508c 2022 essential formulary changes
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2022
Essential Formulary Changes
This list is subject to change throughout the year. Please call us at the Member Service number
listed on your Member ID card or visit bcbst.com/ docs/providers/2022-essential-plus-formulary.pdf
for the most up-to-date information.
Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. | 2022 Essential Formulary Changes Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. | 2022 Essential Formulary Changes 1
Every year, we review our formularies to determine changes based on a drug’s effectiveness, safety, and affordability. While many changes to our formularies occur at the beginning of the year, formulary changes may occur at any time when:
› New drugs are released after FDA approval
› The FDA removes drugs from the market
› New generic drugs are introduced
Please note that the tier structure for the Essential Formulary is different based on the type of plan you have. The drug content, exclusions, and rules are the same for both types of plans. Check with us to determine your type of coverage at the phone number on the back of your Member ID card.
The Essential Formulary is a five tier plan:
Tier 1 Generic Drugs
Tier 2 Preferred Brand Drugs
Tier 3 Non-Preferred Brand Drugs
Tier 4 Specialty Drugs
Tier 5Drugs with $0 Cost Share per the Affordable Care Act (ACA) $0 Copay Preventive List
The Essential Plus Formulary is a six tier plan:
Tier 1 Generic Drugs with copay based on the BlueCross Preventive List
Tier 2 Preferred Brand Drugs with copay based on the BlueCross Preventive List
Tier 3Non-Preferred Brand Drugs with copay based on the BlueCross Preventive List
Tier 4 Specialty Drugs with deductible/coinsurance
Tier 5Drugs with $0 Cost Share per the Affordable Care Act (ACA) $0 Copay Preventive List
Tier 6 Generic or Brand Non-Specialty Drugs with deductible/coinsurance
2022 Essential Formulary Changes | Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur.2
2022 Essential and Essential Plus Drug List
Multi-Source Brand Drugs Moving to Excluded Status
ALINIA 500 MG TABLET KEPPRA 1,000 MG TABLET
ATRIPLA TABLET KEPPRA 100 MG/ML ORAL SOLN
AZOPT 1% EYE DROPS KEPPRA 250 MG TABLET
BANZEL 40 MG/ML SUSPENSION KEPPRA 500 MG TABLET
CARBATROL ER 100 MG CAPSULE KEPPRA 750 MG TABLET
CARBATROL ER 200 MG CAPSULE KEPPRA XR 500 MG TABLET
CARBATROL ER 300 MG CAPSULE KEPPRA XR 500 MG TABLET
CIPRODEX OTIC SUSPENSION KEPPRA XR 750 MG TABLET
CLODERM CREAM 0.1% KLONOPIN 0.5 MG TABLET
COLESTID GRANULES KLONOPIN 1 MG TABLET
DEPAKENE 250 MG CAPSULE KLONOPIN 2 MG TABLET
DEPAKENE 250 MG/5 ML SOLUTION K-TAB ER 20 MEQ TABLET
DEPAKOTE DR 125 MG SPRINKLE CAPSULE KUVAN 100 MG POWDER PACKET
