Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Jan. 1, 2022 – Part 1

Dec. 06, 2021

PHARMACY NETWORK CHANGES

Some Blue Cross and Blue Shield of Montana (BCBSMT) members’ plans may have experienced changes to the pharmacy network as of Jan. 1, 2022. Some members’ plans may have moved to a new pharmacy network and some members' plans may experience changes to the pharmacies participating within the network.

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 patients' records, you may want to ask your patient which pharmacy is their preferred choice.

IMPORTANT PHARMACY BENEFIT REMINDERS

Jan. 1, 2022 is the start of a new year and renewed or new health insurance benefits for most 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 2022.
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.

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 Jan. 1, 2022 are outlined below.

You can view a preview of the January drug lists on our Member Prescription Drug Lists website. The final lists will be available on both the Member Prescription Drug Lists website and Pharmacy Program section of our Provider website closer to the January 1 effective date.

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

Please Note: If you have patients with an individual benefit plan offered on/off the Montana Health Insurance Marketplace, they may be impacted by annual drug list changes. You can view a list of these changes on our Individual and Family Member website.

Drug List Updates (Revisions/Exclusions) – As of January 1, 2022

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
CHANTIX (varenicline tartrate tab 0.5 mg, 1 mg (base equiv))	Smoking Cessation	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
CHANTIX (varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack)	Smoking Cessation	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
INVOKAMET (canagliflozin-metformin hcl tab 50-500 mg, 50-1000 mg, 150-500 mg, 150-1000 mg)	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
INVOKAMET XR (canagliflozin-metformin hcl tab er 24hr 50-500 mg, 24hr 50-1000 mg, 24hr 150-500 mg, 24 hr 150-1000 mg)	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
INVOKANA (canagliflozin tab 100 mg, 300 mg)	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
MITIGARE (colchicine cap 0.6 mg)	Gout	colchicine tablet 0.6 mg
PROLIA (denosumab inj soln prefilled syringe 60 mg/ml)	Osteoporosis	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.

Basic and Multi-Tier Basic Drug List Revisions
PAZEO (olopatadine hcl ophth soln 0.7% (base equivalent))	Allergic Conjunctivitis	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.

Drug1	Drug Class/Condition Used For	Generic Alternatives1,2	Brand Alternatives1,2
Balanced, Performance and Performance Select Drug List Revisions
FLUTAMIDE (flutamide cap 125 mg)	Cancer	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
HYDROCODONE/IBUPROFEN (hydrocodone-ibuprofen tab 5-200 mg)	Pain	hydrocodone/acetaminophen tablets
IVERMECTIN (ivermectin lotion 0.5%)	Parasitic Infections	Permethrin 5% cream, Malathion 0.5% lotion
MENOPUR (menotropins for subc inj 75 unit)	Infertility	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
METHOXSALEN (methoxsalen rapid cap 10 mg)	Psoriasis, Vitiligo	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
STAVUDINE (stavudine cap 15 mg, 20 mg, 30 mg, 40 mg)	Viral Infections	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.

Balanced Drug List Revisions
ALA-SCALP (hydrocortisone lotion 2%)	Inflammatory Conditions	Hydrocortisone 2.5% lotion
MITIGARE (colchicine cap 0.6 mg)	Gout	colchicine tablets
TIMOLOL MALEATE (timolol maleate tab 10 mg)	Hypertension	atenolol, metoprolol, carvedilol

Balanced, Performance and Performance Select Drug List Exclusions
ADASUVE (loxapine aerosol powder breath activated 10 mg)	Schizophrenia, Bipolar Disorder	Members should talk to their doctor or pharmacist about other medication(s) available for their condition. This product and other alternatives may be available under the medical benefit.
ADDERALL XR (amphetamine-dextroamphetamine cap er 24hr 5 mg, 24 hr 10 mg, 24hr 15 mg, 24hr 20 mg, 24hr 25 mg, 24hr 30 mg)	Attention Deficiency Hyperactivity Disorder (ADHD)	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
BANZEL (rufinamide tab 200 mg, 400 mg)	Seizures	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
CHANTIX (varenicline tartrate tab 0.5 mg, 1 mg (base equiv))	Smoking Cessation	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
CHANTIX (varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack)	Smoking Cessation	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
INVOKAMET (canagliflozin-metformin hcl tab 50-500 mg, 50-1000 mg, 150-500 mg, 150-1000 mg)	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
INVOKAMET XR (canagliflozin-metformin hcl tab er 24hr 50-500 mg, 24hr 50-1000 mg, 24hr 150-500 mg, 24hr 150-1000 mg)	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
INVOKANA (canagliflozin tab 100 mg, 300 mg)	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
KALETRA (lopinavir-ritonavir tab 100-25 mg, 200-50 mg)	Viral Infections	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.

