Capital BlueCross Selectively Closed Formulary PDF

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Capital BlueCross Selectively Closed Formulary 2015 Effective July 1, 2015 THE FORMULARY... 4 HOW TO USE THE FORMULARY... 4 ENERIC DRU SUBSTITUTION... 5 NON-PRESCRIPTION MEDICATION (OTC) POLICY*... 5 COMPOUND
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Capital BlueCross Selectively Closed Formulary 2015 Effective July 1, 2015 THE FORMULARY... 4 HOW TO USE THE FORMULARY... 4 ENERIC DRU SUBSTITUTION... 5 NON-PRESCRIPTION MEDICATION (OTC) POLICY*... 5 COMPOUND DRU POLICY... 6 BENEFIT EXCLUSIONS / LIMITATIONS*... 6 PRIOR AUTHORIZATION PRORAM... 6 QUANTITY LIMITATIONS... 6 MAINTENANCE DRUS... 7 INJECTABLE MEDICATION POLICY... 7 SPECIALTY MEDICATION PROVIDER: OUTPATIENT PRESCRIPTION DRU BENEFIT... 7 SPECIALTY DRUS... 7 LEEND... 9 NOTICE... 9 ANALESICS NSAIDs-M NSAIDs COMBINATIONS-M COX-2 INHIBITORS-M OUT-M OPIOID ANALESICS NON-OPIOID ANALESICS ANTI-INFECTIVES ANTIBACTERIALS ANTIFUNALS ANTIMALARIALS ANTIRETROVIRAL AENTS-M ANTITUBERCULAR AENTS ANTIVIRALS MISCELLANEOUS ANTINEOPLASTIC AENTS ALKYLATIN AENTS ANTIMETABOLITES CYTOPROTECTIVE AENTS HORMONAL ANTINEOPLASTIC AENTS IMMUNOMODULATORS KINASE INHIBITORS TOPOISOMERASE INHIBITORS MISCELLANEOUS CARDIOVASCULAR ACE INHIBITORS-M ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS-M ACE INHIBITOR/DIURETIC COMBINATIONS-M ADRENOLYTICS, CENTRAL-M ALDOSTERONE RECEPTOR ANTAONISTS-M ALPHA BLOCKERS-M ANIOTENSIN II RECEPTOR ANTAONISTS/DIURETIC COMBINATIONS-M ANIOTENSIN II RECEPTOR ANTAONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS-M ANIOTENSIN II RECEPTOR ANTAONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS-M ANTIARRHYTHMICS-M ANTILIPEMICS-M BETA-BLOCKERS-M BETA-BLOCKER/DIURETIC COMBINATIONS-M CALCIUM CHANNEL BLOCKERS-M CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS-M DIITALIS LYCOSIDES-M DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS-M DIRECT RENIN INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS-M DIURETICS-M NITRATES-M PULMONARY ARTERIAL HYPERTENSION-M MISCELLANEOUS-M CENTRAL NERVOUS SYSTEM ANTIANXIETY ANTICONVULSANTS-M ANTIDEMENTIA-M ANTIDEPRESSANTS-M ANTIPARKINSONIAN AENTS-M ANTIPSYCHOTICS-M ATTENTION DEFICIT HYPERACTIVITY DISORDER FIBROMYALIA-M HUNTINTON'S DISEASE AENTS-M HYPNOTICS MIRAINE MOOD STABILIZERS-M MULTIPLE SCLEROSIS AENTS-M MUSCULOSKELETAL THERAPY AENTS MYASTHENIA RAVIS NARCOLEPSY/CATAPLEXY PSYCHOTHERAPEUTIC-MISCELLANEOUS RESTLESS LES SYNDROME MISCELLANEOUS ENDOCRINE AND METABOLIC ANDROENS ANTIDIABETICS-M CALCIUM RECEPTOR ANTAONISTS-M CALCIUM REULATORS-M CONTRACEPTIVES ENDOMETRIOSIS ESTROENS-M ESTROEN/PROESTINS-M FERTILITY REULATORS LUCOCORTICOIDS LUCOSE ELEVATIN AENTS HUMAN ROWTH HORMONES HYPERPARATHYROID TREATMENT, VITAMIN D ANALOS-M INSULIN-LIKE ROWTH FACTOR LYSOSOMAL STORAE DISORDERS PHENYLKETONURIA TREATMENT AENTS PHOSPHATE BINDER AENTS-M PROESTINS-M SELECTIVE ESTROEN RECEPTOR MODULATORS-M THYROID AENTS-M VASOPRESSINS MISCELLANEOUS ASTROINTESTINAL ANTIDIARRHEALS ANTIEMETICS ANTISPASMODICS CHOLELITHOLYTICS-M H2 RECEPTOR ANTAONISTS-M * INFLAMMATORY BOWEL DISEASE IRRITABLE BOWEL SYNDROME-M LAXATIVES PANCREATIC ENZYMES-M PROSTALANDINS-M PROTON PUMP INHIBITORS-M * SALIVA STIMULANTS STEROIDS, RECTAL MISCELLANEOUS-M ENITOURINARY BENIN PROSTATIC HYPERPLASIA-M URINARY ANTISPASMODICS-M VAINAL ANTI-INFECTIVES MISCELLANEOUS HEMATOLOIC ANTICOAULANTS ANTIHEMOPHILIC AENTS HEMATOPOIETIC ROWTH FACTORS HEMOSTATICS HEREDITARY ANIOEDEMA AENTS IDIOPATHIC THROMBOCYTOPENIC PURPURA AENTS-M IRON CHELATIN AENTS PLATELET AREATION INHIBITORS-M PLATELET SYNTHESIS INHIBITORS-M STEM CELL MOBILIZERS MISCELLANEOUS-M IMMUNOLOIC AENTS BIOLOIC DISEASE-MODIFYIN AENTS DISEASE-MODIFYIN ANTIRHEUMATIC DRUS (DMARDs)-M IMMUNE LOBULINS IMMUNOMODULATORS-M IMMUNOSUPPRESSANTS-M NUTRITIONAL/SUPPLEMENTS