Pharmacy Program Quarterly Update – Changes Effective Oct. 1, 2019

July 31, 2019

Applies to: All Groups

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 Blue Cross and Blue Shield of Illinois (BCBSIL) drug lists, effective Oct. 1, 2019. Changes by drug list are listed on the chart links below.

Please note: The drug list changes listed below do not apply to BCBSIL members on the Basic Annual, Multi-Tier Basic Annual, Enhanced Annual, Multi-Tier Enhanced Annual or Performance Annual Drug Lists. These drug lists will have the revisions and/or exclusions applied on or after Jan. 1, 2020.

BCBSIL HMO Illinois^® or Blue Advantage HMO^SM members will not have any of these drug list revisions/exclusions applied to their pharmacy benefits until Jan. 1, 2020.

Review Drug List Updates (Revisions/Exclusions) – Effective Oct. 1, 2019

Review Drug List Updates (Coverage Additions/Coverage Tier Changes) – Effective July 1, 2019

Dispensing Limit Changes
BCBSIL’s prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on FDA-approved dosage regimens and product labeling. Changes by drug list are listed below. Note: The dispensing limits listed below do not apply to BCBSIL members on the Basic Annual or Enhanced Annual Drug Lists. Dispensing limits will be applied to these drug lists on or after Jan. 1, 2020.

Effective Oct. 1, 2019:

Drug Class and Medication(s)¹	Dispensing Limit(s)
Basic, Enhanced, Performance, Performance Annual, and Performance Select Drug Lists
Alternative Dosage Form
Tiglutik	600 mL per 30 days

Basic, Enhanced, Performance, and Performance Annual Drug Lists
Vascepa
Vascepa 0.5 mg	240 capsules per 30 days
Vascepa 1 mg	120 capsules per 30 days

Basic and Enhanced Drug Lists
Amifampridine
Firdapse	240 tablets per 30 days
Ruzurgi	300 tablets per 30 days
Neurotrophic Keratitis
Oxervate	56 vials per 56 days
Oral PAH
Uptravi 200 mcg titration bottle	140 tablets per 180 days

Standard Utilization Management Program Package Changes

Step Therapy (ST) Program Changes

Effective Oct. 1, 2019, the Methotrexate Injectable ST program will be added to the Balanced and Performance Select Drug Lists. This program includes the target drugs: Otrexup and Rasuvo.
Effective Oct.1, 2019, new target drugs will be added to the Multiple Sclerosis ST program: Mayzent (preferred brand) and Mavenclad (non-preferred brand/ excluded). This program applies to the Basic, Basic Annual, Enhanced, Enhanced Annual, Balanced, Performance, Performance Annual and Performance Select Drug Lists.

Prior Authorization (PA) Program Changes
Several drug categories and/or targeted medications will be added to the PA programs for standard pharmacy benefit plans upon renewal for non-ASO groups. This includes ASO groups that have selected auto updates. For groups that have not selected auto updates, these programs will be available for selection as of the program effective date. Contact your BCBSIL representative for more information.

Effective July 25, 2019, the Firdapse PA program changed its name to: Amiframpidine. The program, which applies to the Balanced and Performance Select Drug Lists, includes the same targeted medications and a new one, Ruzurgi. The program criteria remains the same.
Effective July 25, 2019, the IL-5 Inhibitors PA program and target drugs Fasenra and Nucala were added to the Basic, Basic Annual, Enhanced, Enhanced Annual, Balanced, Performance, Performance Annual and Performance Select Drug Lists.*
Effective July 25, 2019, the target drug Emgality 100 mg/mL was added to the Calcitonin Gene-Related Peptide (CGRP) PA program, which applies to the Basic, Basic Annual, Enhanced, Enhanced Annual, Balanced, Performance, Performance Annual and Performance Select Drug Lists.*

Please Note: As a reminder, the PA and ST programs for standard pharmacy benefit plans correlate to a member's drug list. Not all standard PA and ST programs may apply, based on the member's current drug list. A list of PA and ST programs per drug list is posted on the member prescription drug plan information section of bcbsil.com.

Members were notified about the PA standard program changes listed in the tables below.