MIACALCIN (calcitonin (salmon) inj 200 unit/ml)	Hypercalcemia	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
PREPIDIL (dinoprostone cervical gel 0.5 mg/3 gm)	Induction of Labor	Members should talk to their doctor or pharmacist about other medication(s) available for their condition. This product and other alternatives may be available under the medical benefit.
PREVIDENT RINSE (sodium fluoride rinse 0.2%)	Oral Fluoride	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
PROSTIN E2 (dinoprostone vaginal suppos 20 mg)	Induction of Labor	Members should talk to their doctor or pharmacist about other medication(s) available for their condition. This product and other alternatives may be available under the medical benefit.
QTERN (dapagliflozin-saxagliptin tab 5-5 mg, 10-5 mg)	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
ribavirin for inhal soln 6 gm	Respiratory Syncytial Virus (RSV)	Members should talk to their doctor or pharmacist about other medication(s) available for their condition. This product and other alternatives may be available under the medical benefit.
THIOLA (tiopronin tab 100 mg)	Homozygous Cystinuria	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.

Performance and Performance Select Drug List Exclusions
betamethasone valerate aerosol foam 0.12%	Inflammatory Conditions	fluocinonide solution 0.05%
clobetasol propionate lotion 0.05%	Inflammatory Conditions	Clobetasol 0.05% cream, Clobetasol 0.05% ointment, Clobetasol 0.05% solution
clobetasol propionate shampoo 0.05%	Inflammatory Conditions	Clobetasol 0.05% solution
clotrimazole w/ betamethasone lotion 1-0.05%	Inflammatory Conditions	clotrimazole w/ betamethasone cream 1-0.05% cream
desonide lotion 0.05%	Inflammatory Conditions	Desonide cream 0.05%, Triamcinolone 0.025% lotion, Triamcinolone 0.025%cream
fluocinonide emulsified base cream 0.05%	Inflammatory Conditions	triamcinolone cream 0.5%
halobetasol propionate oint 0.05%	Inflammatory Conditions	halobetasol cream 0.05%
hydrocodone-acetaminophen tab 5-300 mg	Pain	Hydrocodone/acetaminophen 5/325 mg tablets
hydrocodone-acetaminophen tab 7.5-300 mg	Pain	Hydrocodone/acetaminophen 7.5/325 mg tablets

hydrocodone-acetaminophen tab 10-300 mg	Pain	Hydrocodone/acetaminophen 10/325 mg tablets
HYDROCORTISONE BUTYRATE (hydrocortisone butyrate cream 0.1%)	Inflammatory Conditions	betamethasone valerate cream 0.1%
HYDROCORTISONE BUTYRATE (hydrocortisone butyrate soln 0.1%)	Inflammatory Conditions	Triamcinolone acetonide lotion 0.1%, betamethasone dipropionate lotion 0.05%
hydrocortisone butyrate cream 0.1%	Inflammatory Conditions	betamethasone valerate cream 0.1%
hydrocortisone butyrate oint 0.1%	Inflammatory Conditions	triamcinolone acetonide 0.025% ointment
hydrocortisone butyrate soln 0.1%	Inflammatory Conditions	Triamcinolone acetonide lotion 0.1%, betamethasone dipropionate lotion 0.05%
hydrocortisone valerate cream 0.2%	Inflammatory Conditions	betamethasone valerate cream 0.1%
hydrocortisone valerate oint 0.2%	Inflammatory Conditions	triamcinolone 0.1% ointment
MITIGARE (colchicine cap 0.6 mg)	Gout	colchicine tablets