ELECTROLYTES-M VITAMINS AND MINERALS RESPIRATORY ANAPHYLAXIS TREATMENT AENTS ANTICHOLINERICS-M ANTICHOLINERIC/BETA AONIST COMBINATIONS-M ANTIHISTAMINES, LOW SEDATIN ANTIHISTAMINES, NONSEDATIN-M ANTIHISTAMINES, SEDATIN ANTIHISTAMINE/DECONESTANT COMBINATIONS ANTITUSSIVES ANTITUSSIVE COMBINATIONS BETA AONISTS-M CYSTIC FIBROSIS LEUKOTRIENE RECEPTOR MODIFIERS-M MAST CELL STABILIZERS-M NASAL ANTIHISTAMINES NASAL STEROIDS-M PHOSPHODIESTERASE-4 INHIBITORS PULMONARY FIBROSIS AENTS STEROID/BETA AONIST COMBINATIONS-M STEROID INHALANTS-M XANTHINES-M MISCELLANEOUS TOPICAL DERMATOLOY MOUTH/THROAT/DENTAL AENTS OPHTHALMIC OTIC WEBSITES INDEX THE FORMULARY Capital BlueCross (Capital) has created the Formulary to give members access to quality, affordable medications and to provide physicians with a reference list of preferred medications for cost-effective prescribing. The Formulary represents the cornerstone of drug therapy quality assurance and cost containment efforts. The Capital Formulary was developed and is maintained by the Capital BlueCross Pharmacy and Therapeutics (P&T) Committee. This committee, composed of practicing physicians from various medical specialties, practicing pharmacists, and other health care providers, reviews medications in all therapeutic categories based on safety and effectiveness and designates the most effective agent(s) in each class. Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers. A provider may request a reconsideration of tier status for a medication on the Capital Formulary by completing a Formulary Status Reconsiderations Form or by writing a letter indicating the significant advantages of the specific drug product and mailing it to the address below: Pharmacy Services Capital BlueCross P&T Committee P.O. Box Harrisburg, PA The P&T Committee will review drug-specific requests and communicate the results of the review to the requesting provider. Patient-specific requests need to follow the Professional Provider dispute and appeal process. HOW TO USE THE FORMULARY The Formulary lists the most commonly prescribed medications by therapeutic class. Medications listed in bold lower case print are generic medications, and medications listed in all UPPER CASE PRINT are brand-name medications. For each drug listed, it is indicated whether that drug falls in the eneric category, Brand Preferred category or Brand Non-Preferred category. These categories are defined as follows: eneric (): Drugs that contain the same active ingredient(s) as their corresponding brand-name drug and have been approved by the U.S. Food and Drug Administration (FDA) for therapeutic equivalency to their brand-name product. Brand Preferred (): Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost. Brand Non-Preferred (): Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generics, preferred brands or over-the-counter medications. To help maximize the pharmacy benefit, preferred formulary alternatives, where applicable, are provided. Please note that the information provided is not intended to substitute for the physician's independent medical judgment based on the member's specific needs. The information contained in this document is current at the time of printing, is not all encompassing and is subject to change. The following Selectively Closed Formulary provides access to generic, brand preferred and select brand non-preferred drugs. Under a selectively closed formulary, only select brand non-preferred drugs (nonformulary drugs) are covered unless approved via a Non-Formulary Consideration Process. The provider may request that coverage be granted when medically necessary. The Non-Formulary Consideration Process may require the trial and failure of two (2) formulary alternatives (if two are available) prior to approval of the non-formulary medication. Approvals will be member- and drug-specific. Each unique nonformulary drug exception must be reviewed and approved separately. 