The formulary changes noted below are effective as of 1 de outubro, 2021 and apply to all commercial BCBSRI products, including all large group, small group, and exchange (individual) plans. These changes do not apply to BlueCHiP for Medicare plans. Any changes to this list are the result of a comprehensive review of relevant clinical information by the BCBSRI Pharmacy and Therapeutics Committee.
Large group and small group markets formulary
Brand name drugs available with generic equivalents (Excluded from coverage)
For application across all commercial formularies, the following brand name drugs are now available with generic equivalents. As a result, the brand name will be excluded from coverage, effective 1 de outubro, 2021. The generic equivalent will continue to be covered.
AZOPT
BEPREVE
BROVANA NEB
INTELENCE
KALETRA
LOTEMAX
MIACALCIN
NAFTIFINE CREAM 2%
NORTHERA
PERFOROMIST NEB
THIOLA
TRUVADA
VELETRI
For the Traditional Formulary, these brand products will continue to be covered with non-preferred or specialty copay.
Brand name and generic drugs with available alternatives (Excluded from coverage)
The following generic and brand name drugs with preferred alternatives will be excluded from coverage, effective 1 de outubro, 2021. Request for coverage will require documented medical necessity.
For the Traditional Formulary, these brand products will continue to be covered with non-preferred or specialty copay.
ADDYI TAB
ALLZITAL
ALVESCO
BASAGLAR KWIKPEN
BINOSTO
CLENPIQ
CLINDAMYCIN PHOSPHATE FOAM
CLINDAMYCIN PHOSPHATE/TRETINOIN GEL
DOXEPIN HCL 3MG/6MG
DULOXETINE HCL 40MG
EMVERM
EPINEPHRINE INJ (AVKARE/AMNEAL)
ESTRADIOL VAG TAB
FEMRING VAG RING
FLUNISOLIDE
FORFIVO XL
FOSAMAX PLUS D
FULPHILA
KEVEYIS
LEVALBUTEROL TARTRATE HFA
MITIGARE CAP
MOMETASONE FUROATE
NIVESTYM
NYVEPRIA
OSMOPREP
PANCREAZE
PERTZYE
PREPOPIK
QUAZEPAM
QUILLICHEW ER
QUILLIVANT XR
RESTASIS OPTH
RESTASIS MULTIDOSE
SEEBRI NEOHALER
SUBSYS
TEMAZEPAM
TENCON TAB
TRETINOIN GEL
TRETINOIN MICROSPHERE GEL
TRETINOIN MICROSPHERE PUMP
TUDORZA PRESSAIR
TWIRLA
VISTOGARD
VTOL LQ
XOPENEX HFA
XURIDEN
YUVAFEM
ZIEXTENZO
For the Traditional Formulary, these brand products will continue to be covered with non-preferred or specialty copay.
Prior authorization
The following drugs will now require prior authorization for coverage, effective 1 de outubro, 2021.
AUBAGIO *#
GILENYA *#
KESIMPTA *#
RINVOQ *
SUPPRELIN LA *
ZEPOSIA *#
*Specialty drug
#Step Therapy for new starts only
Drugs that will be designated for coverage under the medical benefit*
The following drug will be covered under the medical benefit, effective 1 de outubro, 2021.
MYOBLOC*
*Specialty drug
Tier changes
The following products have been moved to a higher copay tier, effective 1 de outubro, 2021.
