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Coming January 1, 2013: Updates to Pharmacy Formulary Program

With these changes, members and doctors will continue accessing a variety of safe, clinically effective medications at affordable prices.

Which Plans Will Be Affected?

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

Doctors and hospitals have already been advised of these changes. Members affected by any of these changes will be notified directly no later than December 1, 2012.

Medications Changing to Non-Covered Status—Effective January 1, 2013
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
HMG Cholesterol Inhibitors Lipitor tablets (members currently using this medication will not be required to obtain a formulary exception for coverage)
Phosphate Binders Phoslyra solution
Low Molecular Weight Heparins Arixtra, Fragmin, Innohep and Lovenox injections
Glaucoma Cosopt PF ophthalmic solution
Ophthalmic Antibiotic Combinations Tobradex ST solution

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

Medications Changing Tier Status—Effective January 1, 2013
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, 2013
Diabetic Testing Strips Blood Glucose Test Strips
Control Test Strips
Easy Check Glucose Test Strips
Glucolab Test Strips
Infinity Test Strips
Keynote Test Strips
Microdot Test Strips
Solo V2 Test Strips
Ultratrack Test Strips
Tier 3

For members with the BlueValue Rx formulary, these supplies will be non-covered
Pegylated Interferons Peg-Intron Tier 3

The medication Rozerem (sedative hypnotic) will become a Tier 3 covered medication and members will no longer require a formulary exception for coverage to be provided.

New Quality Care Dosing (QCD) Limits—Effective January 1, 2013
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
Lidoderm (lidocaine) patch 5% 90 patches per prescription

Prior Authorization for Medications Administered Using the Medical Benefit—Effective January 1, 2013
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.

  • Alphanine®' SD
  • Bebulin VH
  • Benefix®'
  • Corifact®'
  • Eylea®'
  • Gammaked®'
  • Gamunex®'-c
  • Lucentis®'
  • Macugen®'
  • Omnontys®'
  • Pegasys®' proclick
  • Regranex®'
  • Wilate®'
  • Xiaflex®'

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

Benefit Exclusions—Effective January 1, 2013
All drugs in the therapeutic class of ophthalmic solutions used to treat allergies will be excluded from our pharmacy benefit coverage. Formulary exceptions, including those previously approved, will no longer be available for this class of medications. This change will apply to all commercial plans, group Medex® plans with pharmacy benefits, and Managed Blue for Seniors.

Drugs currently in this class include: Alamast, Alocril, Alomide, Azelastine HCL, Bepreve, Cromlyn Sodium, Elestat, Emadine, Epinastine HCL, Lastacaft, Pataday, Patanol.

In addition, for group Medex plans with pharmacy and Managed Blue for Seniors, all drugs in the therapeutic class of non-sedating antihistamines will be excluded from our pharmacy benefit coverage effective January 1, 2013. This exclusion already exists within our commercial plans. Medications in this class include Allegra D, and Clarinex.

We are making these changes due to the over-the-counter availability of several products in these classes, which can be purchased without a prescription.

Blue Cross Blue Shield of Massachusetts

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