4 As determined by the member s benefit plan, the member may share more of the cost for brand-name drugs, especially those designated as non-preferred brands. Despite being listed in the formulary, please note that some drugs are excluded by benefit design and therefore are not covered (see Benefit Exclusions/Limitations below). Newly-released brand-name drugs are not covered until the P&T Committee reviews the medication s safety and efficacy profile. Brand-name drugs that have an available generic equivalent, deemed suitable for substitution by the P&T Committee, are placed in the non-preferred brand category. The Formulary applies only to prescription medications dispensed in outpatient pharmacies. The Formulary does not apply to inpatient medications or to medications obtained from and/or administered by a physician or a home health agency. While Capital BlueCross strives to provide prompt notice of changes and updates, the Formulary, as well as the pharmacy clinical programs (such as prior authorization, quantity level limits, etc.), are subject to change. Please visit our website at for current information. If preferred, contact our pharmacy benefit manager via phone at the number listed below. CVS/caremark (for provider and member inquires) On behalf of Capital BlueCross, CVS/caremark assists in the administration of our prescription drug program. CVS/caremark is an independent pharmacy benefit manager. ENERIC DRU SUBSTITUTION eneric drug substitution is encouraged if the FDA has determined the generic drug is bioequivalent to the brand-name product. The member's financial responsibility for a brand-name medication when a generic equivalent is available will vary as indicated below. For members with mandatory generic substitution, if the physician indicates Dispense As Written (DAW) or a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost (ancillary charge) in addition to the member's applicable brand copayment/coinsurance, up to the original cost of the brand-name medication. For members with restricted generic substitution, if a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost in addition to the member's applicable brand copayment/coinsurance, up to the original cost of the brand-name medication. If the physician indicates DAW, then the member pays the applicable copayment/coinsurance for the brand product and is not required to pay the ancillary charge. For members with voluntary generic substitution, the member will pay only the applicable copayment/coinsurance for the brand product. Capital encourages generic substitution, when possible and appropriate, to help reduce the member's out-ofpocket expense, plus help contain the overall cost of the prescription drug benefit. NON-PRESCRIPTION MEDICATION (OTC) POLICY* Select Over-The-Counter (OTC) products may be covered as determined by Capital BlueCross or if mandated by the Patient Protection and Affordable Care Act (PPACA). If a prescription drug has an available OTC equivalent, the prescription drug will not be covered. Physicians and pharmacists should guide and refer members to the OTC equivalent product, when appropriate. *As mandated by PPACA, select Over-The-Counter medications may be covered at $0 cost share for members with individual coverage or members of a non-grandfathered group health plan. Please consult your employer for questions relating to grandfathered status. 