ABACAV/LAMIV TAB /ZIDOVUD
ADDERALL XR CAP 5MG
ADDERALL XR CAP 10MG
ADDERALL XR CAP 15MG
ADDERALL XR CAP 20MG
ADDERALL XR CAP 25MG
ADDERALL XR CAP 30MG
ALBUTEROL NEB 0.083% *
ALENDRONATE SOL 70/75ML
ALPRAZOLAM TAB 0.5MG ER *
ALPRAZOLAM TAB 0.5MG XR *
ALPRAZOLAM TAB 3MG ER *
ALPRAZOLAM TAB 3MG XR *
AMIODARONE TAB 200MG *
AMITRIPTYLIN TAB 10MG *
AMITRIPTYLIN TAB 25MG *
AMITRIPTYLIN TAB 50MG *
AMOX/K CLAV TAB 500-125 *
AMOX/K CLAV TAB 875-125 *
ANAGRELIDE CAP 0.5MG
APREPITANT CAP 40MG
ATOVAQ/PROGU TAB 62.5-25
AVITA CRE 0.025%
AVITA GEL 0.025%
BACLOFEN TAB 10MG *
BENZONATATE CAP 100MG *
BENZONATATE CAP 200MG *
BRIMONIDINE SOL 0.2% OP *
BUPREN/NALOX SUB 2-0.5MG
BUPRENORPHIN DIS 7.5/HR
BUPROPION TAB 150MG SR *
BUSPIRONE TAB 10MG *
BUSPIRONE TAB 15MG *
BUSPIRONE TAB 5MG *
BUT/APAP/CAF CAP
BUT/APAP/CAF CAP CODEINE
BUTAL/APAP TAB 50-325MG
CARBAMAZEPIN CAP 100MG ER
CARBAMAZEPIN CAP 200MG ER
CARBAMAZEPIN CAP 300MG ER
CARBAMAZEPIN TAB 100MG ER
CARBAMAZEPIN TAB 200MG ER
CARBAMAZEPIN TAB 400MG ER
CEPHALEXIN CAP 250MG *
CEPHALEXIN CAP 500MG *
CHLORPROMAZ TAB 10MG
CHLORZOXAZON TAB 500MG
CHLORZOXAZON TAB 750MG
CIMETIDINE TAB 200MG *
CIMETIDINE TAB 300MG *
CIPROFLOXACN SOL 0.3% OP *
CLINDAMYCIN CAP 150MG *
CLINDAMYCIN CAP 300MG *
CLINDAMYCIN SOL 75MG/5ML
CLORAZ DIPOT TAB 15MG
CLORAZ DIPOT TAB 3.75MG
CLORAZ DIPOT TAB 7.5MG
CLOTRIM/BETA LOT DIPROP
CLOZAPINE TAB 100MG
CLOZAPINE TAB 25MG
CLOZAPINE TAB 50MG
COMPRO SUP 25MG *
CROMOLYN SOD SOL 4% OP *
CYCLOBENZAPR TAB 10MG *
CYCLOBENZAPR TAB 5MG *
CYCLOPENTOL SOL 1% OP *
CYCLOPHOSPH CAP 25MG
CYCLOPHOSPH CAP 50MG
CYCLOSPORINE CAP 25MG MOD
CYCLOSPORINE CAP 50MG MOD
DESMOPRESSIN SPR 0.01%
DESOXIMETAS CRE 0.25%
DEXTROAMPHET CAP 5MG ER
DEXTROAMPHET SOL 5MG/5ML
DICLOFENAC SOL 1.5%
DICLOFENAC TAB 50MG DR *
DICLOFENAC TAB 75MG DR *
DILTIAZEM TAB 30MG *
DILTIAZEM TAB 60MG *
DILTIAZEM TAB 90MG *
DIPHENHYDRAM INJ 50MG/ML *
DISOPYRAMIDE CAP 100MG
DONEPEZIL TAB ODT 10MG *
DONEPEZIL TAB 10MG *
DONEPEZIL TAB 10MG ODT *
DONEPEZIL TAB 5MG *
DONEPEZIL TAB 5MG ODT *
DONEPEZIL TAB ODT 5MG *
DOXEPIN HCL CON 10MG/ML *
DOXYCYC MONO CAP 100MG
DOXYCYC MONO CAP 50MG
DOXYCYCL HYC TAB 100MG *
EC-NAPROXEN TAB 375MG *
EMTRICITABIN CAP 200MG
ENDOCET TAB 5-325MG *
ESTRAD VAL INJ 200MG/5
ESTRAD VAL INJ 40MG/ML
ETHOSUXIMIDE CAP 250MG
