The information below is effective as of 1 de janeiro, 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 1 de janeiro, 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 1 de janeiro, 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 1 de janeiro, 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 1 de janeiro, 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 1 de janeiro, 2022.
WILATE INJ
Prior authorization
The following drugs will now require prior authorization for coverage, effective 1 de janeiro, 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 1 de janeiro, 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 1 de janeiro, 2022.
ALOCRIL SOL 2%
Quantity limit
The following drug will now be subject to a quantity limit associated with use, effective 1 de janeiro, 2022.
TOLVAPTAN TAB 30MG