5 COMPOUND DRU POLICY Prescribed compound drug products are considered Brand Non-Preferred () and require prior authorization. BENEFIT EXCLUSIONS / LIMITATIONS* Depending on the member's pharmacy benefit plan, some medications listed may not be covered for individual members based on benefit design purchased by the member or employer group. Examples of contractual exclusions include, but are not limited to: Appetite suppressants (weight loss) Infertility medications Drugs used for cosmetic purposes (wrinkles, hair loss, etc.) Erectile dysfunction medications Smoking cessation products Contraceptives Non self-administered injectable drugs Allergy serums Experimental and investigational (including off-label use) use Some types of vitamins (non-prenatal) Products with OTC equivalents *As mandated by PPACA, select medications in these drug classes may be covered at $0 cost share for members with individual coverage or members of a non-grandfathered group health plan. Please consult your employer for questions relating to grandfathered status. PRIOR AUTHORIZATION PRORAM Pharmacy benefit plans include the prior authorization program. Prior authorization helps encourage appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met. All clinical criteria are regularly reviewed and approved by the P&T Committee. Drugs requiring prior authorization are subject to change. Please always visit our website (www.capbluecross.com) for the most up-to-date information on drugs requiring prior authorization. Drugs requiring prior authorization are designated in the Formulary by PAR (Prior Authorization Required) after the drug name. These drugs require prior authorization before members can obtain them as a covered benefit. For some drugs, part of the criteria may be automated (Enhanced Prior Authorization or EPA) to encourage first-line agents before second-line agents are utilized. If automated criteria are not met, then prior authorization is required by the physician (or representative) or pharmacist by calling / faxing the request with supporting clinical information to the pharmacy benefit manager at: QUANTITY LIMITATIONS CVS/caremark Prior Authorization Department Telephone: Fax: Some drug products may be subject to quantity limitations based on FDA-recommended doses or adopted clinical guidelines. These drugs are designated in the Formulary by QLL (Quantity Level Limits) after the drug name. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity limitations are subject to change. Please check your provider manual or the on-line formulary at our website (www.capbluecross.com) for the most up-to-date information on drugs that are part of this program. If a quantity of medication exceeding the limit is required, the physician (or representative) or pharmacist should call / fax the request with supporting clinical information to the pharmacy benefit manager at: CVS/caremark Prior Authorization Department Telephone: Fax: MAINTENANCE DRUS Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or longterm. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease and diabetes. INJECTABLE MEDICATION POLICY Self-administered pharmacy injectable medications are usually covered under the Capital BlueCross prescription drug benefit. Injectable medications that are not routinely self-administered are not covered under the prescription drug benefit, but may be covered under the member s medical benefit. Procurement of select medical injectable medications may be available from ACRO Pharmaceuticals (by calling or faxing ), Capital BlueCross specialty medical injectable provider, which will assist with distribution and billing of these medications. On behalf of Capital BlueCross, ACRO Pharmaceutical Services LLC assists in the administration of physician-administered specialty medications. ACRO Pharmaceutical Services is an independent company. SPECIALTY MEDICATION PROVIDER: OUTPATIENT PRESCRIPTION DRU BENEFIT Specialty oral medications and self-administered injectable medications are available through Accredo under the Capital BlueCross outpatient prescription drug