Prescription Drug Changes
BlueChoice HealthPlan of South Carolina offers pharmacy benefit programs that provide the highest level of clinical effectiveness and safety for the lowest net spend. A group of network doctors and pharmacists who serve on our Pharmacy and Therapeutics Committee chooses the drugs that are preferred on our Prescription Drug List (PDL). This group also chooses drugs for our Specialty Drug List and approves decisions about our drug management programs, including which drugs will be subject to prior authorization, quantity management and step therapy. They base their decisions on a drug’s effectiveness, safety and value.
Based on their feedback, we will make changes to the PDL and drug management programs effective January 1, 2014. These changes apply to all fully insured groups and self-funded groups that have our pharmacy benefits.
Preferred Drug List Changes
Moving from Preferred to Non-Preferred (due to generic launches)
These drugs are moving to non-preferred status due to the release of a generic equivalent. We typically move preferred drugs to non-preferred when a generic becomes available. However, we do not routinely send target member letters when this occurs. Most members are pleased that their drug is now available at a lower cost, as evidenced by our 81 percent generic dispensing rate!
|Brand Name moving to tier 3||Generic Equivalent||Used to treat|
|Retin A Micro||tretinoin||Acne|
Communications Plan: No member letters will be sent. These changes affect a small proportion of members.
Moving from Preferred to Non-Prefered
|Non-Preferred||Generic or Preferred Alternatives||Used to treat|
Communications Plan: Impacted members will be sent a letter on or around November 1, 2013.
Moving from Non-Preferred to Preferred
|Non-Preferred Moving to Preferred||Used to treat|
Communications Plan: No target member letters will be sent.
Prior Authorization Changes
Beginning January 1, 2014, the following drugs – bolded and underlined – will be added to the prior authorization program. Some of them are already in categories where prior authorization already exists. Prior authorizations for these drugs require, in addition to other documentation, that members have tried at least one alternative drug before the PA drug will be approved.
|Drugs requiring PA||Condition||Alternatives|
|Avalide, Atacand, Atacand HCT, Avapro, Cozaar, Diovan HCT, Edarbi, Edarbyclor, Hyzaar, Tekturna, Tekturna HCT, Teveten, Teveten HCT||High Blood Pressure||Candesartan, candesartan/hydrochlorothiazide, eprosartan, irbesartan, irbesartan/hydrochlorothiazide, losartan, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, Benicar, Benicar HCT, Diovan|
|Crestor*, Vytorin*||High Cholesterol (High Potency)||atorvastatin|
|Altoprev, Lescol, Lescol XL, Lipitor, Livalo, Mevacor, Pravachol, Zocor||High Cholesterol||atorvastatin, fluvastatin, lovastatin, pravastatin, simvistatin|
|Insulins: All Apidra, Humalog and Humulin (except Humulin U-500)||Diabetes (insulin)||Novolog, Novolin|
|Kazano, Nesina, Oseni, Tradjenta, Jentadueto||Diabetes (DPP-4)||Januvia, Janumet, Janumet XR, Kombiglyze, Onglyza|
|Breo Ellipta||Asthma, COPD||Advair, Symbicort|
*Members taking Crestor 40mg or Vytorin 10/80mg will be grandfathered and not subject to the PA. However, they will have a tier change.
Member Impact and Communications Plan:
Diovan HCT (brand only): We will send a letter to impacted members on or around November 1.
Crestor, Vytorin: We will send a letter to impacted members on or around November 1. This letter addresses both the PA and the tier change for this group of members.
Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Zocor (brand only): We will send a letter to impacted members on or around November 1.
Rayos: We will send a letter to impacted members on or around November 1.
Apidra: We will send these members a letter on or around November 1 and then again on December 15.
DPP-4s: Current members (fewer than 30) will be grandfathered; therefore no letters will be sent.
Breo Ellipta: The product is not on the market yet, so no member impact yet/no letters sent.
Step Therapy Changes
Beginning January 1, 2014, Fabior is being added to the current step therapy criteria for acne.
|You must first try one of these drugs or your doctor must request an exception for you …||Used to treat||… before you can get coverage for these drugs|
|First Choice Drugs||Second Choice Drugs|
|generic topical tretinoin||Acne||Atralin, Avita, Differin, Fabior, Retin-A, Retin-A Micro, Tazorac, Tretin-X, Veltin or Ziana|
Communications Plan: There are two current users. We will send a letter to impacted members on or around November 1.
Additions to the Specialty Drug List
Beginning January 1, 2014, the drugs listed will be added to the Specialty Drug List. Members who have a specialty drug benefit (most BlueChoice members) will pay a specialty copayment for these drugs, starting in January. They will also be required to use Accredo*, our preferred specialty pharmacy, to fill these drugs. Accredo is an independent company that provides specialty pharmacy services on behalf of BlueChoice®.
*On November 11, 2013, our current preferred specialty pharmacy will merge with another specialty pharmacy, Accredo. The new company will be called Accredo after November 11.
|Drug Name||Used to treat||PA Added?|
|Gilotrif||Non-small cell lung cancer||No|
|Simponi Aria||Rheumatoid arthritis||Yes|
|Valchlor||Cutaneous T-cell lymphoma||No|
Communications Plan: No members are impacted at this time. Therefore no letters will be sent.
Additions/Deletions to Specialty Drug List Prior Authorizations
Prior authorizations are being added to several specialty drugs, per this table:
|Drug Name||Used to Treat||Implementation for Current Member||Implementation for New Members|
|Tecfidera||Pulmonary Hypertension||Grandfather for life||January 1, 2014|
|Incivek, Victrelis||Hepatitis B||Grandfather until December 31, 2014||January 1, 2014|
Communications Plan: No letter will be sent because there is no member impact at this time
Prior authorizations are being deleted for these specialty drugs, effective January 1, 2014:
|Drug Name||Used to Treat|
|Iron Replacement (i.e. Feraheme, Venofer)||Iron-deficiency Anemia|
Communications Plan: This is a positive change. Therefore no letters will be sent.