Drug categories added to current pharmacy PA standard programs, effective Oct. 1, 2019:

Drug Category	Targeted Medication(s)¹
Basic, Enhanced, Balanced, Performance, Performance Select Drug Lists
Human Fibrinogen Concentrate^✝	Fibryga, RiaSTAP
Procysbi^✝	Procysbi
Basic and Enhanced Drug Lists
Amiframpidine (previously known as Firdapse)	Firdapse, Ruzurgi
Neurotrophic Keratitis	Oxervate
Vascepa	Vascepa

^✝Applies to BCBSIL Performance Annual drug list

Effective Oct. 1, 2019, the Vascepa PA program will also be added to the Performance and Performance Annual Drug Lists.*

Targeted drugs added to current pharmacy PA standard programs, effective Oct. 1, 2019:

Drug Category	Targeted Medication(s)1
Basic, Enhanced, Balanced Drug Lists
Alternative Dosage Form	Tiglutik
Basic, Enhanced, Performance Drug Lists
Therapeutic Alternatives^✝	Diflorasone ointment and cream

^✝Applies to BCBSIL Performance Annual drug list

Effective Oct. 1, 2019, the Alternative Dosage Form program update will also apply to the Performance, Performance Annual and Performance Select Drug Lists.*

Targeted mailings were sent to members affected by drug list revisions and/or exclusions, prior authorization program and dispensing limit changes per our usual process of notifying members prior to the effective date.

View the most up-to-date drug list and list of drug dispensing limits on bcbsil.com.

New Generic Specialty Drug Coverage Tier Changes
With the increase of generic specialty medications in the pharmaceutical market, BCBSIL is changing the way these medications may process starting on Oct.1, 2019. If a member is on the Balanced, Performance, Performance Annual or Performance Select Drug Lists, the following examples of generic specialty medications may be in the lower-cost, preferred specialty tier.

The October prescription drug lists will reflect these tier coverage changes. The medications will be in lower-case boldface type, have a lower-case “p” or “np” indicator and be marked with a dot in the specialty column. Below are some examples of these medications that are currently in the highest cost, non-preferred specialty tier:

abiraterone acetate tab 250 mg (Zytiga)	bexarotene cap 75 mg (Targretin)
capecitabine tab 150 mg, 500 mg (Xeloda)	dalfampridine tab er 12hr 10 mg (Ampyra)
glatiramer acetate soln prefilled syringe 20 mg/ml, 40 mg/ml (Copaxone)	imatinib mesylate tab 100 mg, 400 mg (base equivalent) (Gleevec)
leuprolide acetate inj kit 5 mg/ml	melphalan tab 2 mg (Alkeran)
nilutamide tab 150 mg (Nilandron)	ocetreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100 mcg/ml (0.1 mg/ml), 200 mcg/ml (0.2 mg/ml), 500 mcg/ml (0.5 mg/ml), 1000 mcg/ml (1 mg/ml) (Sandostatin)
ribavirin cap 200 mg (Rebetol)	ribavirin tab 200 mg (Copegus)
sildenafil citrate tab 20 mg (Revatio)	sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)
sodium phenylbutyrate tab 500 mg (Buphenyl)	tadalafil tab 20 mg (Adcirca)
temozolomide cap 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg (Temodar)	tetrabenazine tab 12.5 mg, 25 mg (Xenazine)
tobramycin nebu soln 300 mg / 5 ml (Tobi)	tretinoin cap 10 mg
trientine hcl cap 250 mg (Syprine)	vigabatrin powder pack 500 mg (Sabril)

Multiple Accums Functionality Implementation for Select IL, MT and OK Group Plans
Previously, all pharmacy claims for accounts on 2018 and previous portfolios accumulated to in-network accumulators such as the deductible and out-of-pocket limits. If an account renews or enrolls on the 2019 Mid-Market portfolio (available as of July 1, 2019), pharmacy claims will accumulate as follows on their effective date:

Members Using an In-Network Pharmacy - Pharmacy claims apply to the in-network deductibles (if applicable); copay/coinsurance amounts paid only apply to in-network out-of-pocket limits.
Members Using an Out-of-Network Pharmacy - Pharmacy claims apply to out-of-network deductibles (if applicable); copay/coinsurance amounts paid only apply to the out-of-network out-of-pocket limits. Any additional charges applied for using an out-of-network pharmacy will not apply to the out-of-pocket amounts or deductibles (if applicable).

Please note: This multiple accums functionality change does not impact HMO plans. For any questions regarding implementation, please contact your BCBSIL representative.

Reminder: Select Group Prescription Drug Lists’ Update Frequency Changed April 1, 2019
As a reminder and previously communicated, most of the prescription drug lists that were once updated annually on January 1, or at the group’s renewal date, have moved to a quarterly update. For groups on these affected drug lists, the frequency change is being implemented upon the group’s renewal/effective date starting on or after April 1, 2019. This update frequency change includes the following drug lists:

Enhanced, Multi-Tier Basic and Multi-Tier Enhanced
Note: Fully insured HMO groups will remain on an annual update.
Note: For those drug lists that remain on an annual update, or until a plan has moved to a quarterly update (where applicable), the drug list name has been changed to include “Annual” in the title. Both the quarterly updated and annually updated drug lists are posted on bcbsil.com.

If you have any questions regarding these changes, contact your BCBSIL representative.

¹Third-party brand names are the property of their respective owner.
* Members did not receive letters due to limited utilization.

BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.