Balanced and Performance Select Drug List Exclusions
ABSORICA (isotretinoin cap 10 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg)	Acne	isotretinoin generics (including: amnesteem capsule, claravis capsule, isotretinoin capsule, myorisan capsule, zenatane capsule)
AZOPT (brinzolamide ophth susp 1%)	Glaucoma, Ocular Hypertension	dorzolamide 2% solution
LEVULAN KERASTICK (aminolevulinic acid hcl for soln 20% (stick applicator))	Actinic Keratosis	Members should talk to their doctor or pharmacist about other medication(s) available for their condition. This product and other alternatives may be available under the medical benefit.

Balanced Drug List Exclusions
ABILIFY MYCITE (aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg with sensor)	Schizophrenia, Bipolar Disorder	aripiprazole tablets
ABILIFY MYCITE MAINTENANCE KIT (aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg with sensor&strips (for pod) maint pak)	Schizophrenia, Bipolar Disorder	aripiprazole tablets
ABILIFY MYCITE STARTER KIT (aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg with sensor, strips & pod starter pak)	Schizophrenia, Bipolar Disorder	aripiprazole tablets
ACUVAIL (ketorolac tromethamine (pf) ophth soln 0.45%)	Ocular Pain/Inflammation	ketorolac tromethamine 0.5% ophthalmic solution
AMELUZ (aminolevulinic acid hcl gel 10%)	Actinic Keratosis	Members should talk to their doctor or pharmacist about other medication(s) available for their condition. This product and other alternatives may be available under the medical benefit.
APLENZIN (bupropion hbr tab er 24hr 174 mg, 24hr 348 mg, 24hr 522 mg)	Depression	bupropion generics
BEPREVE (bepotastine besilate ophth soln 1.5%)	Allergic Conjunctivitis	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
BIJUVA (estradiol-progesterone cap 1-100 mg)	Hot Flashes	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
BUNAVAIL (buprenorphine-naloxone buccal film 2.1-0.3 mg, 4.2-0.7 mg, 6.3-1 mg (base equiv))	Opioid Dependence	Buprenorphine /Naloxone sublingual tablet, Buprenorphine /Naloxone film
CAPLYTA (lumateperone tosylate cap 42 mg)	Schizophrenia	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
DRIZALMA SPRINKLE (duloxetine hcl cap delayed release sprinkle 20 mg, 30 mg, 40 mg, 60 mg (base eq))	Depression	duloxetine capsules
EPROSARTAN MESYLATE (eprosartan mesylate tab 600 mg)	Hypertension	Losartan, Valsartan, Irbesartan, Olmesartan, Telmisartan
HELIDAC THERAPY (metronidaz tab-tetracyc cap-bis subsal chew tab therapy pack)	Bacterial Infections	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
HYSINGLA ER (hydrocodone bitartrate tab er 24 hr deter 20 mg, 24hr deter 30 mg, 24hr deter 40 mg, 24hr deter 60 mg, 24hr deter 80 mg, 24hr deter 100 mg, 24hr deter 120 mg)	Pain	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
NAFTIFINE HYDROCHLORIDE (naftifine hcl cream 2%)	Fungal Infections	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.

NEVANAC (nepafenac ophth susp 0.1%)	Ocular Pain/Inflammation	Bromfenac ophthalmic solution, Diclofenac ophthalmic solution, Ketorolac ophthalmic solution
NORTHERA (droxidopa cap 100 mg, 200 mg, 300 mg)	Orthostatic Hypotension	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
OMECLAMOX-PAK (amoxicillin cap-clarithro tab w/ omepraz cap dr therapy pack)	Bacterial Infections	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
PROLENSA (bromfenac sodium ophth soln 0.07% (base equivalent))	Ocular Pain/Inflammation	Bromfenac ophthalmic solution, Diclofenac ophthalmic solution, Ketorolac ophthalmic solution
PYLERA (bismuth subcit-metronidazole-tetracycline cap 140-125-125 mg)	Bacterial Infections	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
SLYND (drospirenone tab 4 mg)	Contraceptives	Members should talk to their doctor or pharmacist about other medication(s) available for their condition.
VELTIN (clindamycin phosphate-tretinoin gel 1.2-0.025%)	Acne	Generic equivalent available. Members should talk to their doctor or pharmacist about other medication(s) available for their condition.