benefit. Members or providers can call or fax to receive more information on starting service. The following medications are available through Accredo. (This list is current as of the printing of this formulary but is subject to change.) On behalf of Capital BlueCross, Accredo Health roup, Inc. assists in the delivery of specialty medications directly to our Members. Accredo Health roup, Inc. is an independent company. Specialty Drugs ACTIMMUNE ADCIRCA PAR ADEMPAS PAR ADVATE AFINITOR ALPHANATE ALPHANINE SD AMPYRA PAR, QLL APOKYN ARANESP PAR ARCALYST AUBAIO PAR AVONEX BEBULIN BEBULIN VH BENEFIX BERINERT BETASERON EPA CAPECITABINE CAPRELSA CARBALU CERDELA PAR CHORIONIC ONADOTROPIN CIMZIA PAR, QLL COMETRIQ PAR COPAXONE CYSTADANE CYSTAON PAR CYSTARAN ERIFTA PAR ELIARD ENBREL PAR, QLL ERIVEDE PAR ESBRIET PAR EXJADE PAR EXTAVIA EPA FEIBA NF FEIBA VH FERRIPROX PAR FIRAZYR FIRMAON FORTEO PAR FUZEON ILENYA PAR ILOTRIF PAR LEEVEC RANIX HARVONI PAR HELIXATE FS HEMOFIL M HIZENTRA HUMATE-P HUMIRA PAR, QLL HYCAMTIN IBRANCE PAR ICLUSI PAR IMBRUVICA PAR INCRELEX PAR INFEREN INLYTA PAR 7 INTRON A JAKAFI PAR JUXTAPID PAR KALYDECO PAR KINERET PAR, QLL KOATE-DVI KOENATE FS KORLYM PAR KUVAN LENVIMA PAR LETAIRIS PAR LEUKINE LEUPROLIDE ACETATE LUPRON DEPOT LYNPARZA PAR MATULANE MEKINIST PAR MONOCLATE-P MONONINE MOZOBIL PAR MYALEPT PAR NEULASTA NEUMEA NEUPOEN NEXAVAR NORDITROPIN PAR NOVAREL NOVOSEVEN RT OCTREOTIDE OFEV PAR ORENCIA 125 mg/ml PAR, QLL ORFADIN PEASYS PEINTRON EPA PEINTRON REDIPEN EPA PRENYL PROCRIT PAR PROFILNINE SD PROMACTA PULMOZYME RECOMBINATE REVATIO SUSP PAR REVLIMID RIBAPAK RIBASPHERE RIBATAB RIBAVIRIN SABRIL SAMSCA SANDOSTATIN LAR SENSIPAR SEROSTIM PAR SINIFOR PAR SILDENAFIL PAR SIMPONI PAR, QLL SOMATULINE PAR SOMAVERT SOVALDI PAR SPRYCEL STIVARA PAR SUTENT SYNAREL TAFINLAR PAR TARCEVA PAR TARRETIN TASINA TEMOZOLOMIDE THALOMID TIKOSYN TOBRAMYCIN INHALATION SOLN TRACLEER PAR TYKERB VALCHLOR VENTAVIS PAR VICTRELIS PAR VOTRIENT WILATE XALKORI XELJANZ PAR, QLL XENAZINE PAR XTANDI PAR ZELBORAF ZOLINZA ZYDELI PAR ZYKADIA PAR ZYTIA PAR 8 LEEND AL EPA M OTC PAR PHC QLL SRx boldface delayed-rel ext-rel Age Limitations apply. Brand Non-Preferred: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generics, preferred brands or over-thecounter medications. Brand Preferred: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost. Enhanced Prior Authorization applies. eneric: Drugs that contain the same active ingredient(s) as their corresponding brand-name drug and have been approved by the Food and Drug Administration (FDA) for therapeutic equivalency to their brand-name product. Maintenance Drugs: An M located after the drug class name indicates the drugs in the class are generally considered maintenance drugs. Over-The-Counter medication. Prior Authorization Required. Preventive Health Care: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and are mandated by the Patient Protection and Affordable Care Act (PPACA) to have $0 cost share for members with individual coverage or members of a group health plan that is not grandfathered under PPACA. Please consult your employer for questions relating to grandfathered status. Quantity Level Limits apply. Specialty Drug available from Accredo. Indicates generic; boldface may not apply to every strength or dosage form under the listed generic name. Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification. Extended-release (also known as sustained-release), refer to the reference brand listed for clarification. NOTICE The information provided is intended to establish a guideline to help promote Formulary compliance, but it is in no way to be considered all encompassing. The Formulary is also in no way meant to interfere with the physician's independent medical judgment ba
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