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Jan 1, 2022

Individual markets formulary update for January 1, 2022

The information below is effective as of January 1, 2022 and applies only to the individual market segment, including direct pay and direct pay through the Exchange (Healthsource RI). Prime Therapeutics offers the Net Results Formulary, which is used to support the individual markets product. 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 drugs will be excluded from the prescription drug list, effective January 1, 2022. 

 

ADASUVE INH

FULPHILA INJ

MAKENA INJ

AFREZZA POW INH

HALOBETASOL  OINT

MITIGARE CAP

AMITIZA  CAP

HC BUTYRATE  CRE

NEULASTA INJ

APIDRA  INJ U-100

HC BUTYRATE  OINT

NEUPOGEN INJ

APIDRA INJ SOLOSTAR

HC BUTYRATE  SOL

PREPIDIL  GEL

BETAMETH VAL AERO

HC VALERATE  CRE

PROCRIT INJ

BREZTRI AERO AER SPHERE

HC VALERATE  OINT

PROSTIN E2 VAG SUP

CLOBETASOL LOTION

HYDROCO/APAP TAB

QTERN TAB

CLOBETASOL SHAM

HYDROXYPROGESTERONE  INJ

RIBAVIRIN FOR INHAL SOL

CLOTRIM/BETAMETH LOTION

INVOKAMET TAB

RIMANTADINE  TAB

DESONIDE LOTION

INVOKAMET XR TAB

SEGLUROMET TAB

DOXEPIN TAB

INVOKANA  TAB

STEGLATRO TAB

EPOGEN INJ

LIVALO TAB

TERIPARATIDE INJ

FLUNISOLIDE  SPR

LUMIGAN SOL

UDENYCA INJ

FLUOCINONIDE EMUL CREAM

 

 

The following drugs are now available with generic equivalents and will be excluded from coverage effective January 1, 2022. The generic equivalent product will continue to be covered.

 

ADDERALL XR  CAP

BEPREVE OPTH DROP

PREVIDENT SOL

AZOPT SUSP OPTH SUS

KALETRA  TAB

THIOLA TAB

BANZEL TAB

MIACALCIN INJ

 

Cost share changes

The following drugs will require a higher copayment, increasing from Tier 1 to Tier 2 effective January 1, 2022.

