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Jul 1, 2021

BCBSRI pharmacy program individual market formulary update July 1, 2021

The information below is effective July 1, 2021 and applies only to the individual market segment including through the state’s healthcare exchange (Healthsource RI). Prime Therapeutics offers the Net Results Formulary, which is used to support individual market products. This 5-tier formulary is developed and maintained with a comprehensive review of relevant clinical information by the Prime Therapeutics National Pharmacy and Therapeutics Committee and includes local review by the BCBSRI Pharmacy and Therapeutics Committee.


Excluded from coverage

As part of the formulary updates, the following drug products will be excluded from the prescription drug list, effective July 1, 2021.

Amantadine Hyrdrochloride               Imipramine Pamoate                           Proair Respiclick

Clindamycin/Benzoyl Perodxide       Kombiglyze XR                                  Tavaborole

Cyclobenzaprine Hydrochloride         Minocycline Hydrochloride               Temazepam

Diclofenac Sodium                             Onglyza                                               Tretinoin

Diclofenac Sodium ER                       Praluent                                               Trexall

Hydrocortisone Butyrate


The following drug products are now available with generic equivalents and will be excluded from coverage effective July 1, 2021. The generic equivalent product will continue to be covered.

Alinia                                      Ferriprox                                 Proair HFA

Atripla                                     Kerydin                                   Sklics

Banzel                                     Kuvan                                     Tytkerb

Bethkis                                    Monurol                                 


Cost share changes

The following products will require a higher out-of-pocket cost share, effective July 1, 2021.

Flurbiprofen                                        Pyrazinamide

Hydrocortisone Butyrate                    Tyblume


Prior authorization

The following drug will now require prior authorization for coverage, effective July 1, 2021.