Performance Drug List Exclusions
calcipotriene ointment 0.005%	Plaque Psoriasis	calcipotriene soln 0.005%, calcipotriene cream 0.005%
isosorbide dinitrate tab 40 mg	Angina	isosorbide dinitrate tab 20 mg
MYTESI (crofelemer tab delayed release 125 mg)	Diarrhea	diphenoxylate/atropine tablet
SEGLUROMET (ertugliflozin-metformin hcl tab 2.5-500 mg, 2.5-1000 mg, 7.5-500 mg, 7.5-1000 mg)	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
STEGLATRO (ertugliflozin l-pyroglutamic acid tab 5 mg, 10 mg (base equiv))	Diabetes		Synjardy, Synjardy XR, Xigduo XR, Farxiga, Jardiance, Trijardy, Glyxambi
zolpidem tartrate sl tab 1.75 mg, 3 mg	Insomnia		zolpidem tablets

Performance Select Drug List Exclusions
travoprost ophth soln 0.004% (benzalkonium free) (bak free)	Glaucoma, Ocular Hypertension	latanoprost solution

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.

Review Drug List Updates (Coverage Tier 1 to Tier 2 Changes) – As of Jan. 1, 2022

The generic drug changes listed below apply to members with a pharmacy benefit plan that includes a cost share differential for generic drugs (e.g. 5-tier or higher plan design with preferred generic and non-preferred generic lower tiers). The following drugs are moving from a preferred generic (tier 1) to a non-preferred generic (tier 2), effective Jan. 1, 2022. Members may pay more for these drugs.

Drug1	Drug Class/Condition Used For
Multi-Tier Basic, Multi-Tier Enhanced and Performance Drug Lists
amlodipine besylate-valsartan tab 5-160 mg, 10-160 mg, 5-320 mg	Hypertension
carbonyl iron susp 15 mg/1.25 ml (elemental iron)	Vitamin/Supplement
famciclovir tab 125 mg	Viral Infections
haloperidol lactate oral conc 2 mg/ml	Schizophrenia
hydrocodone w/ homatropine syrup 5-1.5 mg/5 ml	Cough/Cold
nabumetone tab 750 mg	Pain/Inflammation
nifedipine tab er 24hr osmotic release 60 mg	Hypertension
nitroglycerin td patch 24hr 0.2 mg/hr	Angina
orphenadrine citrate tab er 12hr 100 mg	Pain/Muscle Spasms
perindopril erbumine tab 2 mg, 4 mg	Hypertension
primidone tab 250 mg	Seizures
prochlorperazine maleate tab 10 mg (base equivalent)	Nausea/Vomiting
sotalol hcl (afib/afl) tab 160 mg	Atrial Fibrillation/Atrial Flutter
sotalol hcl tab 160 mg, 240 mg	Arrhythmias
telmisartan tab 80 mg	Hypertension
tetracaine hcl ophth soln 0.5%	Ocular Anesthesia
valacyclovir hcl tab 1 gm	Viral Infections
valsartan tab 160 mg, 320 mg	Hypertension
valsartan-hydrochlorothiazide tab 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg	Hypertension

Multi-Tier Basic and Multi-Tier Enhanced Drug Lists
heparin sodium (porcine) lock flush iv soln 10 unit/ml	Maintenance of IV device patency
naproxen tab ec 375 mg, 500 mg	Pain/Inflammation
nitrofurantoin monohydrate macrocrystalline cap 100 mg	Bacterial Infections

Performance Drug List
nifedipine tab sr 24hr osmotic release 60 mg	Hypertension
orphenadrine citrate tab sr 12hr 100 mg	Pain/Muscle Spasms

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

DISPENSING LIMIT CHANGES

The BCBSMT prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on U.S. Food and Drug Administration (FDA) approved dosage regimens and product labeling. Changes by drug list are listed on the charts below.

