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BCN Drug List Updates – February 2015
This page shows monthly updates to our BCBSM/BCN Custom Drug List, and BCBSM/BCN Custom Select Drug List. These changes are
incorporated in the Drug Lists when it is updated every January and July.
New generic and brand-name drugs
The table below shows drugs that are now available as generics and can be dispensed at the lowest copayment. The brand-name version
of the drug will no longer be covered unless your physician requests coverage based on medical necessity and BCN approves the request.
If a dispense-as-written prescription is not authorized, you must pay the difference in cost between the brand-name product and the generic
drug, in addition to the required copayment for a brand-name medication.
The table also includes new FDA-approved drugs that BCN has reviewed for the Drug List. New drugs that have not been reviewed are not
covered.
Brand Name
Generic Name
Category
New generics
®
Clobex 0.05%
spray (g)
®
Lamictal ODT(g)
Drug List Status
Effective
Tier
5-Tier
6-Tier
Custom
Select Tier
clobetasol propionate
Dermatology
1
1
1B
1B
1/2015
lamotrigine
Central nervous system
1
1
1B
1B
2/2015
morphine sulfate/naltrexone Central nervous system
3
3
3
3
1/2015
ledipasvir/sofosbuvir
Anti-infectives
2
4
4
4
2/2015
beclomethasone
dipropionate
Otic and nasal preparations
3
3
3
Excluded
12/2014
(ombitasvir/paritaprevir/
ritonavir; dasabuvir)
Anti-infectives
2
4
4
4
2/2015
New brand-name drugs
®
Embeda *
®
Harvoni * <s>
®
Qnasl Childrens
™
Viekira Pak * <s>
New drugs pending review
Afrezza
®
Akynzeo
®
Belsomra
Blincyto
®
™
™
Cerdelga <s>
®
Contrave ER
insulin human inhalation
powder
Endocrinology
netupitant/palonosetron hcl
Gastrointestinal agents
suvorexant
Central nervous system
blinatumomab
Antineoplastics and immunosuppressants
eliglustat
Antineoplastics and immunosuppressants
10/2014
Not covered
Pending review for drug list placement
naltrexone hcl/bupropion hcl Lifestyle modification
(g) Generic dispensed
<s> Specialty drug
8/2014
* Step therapy or prior authorization required. Clinical criteria must be met.
11/2014
12/2014
8/2014
10/2014
** Depending on member’s drug rider.
BCN Drug List Updates – February 2015
Brand Name
Generic Name
Category
Drug List Status
Effective
New drugs pending review (Cont.)
®
Esbriet <s>
pirfenidone
Respiratory, cough and cold
9/2014
HPV 9-valent vaccine
Immunology and hematology
10/2014
HyQvia <s>
IGG/hyaluronidase,recombi Immunology and hematology
nant
9/2014
Hysingla ER™
®
Gardasil 9
™
hydrocodone bitartrate
Central nervous system
1/2015
®
miltefosine
Anti-infectives
3/2014
®
Keytruda <s>
pembrolizumab
Antineoplastics and immunossuppresants
9/2014
Lemtrada™<s>
alemtuzumab
Antineoplastics and immunossuppresants
11/2014
Lynparza™
olaparib
Antineoplastics and immunossuppresants
1/2015
methoxy peg-epoetin beta
Immunology and hematology
12/2014
Monovisc <s>
hyaluronic acid derivative
Rheumatology and musculoskeletal
3/2014
Movantik™
naloxegol
Gastrointestinal
10/2014
Obredon™
Impavido <s>
Mircera
®
®
guaifenesin/hydrocodone
Respiratory, cough and cold
®
Ofev <s>
nintedanib esylate
Respiratory, cough and cold
Onexton™
clindamycin phos/
benzoyl perox
Dermatology
12/2014
nivolumab
Antineoplastics and immunossuppresants
12/2014
Plegridy™ <s>
peginterferon beta-1a
Immunology and hematology
10/2014
Rapivab™
peramivir
Anti-infectives
12/2014
Rytary™
carbidopa/levodopa
Central nervous system
1/2015
edoxaban tosylate
Cardiovascular, hypertension, cholesterol
1/2015
ivermectin
Dermatology
1/2015
dulaglutide
Endocrinology
10/2014
meningococcal group B
vaccine
Immunology and hematology
12/2014
Xigduo XR™
dapagliflozin/metformin
Endocrinology
10/2014
Zerbaxa™
ceftolozane/tazobactam
Anti-infectives
12/2014
Opdivo
®
Savaysa™
Soolantra
®
Trulicity™
Trumenba
®
(g) Generic dispensed
<s> Specialty drug
Not covered
Pending review for drug list placement
* Step therapy or prior authorization required. Clinical criteria must be met.
1/2015
10/2014
** Depending on member’s drug rider.
BCN Drug List Updates – February 2015
Other changes
BCN monitors the use of certain medications to ensure that our members receive the most appropriate and cost-effective drug therapy.
This table reflects new or changed prior authorization requirements based on current medical information and the recommendations of
BCN’s Pharmacy and Therapeutics Committee.
Brand Name
Generic Name
Category
Drug List Status
Effective
New prior authorization/step therapy criteria
®
Harvoni * <s>
ledipasvir/sofosbuvir Anti-infectives
™
Viekira Pak * <s>
2/2015
(ombitasvir/
Anti-infectives
paritaprevir/ritonavir;
dasabuvir)
Coverage is provided for the treatment of chronic hepatitis C (HCV)
genotype 1 in members 18 years or older with compensated liver
disease, who have abstained from alcohol consumption for at least 6
months prior to therapy initiation and who have attested to
compliance with the treatment regimen.
Coverage is provided for the treatment of chronic hepatitis C (HCV)
genotype 1 in members 18 years or older with compensated liver
disease who meet clinical criteria.
ledipasvir/sofosbuvir Anti-infectives
1 tablet per day
2/2015
(ombitasvir/
Anti-infectives
paritaprevir/ritonavir;
dasabuvir)
4 tablets per day
2/2015
mometasone furoate Respiratory, cough and
cold
Tier changed to Tier 1/1A for members with the Custom Drug List,
and tier 2 for members with the Custom Select Drug List
1/2015
boceprevir
2/2015
1/2015
2/2015
2/2015
Quantity Limits
®
Harvoni * <s>
™
Viekira Pak * <s>
Miscellaneous
Asmanex HFA
®
®
Victrelis * <s>
Prevacid(g) capsules lansoprazole
Gastrointestinal agents
Tier changed to Tier 3 for 3-Tier benefits and Tier 5 for 5 or 6-Tier
benefits
Step therapy removed
Aciphex(g) tablets
Zanaflex(g) tablets
Gastrointestinal agents
Central nervous system
Step therapy removed
Step therapy removed
rabeprazole
tizanidine
(g) Generic dispensed
<s> Specialty drug
Anti-infectives
* Step therapy or prior authorization required. Clinical criteria must be met.
1/2015
** Depending on member’s drug rider.