ETODOLAC ER TAB 400MG
ETODOLAC ER TAB 500MG
ETODOLAC ER TAB 600MG *
FELBAMATE TAB 600MG
FENOFIBRATE TAB 145MG
FENOFIBRATE TAB 160MG
FENOFIBRATE TAB 48MG
FENOFIBRATE TAB 54MG
FENTANYL DIS 12MCG/HR
FENTANYL DIS 25MCG/HR
FENTANYL DIS 50MCG/HR
FENTANYL DIS 62.5MCG *
FENTANYL DIS 75MCG/HR
FENTANYL DIS 87.5MCG *
FLUCONAZOLE TAB 150MG *
FLUPHENAZINE TAB 10MG *
FLUPHENAZINE TAB 1MG
FLUPHENAZINE TAB 2.5MG
FONDAPARINUX INJ 2.5/0.5
GABAPENTIN TAB 600MG*
GENGRAF CAP 25MG
HALOPERIDOL TAB 0.5MG *
HALOPERIDOL TAB 1MG *
HC BUTYRATE CRE 0.1%
HC/ACET ACID SOL OTIC *
HEPARIN SOD INJ 1000/ML *
HEPARIN SOD INJ 10000/M
HEPARIN SOD INJ 5000/0.5
HEPARIN SOD INJ 5000/ML
HYDROCO/APAP TAB 5-325MG *
HYDROCOD/IBU TAB 5-200MG
HYDROCOD/IBU TAB 7.5-200
HYDROMORPHON TAB 12MG ER
HYDROMORPHON TAB 2MG *
HYDROMORPHON TAB 4MG *
IMIQUIMOD CRE 3.75%
IMIQUIMOD CRE 3.75%PMP
IMIQUIMOD CRE 5%
LAMIVUDINE TAB 100M
LAMOTRIG ODT TAB 100MG
LAMOTRIGINE KIT START 49
LAMOTRIGINE TAB 100MG
LAMOTRIGINE TAB 100MG ER
LAMOTRIGINE TAB 200MG
LAMOTRIGINE TAB 200MG ER
LAMOTRIGINE TAB 250MG ER
LAMOTRIGINE TAB 25MG ER
LAMOTRIGINE TAB 25MG ODT *
LAMOTRIGINE TAB 300MG ER
LAMOTRIGINE TAB 50MG ER
LAMOTRIGINE TAB 50MG
LANSOPRAZOLE CAP 30MG DR *
LEUCOVOR CA TAB 10MG
LEUCOVOR CA TAB 15MG
LEUCOVOR CA TAB 25MG
LEUCOVOR CA TAB 5MG
LEVETIRACETA TAB 250MG *
LEVETIRACETA TAB 500MG *
LEVORPHANOL TAB 2MG
LIDOCAINE PAD 5%
LORCET TAB 5-325MG *
LORZONE TAB 750MG
LORZONE TAB 375MG *
MEPROBAMATE TAB 200MG
METAXALL TAB 800MG
METAXALONE TAB 400MG
METAXALONE TAB 800MG
METFORMIN TAB 500MG E
METFORMIN TAB 750MG ER
METHOTREXATE TAB 2.5MG
METHYLPRED TAB 32MG *
METRONIDAZOL GEL 0.75%
MIRTAZAPINE TAB 15MG *
MIRTAZAPINE TAB 30MG *
MIRTAZAPINE TAB 45MG *
MONDOXYNE NL CAP 100MG
MORPHINE SUL TAB 15MG ER *
MUPIROCIN CRE 2%
NAPROXEN DR TAB 375MG *
NIFEDIPINE TAB 30MG ER *
NIZATIDINE CAP 150MG *
NIZATIDINE CAP 300MG *
OLM MED/AMLO TAB /HCTZ
OLM MED/HCTZ TAB 20-12.5 *
OLM MED/HCTZ TAB 40-12.5 *
OLM MED/HCTZ TAB 40-25MG *
OXANDROLONE TAB 2.5MG
OXCARBAZEPIN SUS 300MG/5M
OXCARBAZEPIN TAB 150MG *
OXYCOD/APAP TAB 5-325MG *
OXYCODONE TAB 5MG *
PACERONE TAB 200MG *
PHENOBARB TAB 100MG *
PHENOBARB TAB 30MG *
PHRENILIN CAP FORTE
PILOCARPINE SOL 1% OP
PREDNISOLONE SOL 15MG/5ML *
PREDNISOLONE TAB 10MG
PREDNISOLONE TAB 15MG
PREGABALIN SOL 20MG/ML