BCBSMT letters all members with a claim for a drug included in the Dispensing Limit Program, regardless of the prescribed dosage. This means members may receive a letter even though their prescribed dosage doesn't meet or exceed the dispensing limit.

Effective Jan. 1, 2022:

Drug Class and Medication(s)1	Dispensing Limit(s)
Basic, Enhanced, Balanced, Performance, Performance Select Drug Lists
Deferasirox
deferasirox 125 mg tablet for oral suspension (EXJADE)	30 tablets per 30 days
deferasirox 250 mg tablet for oral suspension (EXJADE)	30 tablets per 30 days
deferasirox 500 mg tablet for oral suspension (EXJADE)	90 tablets per 30 days
deferasirox 90 mg tablet (JADENU)	30 tablets per 30 days
deferasirox 180 mg tablet (JADENU)	30 tablets per 30 days
deferasirox 360 mg tablet (JADENU)	180 tablets per 30 days
deferasirox 90 mg sprinkle granules (JADENU)	30 packets per 30 days
deferasirox 180 mg sprinkle granules (JADENU)	30 packets per 30 days
deferasirox 360 mg sprinkle granules (JADENU)	180 packets per 30 days
Supplemental Therapeutic Alternatives
Elepsia XR 1000 mg tablet (levetiracetam)	90 tablets per 30 days
Elepsia XR 1500 mg tablet (levetiracetam)	60 tablets per 30 days
Therapeutic Alternatives
ergotamine w/ caffeine tablet 1-100 mg (CAFERGOT)	40 tablets per 28 days
ketoprofen 25 mg capsule	360 capsules per 30 days
Niacor 500 mg tablet (niacin)	360 tablets per 30 days

Basic and Enhanced Drug Lists
Empaveli
pegcetacoplan subcutaneous soln 54 mg/ml (EMPAVELI)*	8 vials per 28 days
Verquvo
vericiguat tablet 2.5 mg (VERQUVO)*	30 tablets per 30 days
vericiguat tablet 5 mg (VERQUVO)*	30 tablets per 30 days
vericiguat tablet 10 mg (VERQUVO)*	30 tablets per 30 days

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

* Not all members may have been notified due to limited utilization.

UTILIZATION MANAGEMENT PROGRAM CHANGES

Effective Jan. 1, 2022, the following changes will be applied:
- The Accrufer PA program will be added to the Balanced, Performance and Performance Select Drug Lists.*
  - Note: This program will be added to the Basic and Enhanced Drug Lists on April 1, 2022.
- The Kerendia PA program will be added to the Balanced, Performance and Performance Select Drug Lists.*
  - Note: This program will be added to the Basic and Enhanced Drug Lists on April 1, 2022.
- The Elagolix PA program will change its name to Elagolix/Relugolix and the target drug Myfembree will be added to the Balanced, Performance and Performance Select Drug Lists.
  - Note: Myfembree will be added to the Basic and Enhanced Drug Lists on April 1, 2022.
- Target Migranal will be removed from the Therapeutic Alternatives PA program and added to the Acute Migraine Agents PA program. This change will apply to the Basic, Enhanced, Balanced, Performance and Performance Select Drug Lists.
- Targets Nurtec ODT and Ubrelvy will be removed from the Acute Migraine Agents PA program and added to the Calcitonin Gene-Related Peptide (CGRP) PA program. This change will apply to the Basic, Enhanced, Balanced, Performance and Performance Select Drug Lists.
- Target Nexium Granules (esomeprazole) will be removed from the non-standard Proton Pump Inhibitors (PPIs) ST program and added to the Alternative Dosage Form PA program. This change will apply to the Basic, Enhanced, Balanced, Performance and Performance Select Drug Lists.

* Not all members may have been notified due to limited utilization.

