Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2023 – Part 1

November 30, 2022

IMPORTANT PHARMACY BENEFIT REMINDERS

Jan. 1, 2023 is the start of a new year and renewed or new health insurance benefits for most

Blue Cross and Blue Shield of Montana (BCBSMT) members. As you see your patients, please consider the following reminders:

  • Members’ benefits may be based on a new drug list when their plans renew in 2023. You can view a preview of the January drug lists on our Member website. The final lists will be available on both the member website and Pharmacy Program section of our Provider website closer to the January 1 effective date.
  • Discuss your patients’ benefits during an office visit or confirm their benefits by calling the number on their ID cards.
  • Review the prescription drug list before prescribing medications.
  • If your patients need a coverage exception or prior authorization request in order to take a medicine that may be excluded from coverage or included in a utilization management program, please visit the Prior Authorization/Step Therapy Programs section of our provider website at bcbsmt.com/provider for the form and more information.

Some members’ plans may experience changes to the pharmacy network starting Jan. 1, 2023. This includes plans that may have moved to a new pharmacy network or changes to pharmacies participating within the network. Based on claims data, members impacted by these changes will receive letters from BCBSMT to alert them.

Members who continue to fill prescriptions at a pharmacy no longer in their network will pay more. In most cases, no action is required on your part for any of these pharmacy network changes as members can easily transfer prescriptions to a nearby in-network pharmacy. If your office stores pharmacy information on your patient’s records, you may want to ask which pharmacy is their preferred choice.

Treatment decisions are always between you and your patients. Coverage is subject to the terms and limits of your patients’ benefit plans. Please advise them to review their benefit materials for details.

DRUG LIST CHANGES

Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) will be made to the BCBSMT drug lists. Your patient(s) may ask you about therapeutic or lower cost alternatives if their medication is affected by one of these changes. Changes effective on or after Jan. 1, 2023 are outlined below.

The January Quarterly Pharmacy Changes Part 2 article with more recent coverage additions will be published closer to the Jan. 1 effective date.

Non-Preferred Brand1

Drug Class/ Condition Used For

Preferred Generic Alternative(s)2

Preferred Brand Alternative(s)1, 2

 

Basic, Multi-Tier Basic, Enhanced and Multi-Tier Enhanced Drug List Revisions

NEXAVAR (sorafenib tosylate tab 200 mg (base equivalent))

Cancer

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

VIMPAT (lacosamide oral solution 10 mg/ml)

Seizures

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

 

Drug1

Drug Class/Condition Used For

Generic Alternatives1,2

Brand Alternatives1,2

 

Balanced, Performance and Performance Select Drug List Revisions

ALENDRONATE SODIUM (alendronate sodium oral soln 70 mg/75 ml)

Osteoporosis

alendronate tablets, ibandronate tablets

 

 

CLOMID (clomiphene citrate tab 50 mg)

Ovulation Induction

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

CLOMIPHENE CITRATE (clomiphene citrate tab 50 mg)

Ovulation Induction

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

HYDROCODONE/
IBUPROFEN  (hydrocodone-ibuprofen tab 10-200 mg)

Pain/Inflammation

hydrocodone/
acetaminophen tablets

 

 

 

Health Insurance Marketplace (HIM) Revisions

CLOMID - clomiphene citrate tab 50 mg

Infertility

 

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

CLOMIPHENE - clomiphene citrate tab 50 mg

Infertility

 

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

HYDROCODONE-IBUPROFEN - hydrocodone/ibuprofen TAB 10-200 MG

Pain

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

PHENELZINE - phenelzine sulfate tab 15 mg

Depression

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

 

 

Balanced, Performance and Performance Select Drug List Exclusions

AKTEN (lidocaine hcl ophth gel 3.5%)

Anesthesia- Ophthalmic

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

ARTISS (fibrin sealant component solution)

Fibrin Sealant

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

clopidogrel bisulfate tab
300 mg (base equivalent)

Acute Coronary Syndrome

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

PRADAXA (dabigatran etexilate mesylate cap
75 mg (etexilate base equivalent))

