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Medicare Part D Formulary Updates

September 19, 2013

A summary of recent BCBSOK 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 BCBSOK members please refer to the following instructions:

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 Oklahoma',
  • '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)
Brand/
Generic Product
Effective
Date
Description
of Change
Comments
oxycodone tabs, 10 mg, 20mg Generic 3.2.13 Addition Tier 2
Buprenorphine/naloxone SL tabs, 2/0.5mg, 8/2mg Generic 3.3.13 Addition Tier 1, Quantity limits apply - First generic for SUBOXONE
PROLASTIN (alpha 1 proteinase inhibitor) for IV soln, 500mg, 1,000mg BRAND 3.6.13 REMOVAL NDC not properly listed with the FDA
Zoledronic acid inj for IV infusion, 4mg/5ml Generic 3.10.13 Addition Tier 3 - First generic for ZOMETA
Risperidone orally disintegrating tabs, 0.25mg Generic 3.17.13 Cost Share Reduction Change to Tier 2 (was 4) - Prior authorization and quantity limits continue to apply
Betamethasone valerate oint, 0.1% Generic 3.20.13 Cost Share Reduction Change to Tier 1 (was 4)
Entacapone tabs, 200mg Generic 3.31.13 Addition Tier 2 - First generic for COMTAN
Acyclovir oint, 5% Generic 4.7.13 Addition Tier 2 - First generic for ZOVIRAX
Sodium phenylbutyrate oral powder Generic 4.14.13 Addition Tier 5 - First generic for BUPHENYL Powder
CREON (pancrelipase (lipase-protease-amylase)) DR caps, 36,000-114,000-180,000 units Generic 4.21.13 Addition Tier 3
Nystatin-triamcinolone crm, 100,000 units/gm 0.1% Generic 4.28.13 Cost Share Reduction Change to Tier 2 (was 4)
BRILANTA (ticagrelor) tabs, 90 mg BRAND 5.1.13 Addition Tier 3
AFINITOR DISPERZ (everolimus) tabs for oral susp, 2 mg, 3 mg, 5 mg BRAND 5.5.13 Addition Tier 5, prior authorization and quantity limits apply
Cephalexin caps, 750mg Generic 5.12.13 Addition Tier 1
Candesartan tabs, 4mg, 8mg, 16mg, 32mg Generic 5.26.13 Addition Tier 2. quantity limits apply. First generic for ATACAND
SUPRAX (cefixime) caps, 400mg BRAND 6.3.13 Addition Tier 4
TAFINLAR (dabrafenib) caps, 50mg, 75mg BRAND 6.3.13 Addition Tier 5. Prior authorization and quantity limits apply
MEKINIST (trametinib) tabs, 0.5mg, 2mg BRAND 6.9.13 Addition Tier 5. Prior authorization and quantity limits apply
REVLIMID (lenalidomide) caps, 20mg BRAND 6.16.13 Addition Tier 5. Prior authorization and quantity limits apply
Riluzole tabs, 50 mg Generic 6.23.13 Addition Tier 5. First generic for RILUTEK
ABILIFY MAINTENA (aripiprazole) IM inj, 300mg, 400mg BRAND 6.26.13 Addition Tier 5. quantity limits apply