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Pharmacy Changes Effective January 1, 2012

To continue providing our members and their health care providers with access to a variety of safe, clinically effective medications at affordable prices, we will be making changes to our pharmacy program, effective January 1, 2012.


Who Will Be Affected?
The pharmacy program changes will apply to the following plans:

  • Commercial plans with pharmacy benefits
  • Medex®' plans with the optional three-tier pharmacy benefit

Health care providers have already been advised of these changes. Our affected members will be notified directly no later than December 1, 2011.


What Changes Will Be Made?
For January 1, 2012, we will be making important changes to:

  • Non-covered medication status
  • Medication tier status
  • Quality Care Dosing limits
  • Step therapy policies

We will also be adding a prior authorization requirement to certain medications that are available through the member's medical benefit (this applies to HMO, POS, and Access BlueSM plans only).


Medications Changing to Non-Covered Status—Effective January 1, 2012
After careful consideration and cost evaluation of each drug's covered alternatives, the following medications will no longer be covered.

Drug Class Non-Covered Medication or Supply
Diabetes Prodigy test strips1

Note: This change applies to BlueValue RxSM formulary only.
Nova Max
Inflammatory bowel Lialda1 (mesalamine)

Please refer to Medical Policy 257 for details on the criteria for Growth Hormone medications
Quinolone Antibiotics Avelox1 (moxifloxacin)
Topical Testosterone Axiron
Topical Vitamin D Analogs Vectical1 (calcitriol)

When medically necessary, a health care provider may request an exception to have these medications covered.

1. Also indicates a change to the BlueValue Rx formulary


Medications Changing Tier Status—Effective January 1, 2012
When we determine that a medication's clinical and financial value changes relative to alternative medications in its class, we change the medication's tier status. Depending on the indicated tier change, members may be required to pay more or less for these medications.

The medications below will be changing to the following tier levels:

Drug Class Medication Name Covered Tier Level as of January 1, 2012
Allergic reaction treatments Twinject Auto-Injector (epinephrine) Tier 3
Anti-inflammatory Voltaren Gel (diclofenac) Tier 3
Asthma Singulair (montelukast) Tier 3
Diabetes Advocate
Nova Max
Tier 3

Note: Medications moving to non-covered within the BlueVaue Rx formulary
Ophthalmic Prostaglandins Travatan
Travatan Z (travoprost)
Tier 2


New Quality Care Dosing (QCD) Limits —Effective January 1, 2012
To monitor that the quantity and dose of medication that a member receives meets Federal Drug Administration (FDA), manufacturer, and clinical recommendations, we are adding the following Quality Care Dosing limits to the medications listed:

Medication Dosage QCD limit
Cymbalta (duloxetine) 20 mg and 60 mg

30 mg
60 per prescription

30 per prescription


New Step Therapy Policy—Effective January 1, 2012
To assist health care providers with appropriate and affordable drug treatments, we require step therapy for the following:

Drug Class Step Requirements for Coverage
Topical Testosterones Step 1: Testim (Tier 2)
Step 2: Androderm (Tier 3)
Step 3: Androgel, Fortesta, Axiron (Non-covered)
Ophthalmic Prostaglandins Step 1: latanoprost (Tier 1)
Step 2: Travatan/Travatan Z (Tier 2), Lumigan (Tier 2), Xalatan (Tier 3)

For our existing overactive bladder step therapy policy, we will be adding the non-covered medications Gelnique and Oxytrol to step 3.


Prior Authorization
For the medications Incivek and Victrelis, prior authorization by a physician will now be required before coverage will be provided. Please review medical policy for Hepatitis C Medications #344 for full detail on medical criteria.


Prior Authorization for Medications Administered Using the Medical Benefit—Effective January 1, 2012
For members enrolled in our HMO, POS, and Access Blue plans, prior authorization is required under members' medical benefits for certain medications that are administered in a doctor's office, hospital outpatient setting, or by a home infusion therapy provider. This requirement will also apply to the following medications.

  • Prolia injection
  • Xgeva injection
  • Xeomin injection
  • Actemra
  • Sylatron injection
  • Makena injection
  • H.P. Acthar Gel

The prior authorization requirements may already apply when members fill their prescriptions at retail pharmacies.

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