The information below is effective as of 1 de abril, 2021 and applies to all commercial BCBSRI products, including all large group, small group and exchange (individual) markets. 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 abril, 2021. The generic equivalent will continue to be covered.
ALINIA
HYCODAN
SAPHRIS
ATRIPLA
JADENU SPRINKLE
SKLICE
BETHKIS
KERYDIN
SYMFI
CIPRODEX
K-TAB
SYMFI LO
DEMSER
KUVAN
TACLONEX
EMTRIVA
MONUROL
TECFIDERA
FERRIPROX
MOVIPREP
TYKERB
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)
ALKINDI SPRINKLE
MYNATAL PLUS
PRENA1 PEARL
ALOGLIPTIN
MYNATAL-Z
PRENATE
ALOGLIPTIN/METFORMIN HCL
NATACHEW
QTERN
ALOGLIPTIN/PIOGLITAZONE
NEEVO DHA
SEGLUROMET
CITRANATAL (all formulations)
NESINA
SELECT-OB+DHA
DUET DHA 400
NESTABS DHA
STEGLATRO
DUET DHA BALANCED
NESTABS ONE
STEGLUJAN
INVOKAMET
OB COMPLETE (all formulations)
TRADJENTA
INVOKAMET XR
ONGENTYS
TRI-TABS DHA
INVOKANA
ONGLYZA
VINATE DHA RF
JENTADUETO
OSENI
VITAFOL (all formulations)
JENTADUETO XR
PNV OB+DHA
VITAMEDMD (all formulations)
KAZANO
PRENA1 CHEW
VITAPEARL
KOMBIGLYZE XR
The following generic and brand name drugs with preferred alternatives will be excluded from coverage, effective 1 de abril, 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.
Tier changes
The following product has been moved to a higher copay tier, effective 1 de abril, 2021.
CONCERTA
Prior authorization
The following drug will now require prior authorization for coverage, effective 1 de abril, 2021.
SUPPRELIN LA*
Drugs that will be designated for coverage under medical*
The following drugs will be covered under the medical benefit, effective 1 de abril, 2021.
ACTEMRA IV
LUPRON DEPOT (3-MONTH)
RUXIENCE
BOTOX
LUPRON DEPOT (4-MONTH)
SIMPONI ARIA
DYSPORT
LUPRON DEPOT (6-MONTH)
TRELSTAR MIXJECT
ELIGARD
LUPRON DEPOT-PED (1-MONTH)
TYSABRI
EYLEA
LUPRON DEPOT-PED (3-MONTH)
XEOMIN
LUCENTIS
PROLIA
XGEVA
LUPRON DEPOT (1-MONTH)
RITUXAN
ZOLADEX
*Specialty drug
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 abril, 2021. The generic equivalent will continue to be covered.
CIPRODEX
MOVIPREP
SYMFI LO
CONCERTA
SYMFI
TIMOPTIC-XE
EMTRIVA
Drugs (Excluded from coverage)
The following drugs are available with alternatives. As a result, they will be excluded from coverage effective 1 de abril, 2021.
BUTALBITAL/ACETAMINOPHEN/CAFFEINE
PRENATAL 19
CONDYLOX
RANITIDINE HCL
PHRENILIN FORTE
RANITIDINE HYDROCHLORIDE
Tier changes
The following brand name drugs have been moved to a higher copay tier effective 1 de abril, 2021.
NIZATIDINE
ISONIAZID
Prior authorization
The following drug will now require prior authorization for coverage, effective 1 de abril, 2021.
FLUOROURACIL CRE 5%
TARGRETIN GEL 1%