Medicare Part D Formulary Updates

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November 14, 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	Description of Change	Comments
nevirapine tab, 200 mg	Generic	5/27/12	Addition	Tier 1. First generic for VIRAMUNE.
PROLIA (denosumab) inj, 60 mg/mL	Brand	6/1/12	Cost Share Reduction	Change to Tier 3 (was 4). Prior Authorization continues to apply.
voriconazole inj, 200 mg	Generic	6/3/12	Addition	Tier 1. First generic for VFEND IV. Prior authorization applies.
cytarabine inj, 20 mg/mL	Generic	6/3/12	Cost Share Reduction	Change to Tier 1 (was 3). May be covered by Medicare Part B or Medicare Part D depending on circum-stances.
PERJETA (pertuzumab) soln for inj, 420 mg/14 mL	Generic	6/17/12	Addition	Tier 4
POTIGA (ezogabine) tabs, 50 mg, 200 mg, 300 mg, 400 mg	Brand	7/1/12	Addition	Tier 3. Step Therapy applies.
abacavir tabs, 300 mg	Generic	7/1/12	Addition	Tier 1.
hydrochlorothiazide tabs, 12.5 mg	Generic	7/8/12	Cost Share Reduction	Change to Tier 1 (was 3).
alfuzosin ER tabs, 10 mg	Generic	8/1/12	Addition	Tier 1. Quantity limits apply.
PICATO (ingenol mebutate) gel, 0.015%, 0.05%	Brand	8/1/12	Addition	Tier 2.
PREVACID SOLUTAB (lansoprazole) delayed-release orally disintegrating tabs, 15 mg, 30 mg	Brand	8/1/12	Addition	Tier 3. Quantity limits apply.
calcipotriene cream, 0.005%	Generic	8/5/12	Addition	Tier 1. First generic for DOVONEX cream.
DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC IM inj, 25-5 units/0.5 mL	Brand	8/5/12	Addition	Tier 3.
montelukast chew tabs, 4 mg, 5 mg; tabs, 10 mg	Generic	8/5/12	Addition	Tier 1. First generic for SINGULAIR.
LYRICA (pregabalin) oral soln, 20 mg/mL	Brand	8/12/12	Addition	Tier 2.
pioglitazone tabs, 15 mg, 30 mg, 45 mg	Generic	8/19/12	Addition	Tier 1. Quantity limits apply. First generic for ACTOS.
ZALTRAP (ziv-aflibercept) IV soln, 100 mg/4 mL, 200 mg/8 mL	Brand	8/19/12	Addition	Tier 4.
ZYCLARA (imiquimod) pump cream, 2.5%	Brand	8/19/12	Addition	Tier 2. Prior authorization and quantity limits apply
modafinil tabs, 100 mg, 200 mg	Generic	8/22/12	Addition	Tier 1. Prior authorization and quantity limits apply. First generic for PROVIGIL.