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Blue Cross and Blue Shield of
Alabama Prescription Drug Guide Updates
January 2015
Brand/Generic
Product
Effective Date
CYCLOPHOSPHAMIDE caps, 25 mg, 50 mg
Brand
6/29/14
Addition to Tier 2
DIOVAN (valsartan tabs 40 mg, 80 mg, 160 mg, 320 mg)
Brand
9/15/14
Move from Tier 2 to Tier 3,
generics available
HUMALOG (insulin lispro [human] inj, 100 unit/mL)
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMALOG KWIKPEN (insulin lispro [human] inj, 100 unit/mL)
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMALOG MIX 50/50 (insulin lispro protamine & lispro [human] inj, 100 unit/mL
[50/50])
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMALOG MIX 50/50 KWIKPEN (insulin lispro protamine & lispro [human] inj,
100 unit/mL [50/50])
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMALOG MIX 75/25 (insulin lispro protamine & lispro [human] inj, 100 unit/mL
[75/25])
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMALOG MIX 75/25 KWIKPEN (insulin lispro protamine & lispro [human] inj,
100 unit/mL [75/25])
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMULIN 70/30 (insulin isophane & regular [human] inj, 100 unit/mL [70/30])
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMULIN 70/30 KWIKPEN (insulin isophane & regular [human] inj, 100 unit/mL
[70/30])
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMULIN N (insulin isophane [human] inj, 100 unit/mL)
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMULIN N KWIKPEN (insulin isophane [human] inj, 100 unit/mL)
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMULIN R (insulin regular [human] inj, 100 unit/mL)
Brand
1/1/15
Move from Tier 2 to Tier 3
HUMULIN R U-500 [concentrated] (insulin regular [human] inj, 500 unit/mL)
Brand
1/1/15
Move from Tier 2 to Tier 3
ISENTRESS (raltegravir for susp, 100 mg)
Brand
6/29/14
Addition to Tier 2
MICARDIS (telmisartan tabs, 20 mg, 40 mg, 80 mg)
Brand
11/1/14
Move from Tier 2 to Tier 3,
generics available
MICARDIS HCT (telmisartan/hydrochlorothiazide tabs, 40-12.5 mg, 80-12.5 mg,
80-25 mg)
Brand
11/1/14
Move from Tier 2 to Tier 3,
generics available
PLEGRIDY (peginterferon beta-1a soln pen-injector, prefilled syringe,
125 mcg/0.5 mL)
Brand
1/1/15
Addition to Tier 2
PLEGRIDY STARTER PACK (peginterferon beta-1a soln pen-injector pack,
63 mcg/0.5 mL & 94 mcg/0.5 mL)
Brand
1/1/15
Addition to Tier 2
TRIUMEQ (abacavir/dolutegravir/lamivudine tabs, 600-50-300 mg)
Brand
8/31/14
Addition to Tier 2
VIRAMUNE XR (nevirapine sustained-released 24 hour tabs, 400 mg)
Brand
9/15/14
Move from Tier 2 to Tier 3,
generics available
ZYDELIG (idelalisib tabs, 100 mg, 150 mg)
Brand
8/3/14
Addition to Tier 2
TRADE NAME (generic name)
January 2015 | Alabama Prescription Drug Guide Updates
Description of Change
October 2014
Blue Cross and Blue Shield of
Alabama Prescription Drug Guide Updates continued
Clinical Program Updates – Effective January 1, 2015
The following medication dispensing limits (DL), prior authorization (PA), and/or step therapy (ST) programs have been added or revised:
New or Revised PA or ST Programs
Policy Name
Type of Policy
Coverage Criteria and Changes
Doxycycline/Minocycline
ST/QL
REVISED – Addition of NicazelDoxy to the existing program. Revision of criteria to
require the use of both oral generic doxycycline and oral generic minocycline prior
to the use of a targeted agent.
Forteo
PA/QL
REVISED – The requirement for very low bone mineral density has been removed.
GLP-1
ST/QL
REVISED – Addition of Trulicity to the existing program. If approved, Trulicity will be
subject to a quantity limit of 2mL (4 pens) per 28 days.
Hereditary Angioedema
PA/QL
REVISED – Addition of Ruconest to the existing program. Quantity limits were
decreased to allow treatment of an average of two attacks per month.
HP Acthar
PA
REVISED – Use of a disease modifying drug to control Multiple Sclerosis disease
progression is now required.
Immune Globulins
PA
REVISED – Addition of Hyqvia to the existing program.
Insulin
PA
NEW – Prior Authorization for Tier 3 insulins (Apidra, Humalog, Humulin) will be
required for Exchange Marketplace plans. Approval will be provided for diabetic
patients that have tried and failed or have a contraindication to the Tier 2 rapid/
intermediate acting insulins (Novolin, Novolog).
Multiple Sclerosis
ST/QL
REVISED – Addition of Plegridy as a preferred product to the existing program. If
approved, Plegridy will be subject to a quantity limit of 2 syringes or pens per month
or 1 starter kit per 180 days. Revision of criteria to require the trial and failure of one
preferred product instead of the trial and failure of two preferred products.
Self Administered Oncology
PA/QL
REVISED – The contraindication requirement now applies to all patients, not just
those that are new to therapy.
Suboxone/Subutex
PA/QL
REVISED – Addition of Bunavail to the existing program. If approved, Bunavail will be
subject to a quantity limit of 60 films per month.
Topical Androgens
ST/QL
REVISED – Addition of Testosterone TD Gel to the existing program. If approved,
Testosterone TD Gel will be subject to a quantity limit of 2 pump bottles per month.
Triptans
ST/QL
REVISED – Addition of Sumavel to the existing program. If approved, Sumavel will be
subject to a quantity limit of 6 mL (12 syringes) per month.
New or Revised Dispensing Limits
Brand Name (generic if available)
Strength
Dispensing Limit per Month
New or Revised
Akynzeo
300 mg/0.5 mg
2 capsules
NEW
Butrans
7.5 mcg/hour
4 patches
NEW
Spiriva Respimat
2.5 mcg/actuation
1 inhaler
NEW
Triumeq
600 mg/50 mg/300 mg
30 tablets
NEW
Tybost
150 mg
30 tablets
NEW
Xarelto Starter Therapy Pack
15 mg & 20 mg
1 pack (51 tablets)
NEW
Xigduo XR
5 mg/500 mg, 10 mg/500 mg
30 tablets
NEW
Xigduo XR
5 mg/1000 mg
60 tablets
NEW
Note: Coverage is subject to each member’s specific benefits. Group specific policies will supersede these policies when applicable. Please refer to the
member’s benefit plans.
For complete details, pharmacy policies may be viewed on the Blue Cross website at
AlabamaBlue.com/providers/pharmPolicies/final.cfm
January 2015 | Alabama Prescription Drug Guide Updates
4157-A AL © Prime Therapeutics LLC 01/15