DEPAKOTE DR 125 MG TABLET KUVAN 100 MG TABLET
DEPAKOTE DR 250 MG TABLET KUVAN 500 MG POWDER PACKET
DEPAKOTE DR 500 MG TABLET LAMICTAL 100 MG TABLET
DIASTAT 2.5 MG PEDI SYSTEM LAMICTAL 150 MG TABLET
DIASTAT ACUDIAL 12.5-15-20 MG LAMICTAL 200 MG TABLET
DIASTAT ACUDIAL 5-7.5-10 MG KIT LAMICTAL 25 MG DISPER TABLET
DILANTIN 100 MG CAPSULE LAMICTAL 25 MG TABLET
DILANTIN 125 MG/5 ML SUSP LAMICTAL 5 MG DISPER TABLET
DILANTIN 50 MG INFATAB LAMICTAL ODT 100 MG TABLET
DYRENIUM 100 MG CAPSULE LAMICTAL ODT 200 MG TABLET
DYRENIUM 50 MG CAPSULE LAMICTAL ODT 25 MG TABLET
EMTRIVA 200 MG CAPSULE LAMICTAL ODT 50 MG TABLET
ERYGEL GEL 2% LAMICTAL ODT START KIT (BLUE)
FELBATOL 400 MG TABLET LAMICTAL ODT START KIT (GREEN)
FELBATOL 600 MG TABLET LAMICTAL ODT START KT (ORANGE)
FELBATOL 400 MG TABLET LAMICTAL TAB START KIT (BLUE)
FELBATOL 600 MG TABLET LAMICTAL TAB START KIT (GREEN)
FELBATOL 600 MG/5 ML SUSP LAMICTAL TB START KIT (ORANGE)
GABITRIL 12 MG TABLET LAMICTAL XR 100 MG TABLET
GABITRIL 2 MG TABLET LAMICTAL XR 200 MG TABLET
GABITRIL 4 MG TABLET LAMICTAL XR 25 MG TABLET
JADENU 180 MG TABLET LAMICTAL XR 250 MG TABLET
Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. | 2022 Essential Formulary Changes 3
LAMICTAL XR 300 MG TABLET ONFI 2.5 MG/ML SUSPENSION TECFIDERA DR 120 MG CAPSULE
LAMICTAL XR 50 MG TABLET ONFI 20 MG TABLET TECFIDERA DR 240 MG CAPSULE
LANOXIN 125 MCG TABLET PHENOBARBITAL-BELLADONNA ELIXR TECFIDERA STARTER PACK
LANOXIN 250 MCG TABLET PHENYTEK 200 MG CAPSULE TEGRETOL 100 MG/5 ML SUSP
LYRICA 100 MG CAPSULE PHENYTEK 300 MG CAPSULE TEGRETOL 200 MG TABLET
LYRICA 150 MG CAPSULE QUDEXY XR 100 MG CAPSULE TEGRETOL XR 100 MG TABLET
LYRICA 20 MG/ML ORAL SOLUTION QUDEXY XR 150 MG CAPSULE TEGRETOL XR 200 MG TABLET
LYRICA 200 MG CAPSULE QUDEXY XR 200 MG CAPSULE TEGRETOL XR 400 MG TABLET
LYRICA 225 MG CAPSULE QUDEXY XR 200 MG CAPSULE TIMOPTIC 0.5% OCUDOSE DROP
LYRICA 25 MG CAPSULE QUDEXY XR 25 MG CAPSULE TOPAMAX 100 MG TABLET
LYRICA 300 MG CAPSULE QUDEXY XR 50 MG CAPSULE TOPAMAX 15 MG SPRINKLE CAP
LYRICA 50 MG CAPSULE RIOMET 500 MG/5 ML SOLUTION TOPAMAX 200 MG TABLET
LYRICA 75 MG CAPSULE SABRIL 500 MG POWDER PACKET TOPAMAX 25 MG SPRINKLE CAP
LYRICA CR 165 MG SABRIL 500 MG TABLET TOPAMAX 25 MG TABLET
LYRICA CR 330 MG SAMSCA 30 MG TABLET TOPAMAX 50 MG TABLET
LYRICA CR 82.5 MG SAPHRIS 10 MG TAB SUBLINGUAL TRILEPTAL 150 MG TABLET
MINIVELLE 0.025 MG PATCH SAPHRIS 2.5 MG TAB SUBLINGUAL TRILEPTAL 300 MG TABLET
MINIVELLE 0.0375 MG PATCH SAPHRIS 5 MG TAB SUBLINGUAL TRILEPTAL 300 MG/5 ML SUSP
MINIVELLE 0.05 MG PATCH SKLICE 0.5% LOTION TRILEPTAL 600 MG TABLET
MINIVELLE 0.075 MG PATCH SYMFI 600-300-300 MG TABLET TRUVADA 100 MG-150 MG TABLET
MINIVELLE 0.1 MG PATCH SYMFI LO 400-300-300 MG TABLET TRUVADA 133 MG-200 MG TABLET
