quantity limits apply.

SUPRAX (cefixime) chew tabs, 100 mg, 200 mg

Brand

1/1/13

Addition

Tier 4.

SYNRIBO
for inj, 3.5 mg

Brand

1/1/13

Addition

Tier 5.

tiagabine
tabs, 2 mg, 4 mg

Generic

1/1/13

Addition

Tier 2. First generic for GABITRIL.

tolterodine
tabs, 1 mg, 2 mg

Generic

1/1/13

Addition

Tier 2. Quantity limits apply. First generic for DETROL

trospium ER
caps, 60 mg

Generic

1/1/13

Addition

Tier 2. Quantity limits apply. First generic for SANCTURA XR.

valsartan/
hydrochlorothiazide tabs, 80-12.5 mg,
160-12.5 mg,
160-25 mg,
320-12.5 mg,
320-25 mg

Generic

1/1/13

Addition

Tier 2. Quantity limits apply. First generic for DIOVAN HCT.

VIOKACE (pancrelipase (lipase/protease/
amylase)) tabs,
10440-39150-39150 units,
20880-78300-78300 units

Brand

1/1/13

Addition

Tier 4.

XTANDI (enzalutamide)
caps, 40 mg

Brand

1/1/13

Addition

Tier 5. Prior authorization and quantity limits apply.

ZALTRAP
(ziv-aflibercept)

IV soln,

100 mg/4 mL,
200 mg/8 mL

Brand

1/1/13

Addition

Tier 5.

rizatriptan orally disintegrating
tabs, 5 mg, 10 mg

Generic

1/6/13

Addition

Tier 2. Quantity limits apply. First generic for MAXALT-MLT.

rizatriptan
tabs, 5 mg, 10 mg

Generic

1/6/13

Addition

Tier 2. Quantity limits apply. First generic for MAXALT.

AMEVIVE (alefacept)
for IM inj, 15 mg

Brand

4/25/13

Removal

Manufacturer has discontinued marketing this drug.

ergotamine/caffeine tabs, 1-100 mg

Generic

4/25/13

Removal

Manufacturer has discontinued marketing this drug.

GANCICLOVIR
caps, 250 mg,
500 mg

Brand

4/25/13

Removal

Manufacturer has discontinued marketing this drug.

LYBREL (levonorgestrel-ethinyl estradiol)
tabs, 90-20 mcg

Brand

4/25/13

Removal

Manufacturer has discontinued marketing this drug.

MYDRIACYL (tropicamide) ophth soln, 1%

Brand

4/25/13

Removal

RxCUI removed by CMS. No longer Med D eligible.

tropicamide ophth soln, 0.5%, 1%

Generic

4/25/13

Removal

RxCUI removed by CMS. No longer Med D eligible.

COMETRIQ (cabozantinib)
caps, kit, 60 mg,
100 mg, 140 mg

Brand

2/1/13

Addition

Tier 5. Prior authorization and quantity limits apply.

clindamycin in D5W
IV soln,
300 mg/50 mL,
600 mg/50 mL,
900 mg/50 mL

Generic

2/10/13

Addition

Tier 2. First generic for CLEOCIN/D5W injection.