Thromboembolism/stroke prophylaxis, DVT/PE Treatment, DVT/PE Prophylaxis

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

proparacaine hcl ophth soln 0.5%

Anesthesia- Ophthalmic

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

RADIOGARDASE (prussian blue insoluble cap 0.5 gm)

Cesium or Thalium Contamination

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

RECOTHROM (thrombin (recombinant) for soln
20000 unit, 5000 unit)

Pseudoaneurysms

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

RECOTHROM SPRAY KIT  (thrombin (recombinant) for soln 20000 unit)

Pseudoaneurysms

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

RECOTHROM/SPRAY APPLICATOR KIT (thrombin (recombinant) for soln
20000 unit)

Pseudoaneurysms

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

THROMBIN-JMI DILUENT (thrombin for soln
20000 unit, 5000 unit)

Pseudoaneurysms

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

THROMBIN-JMI EPISTAXIS  (thrombin for soln kit
5000 unit)

Pseudoaneurysms

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

THROMBIN-JMI SYRINGE SPRAY KIT (thrombin for soln kit 5000 unit,
20000 unit)

Pseudoaneurysms

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

THROMBIN-JMI W/DIL SPRAY PUMP ACTUATOR (thrombin for soln kit
20000 unit)

Pseudoaneurysms

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

TISSEEL (fibrin sealant component kit 2 ml, 4 ml,
10 ml)

Fibrin Sealant

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

TISSEEL (fibrin sealant component solution)

Fibrin Sealant

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

VAGIFEM (estradiol vaginal tab 10 mcg)

Vulvovaginal Atrophy

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

VIIBRYD (vilazodone hcl tab 10 mg, 20 mg, 40 mg)

Depression

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

VIMPAT (lacosamide oral solution 10 mg/ml)

Seizures

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

 

Performance and Performance Select Drug List Exclusions

amiodarone hcl tab
400 mg

Arrhythmia

amiodarone tablet
200 mg

 

 

bromfenac sodium ophth soln 0.09% (base equivalent) (once-daily)

Inflammation-Ophthalmic

diclofenac ophth soln 0.1%, ketorolac tromethamine ophth soln 0.5%

 

 

CETRAXAL (ciprofloxacin hcl otic soln 0.2% (base equivalent))

Infections- Otic

 

Ciprofloxacin otic soln 0.2%

 

cholestyramine light powder packets 4 gm

Hypercholesterolemia

cholestyramine light powder pak 4 gm

 

 

cholestyramine powder packets 4 gm

Hypercholesterolemia

cholestyramine powder pak 4 gm

 

 

ciclopirox olamine susp 0.77% (base equivalent)

Fungal Infections-Topical

ciclopirox gel 0.77%, ciclopirox cream 0.77%

 

 

diltiazem hcl coated beads tab er 24hr
240 mg

Angina, Hypertension, Atrial Fibrillation/
Flutter

diltiazem hcl coated beads capsule er 24 hr 240 mg

 

 

diltiazem hcl coated beads cap er 24hr
180 mg, 360 mg

Angina, Hypertension, Atrial Fibrillation/
Flutter

diltiazem hcl coated beads capsule er 24 hr 180 mg

 

 

diltiazem hcl coated beads tab er 24hr
300 mg

Angina, Hypertension, Atrial Fibrillation/
Flutter

diltiazem hcl coated beads capsule er 24 hr 300 mg

 

 

diltiazem hcl coated beads tab sr 24 hr
180 mg, 360 mg

Angina, Hypertension, Atrial Fibrillation/
Flutter

diltiazem hcl coated beads capsule er 24 hr 180 mg

 

 

diltiazem hcl coated beads tab sr 24hr
240 mg

Angina, Hypertension, Atrial Fibrillation/

Flutter

diltiazem hcl coated beads capsule er 24 hr 240 mg

 

 

diltiazem hcl coated beads tab sr 24 hr
300 mg

Angina, Hypertension, Atrial Fibrillation/

Flutter

diltiazem hcl coated beads capsule er 24 hr 300 mg

 

 

leucovorin calcium tab
10 mg

High Dose Methotrexate or Methotrexate Overdose

leucovorin calcium tablet 5 mg

 