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

Targeted drugs added to current pharmacy PA standard programs, effective Jan. 1, 2022:

Drug Category	Targeted Medication(s)1
Basic and Enhanced Drug Lists
Empaveli	pegcetacoplan subcutaneous soln 54 mg/mL (EMPAVELI)*
Supplemental Therapeutic Alternatives	Elepsia XR 1000 mg tablet (levetiracetam), Elepsia XR 1500 mg tablet (levetiracetam)
Verquvo	vericiguat tablet 2.5 mg (VERQUVO), vericiguat tablet 5 mg (VERQUVO), vericiguat tablet 10 mg (VERQUVO)*
Basic, Enhanced, Balanced, Performance and Performance Select Drug Lists
Deferasirox	deferasirox 125 mg tablet for oral suspension (EXJADE), deferasirox 250 mg tablet for oral suspension (EXJADE), deferasirox 500 mg tablet for oral suspension (EXJADE), deferasirox 90 mg tablet (JADENU), deferasirox 180 mg tablet (JADENU), deferasirox 360 mg tablet (JADENU), deferasirox 90 mg sprinkle granules (JADENU), deferasirox 180 mg sprinkle granules (JADENU), deferasirox 360 mg sprinkle granules (JADENU)
Therapeutic Alternatives	ergotamine w/ caffeine tablet 1-100 mg (CAFERGOT), flurandrenolide lotion 0.05% (CORDRAN), Halog Solution 0.1% (halcinonide), hydrocortisone lotion 2% (ALA SCALP), ketoprofen 25 mg capsule, Lexette Foam 0.05% (halobetasol propionate), Niacor 500 mg tablet (niacin)

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

* Not all members may have been notified due to limited utilization.

Drug categories added to current pharmacy ST standard programs, effective Jan. 1, 2022:

Drug Category	Targeted Medication(s)1
Basic and Enhanced Drug Lists
SGLT-2 Inhibitors and Combinations	Invokamet 50-1000 mg (canagliflozin/metformin), Invokamet 150-500 mg (canagliflozin/metformin), Invokamet 150-1000 mg (canagliflozin/metformin), Invokamet XR 50-500 mg (canagliflozin/metformin ER), Invokamet XR 50-1000 mg (canagliflozin/metformin ER), Invokamet XR 150-500 mg (canagliflozin/metformin ER), Invokamet XR 150-1000 mg (canagliflozin/metformin ER), Invokana 100 mg (canagliflozin), Invokana 300 mg (canagliflozin), Qtern 5-5 mg (dapagliflozin/saxagliptin), Qtern 10-5 mg (dapagliflozin/saxagliptin), Segluromet 2.5-500 mg (ertugliflozin/metformin), Segluromet 2.5-1000 mg (ertugliflozin/metformin), Segluromet 7.5-500 mg (ertugliflozin/metformin), Segluromet 7.5-1000 mg (ertugliflozin/metformin), Steglatro 5 mg (ertugliflozin), Steglatro 15 mg (ertugliflozin), Steglujan 5-100 mg (ertugliflozin/sitagliptin), Steglujan 15-100 mg (ertugliflozin/sitagliptin)*

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

* Not all members may have been notified due to limited utilization. Continuation of therapy will not be in place. Members on a current drug regimen will be impacted.

Per our usual process of member notification prior to implementation, targeted mailings were sent to members affected by drug list revisions and/or exclusions, dispensing limit, prior authorization program and step therapy program changes. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of our Provider website.

If your patients have any questions about their pharmacy benefits, please advise them to contact the number on their member ID card. Members may also visit bcbsmt.com and log in to Blue Access for MembersSM (BAMSM) or MyPrime.com for a variety of online resources.

Diabetic Test Strips at a Reduced Cost-Share

Effective Jan. 1, 2022 (regardless of renewal), select diabetic test strips will be moved to a lower tier from a preferred brand to either a non-preferred generic or generic tier, based on plan benefits.

Details: This will apply across all drug lists for our group BCBSMT members.

This benefit change applies at retail and home delivery pharmacies.
Dispensing/quantity limits will still apply.
Any additional charges for using a non-value or out-of-network pharmacy will still apply. Note: Some members' benefit plans may include a Value Pharmacy Network, which offers reduced out-of-pocket expenses if members use a value pharmacy instead.
The drug list publications will not show the distinction in tier change.

If your patients have questions, please advise them to call the number on their ID card to verify coverage and confirm if their pharmacy of choice offers the diabetic test strips at a reduced cost-share.

