Advantage and Value Plus formulary update

(2nd Quarter 2022 Effective January 1, 2023)

The Capital Blue Cross formulary is a reference list of prescription drugs that contains a wide range of generic and brand drugs that have been approved by the U.S. Food and Drug Administration (FDA). The formulary is updated on a quarterly basis or when new generic or brand-name medications become available and as discontinued drugs are removed from the marketplace.

The Advantage and Value Plus formularies were created by Capital Blue Cross to give members access to quality, affordable prescription drugs and to provide physicians with a list of preferred drugs for cost-effective prescribing.

Several new drugs have come to market and are now included in our formulary.

Pharmacy Management Program update

Key:

(PAR) = Prior Authorization Required

(ST) = Step Therapy Required

(QLL) = Quantity Level Limits Apply — Quantity Level Limit (QLL) Program

(BP) = Brand Preferred

(BNP) = Brand Non-Preferred

(GP) = Generic Preferred

(GNP) = Generic Non-Preferred

(NC) = Not Covered

(NF) = Non-Formulary

UPPERCASE names = Brand

lowercase names = Generic

Newly marketed drugs

Effective immediately

Brand name

Tier status

Indication

Preferred alternatives

ADBRY1 (PA, QLL)

BP

Atopic Dermatitis

DUPIXENT, RINVOQ

CIBINQO1 (PA,QL)

BP

Atopic Dermatitis

DUPIXENT, RINVOQ

IBSRELA (QLL)

BNP

IBS-C

AMITZA, linaclotide, LINZESS, lubiprostone, tegaserod, ZELNORM

PYRUKYND1 (PA, QLL)

BNP

Pyruvate Kinase Deficiency

MITAPIVAT

RECORLEV1 (PA, QLL)

BNP

Cushing’s Disease

ISTURISA, KORLYM, mifepristone, osilodrostat, pasireotide, SIGNIFOR

VONJO1 (PA, QLL)

BNP

Myelfibrosis

fedratinib, INREBIC, JAKAFI, ruxolitinib

Products changing tier status3

Effective January 1, 2023 (unless otherwise noted below)

Brand name

Current tier

New tier

Effective date

torsemide tabs

GP

BNP

 

Prior authorization (PAR) utilization management program changes or updates

Drug class/Drug

Purpose/Guidelines

ADBRY1 (PA, QLL)

Atopic Dermatitis

CIBINQO1 (PA, QLL)

Atopic Dermatitis

CITALOPRAM HYDROBROMIDE

Antidepressant

DARTISLA

Peptic Ulcer

FLEQSUVY

Baclofen

PYRUKYND1 (PA, QLL)

Pyruvate Kinase Deficiency

RECORLEV1 (PA, QLL)

Cushing’s Disease

RELEUKO

Colony Stimulating Factor

SEGLENTIS

Opioid

TARPEYO

Kidney Disease

VONJO1 (PA, QLL)

Myelfibrosis

VUMERITY

Multiple Sclerosis

VYVANSE

Attention Deficit Hyperactivity Disorder (ADHD)

ZIMHI

Opioid

Quantity level limit (QLL) program3

Drug class/Drug

Quantity limits (per 30 days or as specified)

ADBRY1 150 mg/mL syringe

4 syringes (4 mL)/28 days

CIBINQO1 50 mg tablet, 100 mg tablet, 200 mg tablet

1 tablets/Day

CITALOPRAM 10mg tablet, 20 mg tablet, 40 mg tablet,

 

CITALOPRAM 10 mg/5 mL sol

 

CITALOPRAM 30 mg capsule

 

DARTISLA ODT

4 tablets/Day

FLEQSUVY1 Baclofen Susp 25 MG/5ML

25 mg/5mL/30 Days

IBSRELA 50 mg tablet

2 tablets/Day

PYRUKYND1 TAPER PACK

Mitapivat Sulfate Tab Therapy Pack 5 MG

7 tablets/Year

PYRUKYND1 TAPER PACK

Mitapivat Sulfate Tab Therapy Pack 7 x 20 MG & 7 x 5 MG

7 tablets/Year

PYRUKYND1 TAPER PACK

Mitapivat Sulfate Tab Therapy Pack 7 x 50 MG & 7 x 20 MG

7 tablets/Year

PYRUKYND1 mitapivat sulfate tab

56 tablets/28 Days

QULIPTA

RECORLEV1 150 mg tablet

240 tablets/30 Days

SEGLENTIS

VONJO1 100 mg capsule

4 capsules/Day

VUMERITY Starter bottle 231 mg delayed release capsule

106 capsules/180 Days

VUMERITY 231 mg

delayed release capsule

4 capsules/Days

VYVANSE 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg capsule

 

VYVANSE Chewable 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg chewable tablet

 

Step therapy program

Drug class/Drug

Indication

Purpose/Guidelines

CGRP1 (ST, QLL)

Migraine

AIMOVIG, AJOVY, atogepant, EMGALITY, erenumab, fremanezumab, galcanezumab, NURTEC ODT, QULIPTA, rimegepant, UBREVLY, ubregepant

Ergotamine (ST, QLL)

Migraine

CAFERGOT, D.H.E 45, dihydroergotamine mesylate, ergotamine, ERGOMAR, MIGERGOT

GLP-1

 

ADLYXIN, BYDUREON BCISE, BYETTA, dulaglutide, exenatide, liraglutide, lixisenatide, OZEMPIC, RYBELSUS, semaglutide, TRULICITY, VICTOZA

Insulin Combination

 

insulin glaregine-lixisenatide, insulin degludec-liraglutide, SOLIQUA, XULTOPHY

Triptans

 

AMERGE, FROVA, frovatriptan, IMITREX, MAXALT naratriptan, ONZETRA, RELPAX, rizatriptan, sumatriptan, SUMATRIPTAN, TOSYMRA, TREXIMET, ZEMBRACE, ZOLMITRIPTAN, ZOMIG, zolmitriptan

Products going obsolete3

Effective January 1, 2023 (unless otherwise noted below)

Brand name

Current tier

New tier

Effective date

adapalene-benzoyl peroxide gel

GNP

Exclude

1/1/2023

APO-VARENICLINE 0.5MG, 1MG

BP

Exclude

1/1/2023

CITALOPRAM HYDROBROMIDE 30MG

BNP

Exclude

10/1/2022

COPAXONE

GNP

Exclude

5/16/2022

TRETINOIN 0.025%

BNP

Exclude

1/1/2023

Specialty drug program3

Brand name

Tier status

Indication

ADBRY1 (PA, QLL)

BP

Atopic Dermatitis

CIBINQO1 (PA, QLL)

BP

Atopic Dermatitis

PYRUKYND1 (PA, QLL)

BNP

Pyruvate Kinase Deficiency

RECORLEV1 (PA, QLL)

BNP

Cushing’s Disease

VONJO1 (PA, QLL)

BNP

Myelfibrosis

1Indicates specialty medication

2Split Fill Program available

3Impacted members will be notified prior to change.

The information contained on this page is not all encompassing and is subject to change. Please refer to your Certificate of Coverage for specific terms, conditions, exclusions and limitations relating to your coverage.