Medicare Part D Formulary Updates 1st Quarter 2012

This link will take you to a new site not affiliated with BCBSTX. It will open in a new window. To return to our website, simply close the new window. Refer to important information for our linking policy.

Text Size: A A A

Welcome

Employers

Producers

Providers

Company InformationContact Us

May 9, 2012

A summary of recent Blue Cross and Blue Shield of Texas (BCBSTX) Medicare Part D formulary changes can be found below. The BlueMedicareRx formulary is updated monthly by our pharmacy provider, Prime Therapeutics. For a complete formulary listing and for future inquiries regarding prior authorizations, step therapy, coverage determinations/RE-determinations, transition plan benefits, and appointment of representative for your BCBSTX members please follow the following instructions:

Utilize https://www.myprime.com to access the Prime Therapeutics’ Medicare Part D member website:

a) Click on ‘Find Drugs & Estimates’,

b) Follow directions to

‘Select your Health Plan’ click on ‘BCBS Texas’,
‘Medicare Part D Member?’ Click ‘YES’,
‘Select Your Health plan type’ Click ‘Blue MedicareRx’

c) From this page you will be able to determine the formulary status and applicable utilization management programs for individual drugs or access any of the important databases outlined above.

Generic name (TRADE NAME)	BRAND Generic Product	Effective Date	Nature of Change	Comments
ANDRODERM (testosterone) transdermal patch, 2 mg/24hr, 4 mg/24 hr	Brand	1/1/12	Addition	Tier 2.
atorvastatin tabs, 10 mg, 20 mg, 40 mg, 80 mg	Generic	1/1/12	Cost Share Reduction	Change to Tier 1 (was 3). Quantity Limits continue to apply.
atovaquone/proguanil tabs, 250-100 mg	Generic	1/1/12	Addition	Tier 1. First generic for this strength of Malarone.
BRILINTA (ticagrelor) tabs, 90 mg	Brand	1/1/12	Addition	Tier 3.
calcium acetate tabs, 667 mg	Generic	1/1/12	Addition	Tier 1. First generic for this strength of Eliphos.
camrese (levonorgestrel/ethinyl estradiol and ethinyl estradiol) tabs, 0.15-0.03 mg and 0.01 mg	Generic	1/1/12	Addition	Tier 1. First generic for Seasonique.
cromolyn sodium oral soln, 100 mg/5 mL	Generic	1/1/12	Addition	Tier 1. First generic for Gastrocrom.
DIFICID (fidaxomicin) tabs, 200 mg	Brand	1/1/12	Addition	Tier 4.
diltiazem ER caps, 360 mg	Generic	1/1/12	Addition	Tier 1. First generic for this strength of Cardizem CD.
eprosartan tabs, 600 mg	Generic	1/1/12	Addition	Tier 1. First generic for Teveten. Quantity Limits apply.
felbamate susp, 600 mg/5 mL	Generic	1/1/12	Addition	Tier 1. First generic for Felbatol suspension.
felbamate tabs, 400 mg, 600 mg	Generic	1/1/12	Addition	Tier 1. First generic for Felbatol.
flucytosine caps, 250 mg, 500 mg	Generic	1/1/12	Addition	Tier 1. First generic for Ancobon.
GEMCITABINE inj, 200 mg/5.26 mL, 1g/26.3 mL, 2 g/52.6 mL	Brand	1/1/12	Addition	Tier 4.
PROMACTA (eltrombopag olamine) tab, 12.5 mg	Brand	1/22/12	Addition	Tier 4. Prior authorization applies.
JUVISYNC (sitagliptin-simvastatin) tab, 100-10 mg, 100-20 mg, 100-40 mg	Brand	2/1/12	Addition	Tier 2. Step therapy and quantity limits apply.
caffeine citrate oral soln, 60 mg/3 mL	Generic	2/1/12	Addition	Tier 1.
NICOTROL INHALER (nicotine) inhaler, 10 mg	Brand	2/1/12	Addition	Tier 3.
NUEDEXTA (dextromethorphan hbr-quinidine sulfate) cap, 20-10 mg	Brand	2/1/12	Addition	Tier 3.
NUCYNTA ER (tapentadol hcl) tab, 50 mg, 100 mg, 150 mg, 200 mg, 250 mg	Brand	2/1/12	Addition	Tier 2. Quantity limits apply.
VIREAD (tenofovir disoproxil fumarate) tab, 150 mg, 200 mg, 250 mg, and 40 mg/gm powder for susp	Brand	1/29/12	Addition	Tier 3.
LATUDA (lurasidone hydrochloride) tab, 20 mg	Brand	1/29/12	Addition	Tier 3. Step therapy and quantity limits apply.
SANDIMMUNE (cyclosporine) oral soln, 100 mg/mL	Brand	2/13/12	Addition	Tier 3. May be covered by Medicare Part B or Medicare Part D depending on circumstances.
INLYTA (axitinib) tabs, 1 mg, 5 mg	Brand	2/14/12	Addition	Tier 4. Prior authorization and quantity limits apply.
RELISTOR (methynaltrexone) inj, 8 mg/0.4 mL	Brand	2/13/12	Addition	Tier 3. Prior authorization applies.