Insulin Copay Maximum Added to Pharmacy Benefit Plans

A $25 copay cap for a 30-day supply of a preferred insulin drug will be applied to BCBSMT pharmacy benefit plans starting Jan. 1, 2022, regardless of renewal.

Details: Members can get preferred insulin medication at a $25 copay cap for a 30-day supply at a value or home delivery pharmacy.

Dispensing/quantity limits will still apply.
For plans on the Value Pharmacy Network, members will pay the reduced cost-share at a value pharmacy only. Members who use other pharmacies will pay the applicable cost-share for that pharmacy based on their plan. The cost-share will not be capped at $25.
For plans that do not have the Value Pharmacy Network, members will pay the reduced cost-share at any in-network pharmacy based on their plan.
For a High Deductible Health Plan (HDHP) that does not have preventive benefit coverage for insulin, members must meet their deductible first before the insulin cost-share cap would apply.
The drug list publications will not show which insulins are eligible for the copay cap.

If your patients have questions, please advise them to call the number on their ID card to verify coverage and confirm if their pharmacy of choice offers the preferred insulin at a reduced cost-share.

Change in Benefit Coverage for Select High-Cost Products

Several high-cost products that either are new to market or have therapeutic equivalents available have been excluded on the pharmacy benefit for select drug lists. This change impacts BCBSMT members who have prescription drug benefits administered by Prime Therapeutics. This change is part of an ongoing effort to make sure our members and employer groups have access to safe, cost-effective medications.

Please note: Members were not notified of these changes because there is no utilization or the pharmacist can easily fill a member's prescription with the equivalent without needing a new prescription from the doctor. The following drugs are excluded on select drug lists:

Product(s) No Longer Covered1*	Condition Used For	Covered Alternative(s)1,2
ACCRUFER	IRON DEFICIENCY	OTC IRON
DERMACINRX PRETRATE	PREGNANCY†	PRENATAL 19, VINATE M, PRENATAL+FE TAB 29-1, TRINATE, SE-NATAL 19
DICLOFENAC POTASSIUM 25 MG TABLETS	PAIN	DICLOFENAC POT 50 MG, MELOXICAM, IBUPROFEN, NAPROXEN
TERIPARATIDE SOLN PEN-INJ 620 MCG/2.48 ML	OSTEOPOROSIS	TYMLOS OR FORTEO

1 All brand names are the property of their respective owners.

2 This list is not all-inclusive. Other products may be available.

* This chart applies to members on the Basic, Multi-Tier Basic, Enhanced and Multi-Tier Enhanced Drug Lists.

† The prenatal products also apply to members on the Balanced, Performance and Performance Select Drug Lists.

Please call the number on the member's ID card to verify coverage, or for further assistance or clarification on your patient's benefits.

Prescription Opioid Duration Limits to Change for Select Members 19 Years of Age and Younger

BCBSMT's Appropriate Use of Opioids program is reducing the 7-day supply limit on an initial fill of an immediate-release opioid medication to a 3-day supply limit effective Jan. 1, 2022.

The Details:

This change applies to select members 19 years of age and younger who are considered opioid naïve.

Opioid naïve means the member does not have opioids on hand within the past 60 days per pharmacy claims.
No member lettering is needed due to acute or one-time use of opioids.
Members with an oncology medication on hand in the past 90 days per pharmacy claims will not be subject to the day supply limit.
If members have an oncology or hospice diagnosis and a recent opioid fill (within the past six months), continuation of therapy will be in place.
Once the first three-day supply has been filled, later fills will not call for the three-day duration need, as long as the member is not opioid naïve.
Prior authorization is required for members to fill an opioid prescription at the pharmacy if they exceed the program limit. Prescribing physicians can find the authorization request form on the Prior Authorization/Step Therapy Programs section of our provider website at bcbsmt.com/provider.

The Centers for Disease Control and Prevention (CDC) Says:

The treatment of acute pain can lead to long-term opioid use.1
For patients to safely use opioid therapy for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids – three days or less will often be sufficient.1
Adolescents who misuse opioid medication commonly use from their leftover prescription.1

Reminder:

The Appropriate Use of Opioids Program promotes safe and effective use of prescription opioids for our members who have prescription drugs benefits administered through Prime Therapeutics®.