 

megestrol acetate susp
625 mg/5 ml

Anorexia, Cachexia

megestrol acetate suspension 40 mg/ml

 

 

oxycodone hcl cap 5 mg

Pain

oxycodone hcl tablet
5 mg

 

 

PREDNISONE INTENSOL (prednisone conc 5 mg/ml)

Inflammatory Conditions

 

Prednisone solution
5 mg/5 ml

 

zolmitriptan orally disintegrating tab 2.5 mg, 5 mg

Migraine

zolmitriptan tablet, rizatriptan orally disintegrating tablet

 

 

 

Balanced and Performance Select Drug List Exclusions

NEXAVAR (sorafenib tosylate tab 200 mg (base equivalent))

Cancer

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

PENNSAID (diclofenac sodium soln 2%)

Inflammation- Topical

diclofenac sodium solution 1.5%

 

 

PICATO (ingenol mebutate gel 0.015%, 0.05%)

Actinic Keratosis

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

SPIRO PD (respiratory therapy supplies - devices)

Respiratory supplies/devices

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

THRESHOLD PEP (respiratory therapy supplies - devices)

Respiratory supplies/devices

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

 

Balanced Drug List Exclusions

BUPROPION HYDROCHLORIDE E R (XL) (bupropion hcl tab er 24hr 450 mg)

Depression

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

calcipotriene-betamethasone dipropionate oint
0.005-0.064%

Plaque Psoriasis

 

Enstilar, Duobrii, Tazorac

 

calcipotriene-betamethasone dipropionate susp
0.005-0.064%

Plaque Psoriasis

 

Enstilar, Duobrii, Tazorac

 

EXFORGE HCT (amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg)

Hypertension

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

FORFIVO XL (bupropion hcl tab er 24 hr 450 mg)

Depression

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

LIDOCAINE HCL JELLY (lidocaine hcl urethral/mucosal gel 2%)

Anesthesia- Urethral/
Mucosal

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

NALFON (fenoprofen calcium cap 400 mg)

Pain/

Inflammation

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

PENTASA (mesalamine cap er 500 mg)

Ulcerative Colitis

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

 

Performance Select Drug List Exclusions

diclofenac sodium soln 2%

Inflammation- Topical

diclofenac sodium solution 1.5%

 

 

penicillamine cap 250 mg

Cystinuria, Rheumatoid Arthritis, Wilson's Disease

penicillamine tablet
250 mg

 

 

 

Health Insurance Marketplace (HIM) Exclusions

cholestyramine powder packets 4 gm

Hypercholesterolemia

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

cholestyramine light powder packets 4 gm

Hypercholesterolemia

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

ciclopirox olamine susp 0.77% (BASE EQUIV)

Fungal Skin Infections

Please talk to your doctor or pharmacist about other medication(s) available for your condition

 

diltiazem hcl coated beads tab ER 24HR 180mg, 240 mg

Hypertension/Angina

Please talk to your doctor or pharmacist about other medication(s) available for your condition

 

leucovorin calcium tabs 10 mg

Cancer

Please talk to your doctor or pharmacist about other medication(s) available for your condition

 

lidocaine hcl urethral/mucosal gel 2%

Anesthesia

Please talk to your doctor or pharmacist about other medication(s) available for your condition

 

NEXAVAR - sorafenib tosylate tab 200 mg (base equivalent)

Cancer

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

 

PRADAXA - dabigatran etexilate mesylate cap 75 mg (etexilate base equivalent)

Anticoagulation

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

proparacaine hcl ophth soln 0.5%

Anesthesia

Please talk to your doctor or pharmacist about other medication(s) available for your condition

 

VIIBRYD - vilazodone hcl tab 10 mg, 20 mg, 40 mg

Depression

There is a generic equivalent available. Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 

zolmitriptan orally disintegrating tab 2.5 mg, 5 mg

Migraine

Please talk to your doctor or pharmacist about other medication(s) available for your condition.

 
             

 

1Third-party brand names are the property of their respective owner.

2This list is not all inclusive. Other medicines may be available in this drug class.