PROCENTRA SOL 5MG/5ML
PROCHLORPER SUP 25MG *
PROCHLORPER TAB 10MG *
PROCHLORPER TAB 5MG *
PROMETHAZINE SOL 6.25/5ML *
PROMETHAZINE SUP 50MG *
PROMETHAZINE SYP 6.25/5ML *
PROMETHAZINE TAB 12.5MG *
PROMETHAZINE TAB 25MG *
PROMETHAZINE TAB 50MG *
PROPRANOLOL TAB 10MG *
RISPERIDONE TAB 0.5MG OD
RISPERIDONE TAB 1MG ODT
RISPERIDONE TAB 2MG ODT
RISPERIDONE TAB 3MG ODT
ROSADAN GEL 0.75%
ROWEEPRA TAB 500MG
SIROLIMUS SOL 1MG/ML
SUBVENITE KIT START 49
TACROLIMUS CAP 0.5MG
TACROLIMUS CAP 1MG
TEMAZEPAM CAP 30MG *
TIAGABINE TAB 12MG
TIAGABINE TAB 16MG *
TIAGABINE TAB 2MG *
TIMOLOL GEL SOL 0.25% OP
TIMOLOL GEL SOL 0.5% OP
TIMOLOL MAL SOL 0.25% OP *
TIMOLOL MAL SOL 0.5% OP *
TRAZODONE TAB 100MG *
TRAZODONE TAB 150MG *
TRAZODONE TAB 50MG *
TRETINOIN CRE 0.025%
TRETINOIN GEL 0.025%
TRIAMCINOLON OIN 0.025%
TRIAMCINOLON OIN 0.1%
TRIAMCINOLON OIN 0.5%
TRIAMTERENE CAP 100MG
TRIAMTERENE CAP 50MG *
VALSART/HCTZ TAB 160-12.5 *
VALSART/HCTZ TAB 160-25MG *
VALSART/HCTZ TAB 80-12.5 *
VERAPAMIL TAB 120MG ER *
VERAPAMIL TAB 180MG ER *
VERAPAMIL TAB 240MG ER *
XULANE DIS 150-35
ZONISAMIDE CAP 50MG *
* 5-tier generic formulary only
Individual market (direct pay/direct pay exchange) formulary
Brand name drugs (Excluded from coverage)
The following brand name drugs are now available with generic equivalents. As a result, the brand name will be excluded from coverage effective 1 de outubro, 2021. The generic equivalent will continue to be covered.
GLUCAGON KIT 1MG
LOTEMAX GEL 0.5%
NAFTIFINE CRE HCL 2%
SAPHRIS SUB
TRUVADA TAB
VELTIN GEL
ZYTIGA TAB
Drugs (Excluded from coverage)
The following drugs are available with alternatives. As a result, they will be excluded from coverage effective 1 de outubro, 2021.
APAP-CAFFEIN CAP DIHYDROCODEINE
EX-NAPROXEN TAB
FEMRING
FENOFIBRATE CAP
FENOFIBRIC CAP
LIDOCAINE SOL 4%
NAPROXEN DR TAB
TRAZODONE TAB
TREZIX CAP
Tier changes
The following brand name drugs have been moved to a higher copay tier effective 1 de outubro, 2021.
CEFACLOR CAP SODIUM POLYSTYRENE SULFONATE ORAL SUSP
CEFADROXIL TAB VCF VAGINA GEL
CYCLOSERINE CAP
Prior authorization
The following drugs will now require prior authorization for coverage, effective 1 de outubro, 2021.
CODEINE
FIORINAL w/ CODEINE
NOVOSEVEN RT
QDOLO
SEVENFACT
TRAMADOL
TREZIX
TYLENOL w/ CODEINE