Please call the number on the member's ID card to verify coverage, or for further assistance or clarification on your patient's benefits.

Source:

1 Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1

HDHP-HSA Preventive Drug Program Reminder

Select BCBSMT members' High Deductible Health Plan (with a Health Savings Account) may include a preventive drug program, which offers a reduced or $0 cost-share for members using certain medications for preventive purposes. Please note: If coverage of the member's medication is changed on their prescription drug list, the amount the member will pay for the same medication under their preventive drug benefit may also change.

Please call the number on the member's ID card to verify coverage, or for further assistance or clarification on your patient's benefits.

New Insulin Products Available for Coverage

Starting Jan. 1, 2022, Semglee (insulin glargine-yfgn) and insulin glargine-yfgn (unbranded Semglee) will be added to the preferred brand tier on select drug lists, and Lantus (insulin glargine) will be excluded as a benefit denial across all drug lists.

This drug list change is the result of the U.S. Food and Drug Administration (FDA)'s approval of Semglee as the first interchangeable biosimilar insulin product to treat adults and pediatric patients with Type 1 diabetes mellitus and adults with Type 2 diabetes mellitus on July 28, 2021. 1

Background:

An interchangeable biosimilar is a biologic drug considered highly similar to and has no clinically meaningful differences from the original biologic. There are no clinically meaningful differences between Semglee/insulin glargine-yfgn (unbranded) and Lantus (original biologic).
The FDA defines biologic drugs or biologics as, “generally large, complex molecules that are made from living sources such as bacteria, yeast and animal cells.” 2

Why it matters:

Semglee/insulin glargine-yfgn (unbranded) can be substituted for Lantus at the pharmacy in the same way that a generic drug is being substituted for a brand drug – meaning the pharmacist does not need a new prescription from the doctor.
Interchangeable biosimilars have undergone studies to ensure members can safely switch to the biosimilar without safety or efficacy issues.
Biosimilars and interchangeable biosimilars are important because they can introduce competition into the market at lower prices than the original biologic, which can help lower overall drug prices.

Member notices: Members will receive a letter explaining the insulin changes listed below in early November 2021.

Insulin Coverage Updates by Drug Lists:

Basic, Multi-Tier Basic, Enhanced, Multi-Tier Enhanced and Performance Drug Lists –

Changes effective Jan. 1, 2022

Product(s) No Longer Covered1

Condition Used For

Covered Alternative(s)1,2

LANTUS – insulin glargine inj 100 unit/ml

Diabetes

INSULIN GLARGINE – insulin glargine-yfgn inj 100 unit/ml,

SEMGLEE – insulin glargine-yfgn inj 100 unit/ml

LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml

Diabetes

INSULIN GLARGINE – insulin glargine-yfgn soln pen-injector 100 unit/ml,

SEMGLEE – insulin glargine-yfgn soln pen-injector 100 unit/ml

1 All brand names are the property of their respective owners.

2 This list is not all-inclusive. Other products may be available.

Balanced and Performance Select Drug Lists – Changes effective Jan. 1, 2022

Product(s) No Longer Covered1	Condition Used For	Covered Alternative(s)1,2
LANTUS – insulin glargine inj 100 unit/ml	Diabetes	SEMGLEE – insulin glargine-yfgn inj 100 unit/ml
LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml	Diabetes	SEMGLEE – insulin glargine-yfgn soln pen-injector 100 unit/ml

1 All brand names are the property of their respective owners.

2 This list is not all-inclusive. Other products may be available.

Sources:

1 FDA. FDA News Release: FDA Approves First Interchangeable Biosimilar Insulin Product for Treatment of Diabetes , July 28, 2021

2 FDA. Health Care Provider Materials – Fact Sheets: Overview of Biosimilar Products .

Please call the number on the member's ID card to verify coverage, or for further assistance or clarification on your patient's benefits.

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSMT contracts with Prime to provide pharmacy benefit management and related other services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The relationship between BCBSMT and contracting pharmacies is that of independent contractors. BCBSMT, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. MyPrime.com is an online resource offered by Prime Therapeutics.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member's certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.