ALBUTEROL    NEB 0.083%

GABAPENTIN   TAB 600MG

ONDANSETRON  TAB 8MG ODT

ALPRAZOLAM   TAB 0.5MG XR

GLYBURID MCR TAB 6MG

OXCARBAZEPIN TAB 150MG

ALPRAZOLAM   TAB 3MG XR

HALOPERIDOL  TAB 0.5MG

OXYCOD/APAP  TAB 5-325MG

AMIODARONE   TAB 200MG

HALOPERIDOL  TAB 1MG

OXYCODONE    TAB 5MG

AMITRIPTYLIN TAB 10MG

HYDROCO/APAP TAB 5-325MG

PACERONE     TAB 200MG

AMITRIPTYLIN TAB 25MG

HYDROCORT    OIN 2.5%

PHENOBARB    TAB 100MG

AMITRIPTYLIN TAB 50MG

HYDROMORPHON TAB 2MG

PHENOBARB    TAB 30MG

AMOX/K CLAV  TAB 500-125

HYDROMORPHON TAB 4MG

PREDNISOLONE SOL 15MG/5ML

AMOX/K CLAV  TAB 875-125

ISONIAZID    TAB 100MG

PREDNISONE   PAK 5MG

BACLOFEN     TAB 10MG

ISRADIPINE   CAP 2.5MG

PROCHLORPER  TAB 10MG

BRIMONIDINE  SOL 0.2% OP

LANSOPRAZOLE CAP 30MG DR

PROCHLORPER  TAB 5MG

BUPROPION    TAB 150MG SR

LEUCOVOR CA  TAB 25MG

PROMETHAZINE SYP 6.25/5ML

BUSPIRONE    TAB 10MG

LEUCOVOR CA  TAB 5MG

PROMETHAZINE TAB 12.5MG

BUSPIRONE    TAB 15MG

LEVETIRACETA TAB 250MG

PROMETHAZINE TAB 25MG

BUSPIRONE    TAB 5MG

LEVETIRACETA TAB 500MG

PROMETHAZINE TAB 50MG

CALCITRIOL   CAP 0.25MCG

LEVOBUNOLOL  SOL 0.5% OP

PROPRANOLOL  TAB 10MG

CEPHALEXIN   CAP 250MG

LORCET       TAB 5-325MG

ROWEEPRA     TAB 500MG

CEPHALEXIN   CAP 500MG

MEGESTROL AC TAB 20MG

SELENIUM SUL LOT 2.5%

CIPROFLOXACN SOL 0.3% OP

MELPHALAN    TAB 2MG

SUMATRIPTAN  TAB 100MG

CLINDAMYCIN  CAP 150MG

METFORMIN    TAB 500MG ER

SUMATRIPTAN  TAB 25MG

CLINDAMYCIN  CAP 300MG

METFORMIN    TAB 750MG ER

SUMATRIPTAN  TAB 50MG

CROMOLYN SOD SOL 4% OP

METHOTREXATE INJ 1GM/40ML

TADALAFIL    TAB 2.5MG

CYCLOBENZAPR TAB 10MG

METHOTREXATE INJ 25MG/ML

TEMAZEPAM    CAP 15MG

CYCLOBENZAPR TAB 5MG

METHOTREXATE TAB 2.5MG

TEMAZEPAM    CAP 30MG

CYCLOPENTOL  SOL 1% OP

METHYLPRED   TAB 32MG

TIMOLOL MAL  SOL 0.25% OP

CYCLOPHOSPH  CAP 25MG

MIRTAZAPINE  TAB 15MG

TIMOLOL MAL  SOL 0.5% OP

CYCLOPHOSPH  CAP 50MG

MIRTAZAPINE  TAB 30MG

TRANDOLAPRIL TAB 2MG

DICLOFENAC   TAB 50MG DR

MIRTAZAPINE  TAB 45MG

TRAZODONE    TAB 100MG

DICLOFENAC   TAB 75MG DR

MORPHINE SUL SOL 100/5ML

TRAZODONE    TAB 150MG

DILTIAZEM    TAB 30MG

MORPHINE SUL SOL 10MG/5ML

TRAZODONE    TAB 50MG

DILTIAZEM    TAB 60MG

MORPHINE SUL SOL 20MG/ML

TRIAMCINOLON OIN 0.025%

DILTIAZEM    TAB 90MG

MORPHINE SUL TAB 15MG

TRIAMCINOLON OIN 0.1%

DONEPEZIL    TAB 10MG

MORPHINE SUL TAB 15MG ER

TRIHEXYPHEN  TAB 5MG

DONEPEZIL    TAB 5MG

NEOMYCIN     TAB 500MG

TRIMETHOPRIM TAB 100MG

DOXEPIN HCL  CON 10MG/ML

NIFEDIPINE   TAB 30MG ER

VALSART/HCTZ TAB 160-12.5

DOXYCYCL HYC TAB 100MG

NIZATIDINE   CAP 150MG

VALSART/HCTZ TAB 160-25MG

ENDOCET      TAB 5-325MG

NIZATIDINE   CAP 300MG

VALSART/HCTZ TAB 80-12.5

ESZOPICLONE  TAB 3MG

OLM MED/HCTZ TAB 20-12.5

VERAPAMIL    TAB 120MG ER

FA-8         CAP 800MCG

OLM MED/HCTZ TAB 40-12.5

VERAPAMIL    TAB 180MG ER

FLUCONAZOLE  TAB 150MG

OLM MED/HCTZ TAB 40-25MG

VERAPAMIL    TAB 240MG ER

FLURBIPROFEN TAB 50MG

ONDANSETRON  TAB 4MG ODT

ZONISAMIDE   CAP 50MG

FOLIC ACID   CAP 800MCG

 

The following drugs will require a higher copayment, increasing from Tier 2 to Tier 4 effective January 1, 2022.

 

CLOMIPHENE   TAB 50MG

METHOXSALEN  CAP 10MG

STAVUDINE    CAP 40MG

FLUTAMIDE    CAP 125MG

STAVUDINE    CAP 15MG

TIMOLOL MAL  TAB 10MG

HYDROCOD/IBU TAB 5-200MG

STAVUDINE    CAP 20MG

IVERMECTIN   LOT 0.5%

STAVUDINE    CAP 30MG

 

The following drug will require a higher copayment, increasing from Tier 4 to Tier 5 effective January 1, 2022.

 

WILATE INJ

 

Prior authorization

 

The following drugs will now require prior authorization for coverage, effective January 1, 2022.

 

XOLAIR       INJ 150MG/ML

XOLAIR       INJ 75/0.5

XOLAIR       SOL 150MG

 

Prior authorization with quantity limit

The following drugs will now require prior authorization and be subject to a quantity limit for coverage, effective January 1, 2022.

EVEROLIMUS   TAB 10MG

EVEROLIMUS   TAB FOR ORAL SUSP 3MG

 

EVEROLIMUS   TAB FOR ORAL SUSP 5MG

EVEROLIMUS   TAB FOR ORAL SUSP 2MG

 

Step therapy

 

The following drug will now be subject to step therapy prior to authorization for coverage, effective January 1, 2022.

ALOCRIL      SOL 2%

 

Quantity limit

 

The following drug will now be subject to a quantity limit associated with use, effective January 1, 2022.

 

TOLVAPTAN    TAB 30MG