MIRALAX POW 3350 NF SYNTHROID 100 MCG TABLET TRUVADA 167 MG-250 MG TABLET
MONUROL 3 GM SACHET SYNTHROID 112 MCG TABLET TRUVADA 200 MG-300 MG TABLET
MYSOLINE 250 MG TABLET SYNTHROID 125 MCG TABLET TYKERB 250 MG TABLET
MYSOLINE 50 MG TABLET SYNTHROID 137 MCG TABLET VIVELLE-DOT 0.025 MG PATCH
NEURONTIN 100 MG CAPSULE SYNTHROID 150 MCG TABLET VIVELLE-DOT 0.0375 MG PATCH
NEURONTIN 250 MG/5 ML SOLN SYNTHROID 175 MCG TABLET VIVELLE-DOT 0.05 MG PATCH
NEURONTIN 250 MG/5 ML SOLUTION SYNTHROID 200 MCG TABLET VIVELLE-DOT 0.075 MG PATCH
NEURONTIN 300 MG CAPSULE SYNTHROID 25 MCG TABLET VIVELLE-DOT 0.1 MG PATCH
NEURONTIN 400 MG CAPSULE SYNTHROID 300 MCG TABLET VUSION OINTMENT
NEURONTIN 600 MG TABLET SYNTHROID 50 MCG TABLET ZARONTIN 250 MG CAPSULE
NEURONTIN 800 MG TABLET SYNTHROID 75 MCG TABLET ZARONTIN 250 MG/5 ML SOLUTION
NITROSTAT 0.3 MG TABLET SL SYNTHROID 88 MCG TABLET ZONEGRAN 100 MG CAPSULE
NITROSTAT 0.4 MG TABLET SL TACLONEX 0.005%-0.064% SUSPENS ZONEGRAN 25 MG CAPSULE
NITROSTAT 0.6 MG TABLET SL TAMIFLU 30 MG CAPSULE ZYTIGA 500 MG
NORTHERA 100 MG CAPSULE TAMIFLU 45 MG CAPSULE ZOMIG 2.5 MG SPRAY
NORTHERA 200 MG CAPSULE TAMIFLU 6 MG/ML SUSPENSION ZOMIG 5 MG SPRAY
ONFI 10 MG TABLET TAMIFLU 75 MG CAPSULE
NOTE: All of these drugs have generic equivalents that are covered on the Essential Formulary. They might have a different shape or color, but they have the same active ingredients.
2022 Essential Formulary Changes | Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur.4
2022 Essential and Essential Plus Drug List
Formulary Removals
Non-Formulary Drugs
AFREZZA KINERET
DICLOFENAC SODIUM 1% GEL KITABIS
EDARBI MAVYRET
EDARBYCLOR NIVESTYM
IVERMECTIN 0.5% LOTION OLOPATADINE EYE DROPS
INVOKAMET OLUMIANT
INVOKAMET XR SILIQ
INVOKANA XYREM
KEVZARA
Formulary Removals (Oncology)
Non-Formulary Drugs
ALUNBRIG MEKTOVI SYNRIBO
AYVAKIT MELPHALAN TABLOID
BRAFTOVI MATULANE TABRECTA
BRUKINSA MYLERAN TARGRETIN
CAPRELSA NILUTAMIDE TAZVERIK
COMETRIQ ODOMZO TEPMETKO
COTELLIC ONUREG THERACYS
DAURISMO ORGOVYX TURALIO
GILOTRIF PEMAZYRE VALCHLOR
HEXALEN PIQRAY VIZIMPRO
ICLUSIG PURIXAN XALKORI
IDHIFA QINLOCK XPOVIO
INQOVI RETEVMO YONSA
INREBIC ROZLYTREK ZELBORAF
KOSELUGO RYDAPT ZYKADIA
LORBRENA SYLATRON
Formulary Removals
Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. | 2022 Essential Formulary Changes 5
2022 Essential and Essential Plus Drug List
Formulary Additions
Drug Name
ALBENDAZOLE 200 MG TABLET GEMMILY CAPSULE
BETAXOLOL HCL 0.5% EYE DROP NORE/ETH/FER CAPSULE
DOXEPIN HCL 3 MG TABLET PLENVU
DOXEPIN HCL 6 MG TABLET SUTAB
KYLEENA IUD 19.5MG SUMATRIPTAN-NAPROXEN 85-500 MG
LILETTA IUD 52MG TWIRLA PATCH
MIRENA IUD SYSTEM TYBLUME CHEW TAB
NEXPLANON IMP 68MG ZYLET EYE DROPS
PARAGARD IUD T380A ZOLMITRIPTAN 2.5 MG SPRAY
SKYLA IUD 13.5MG ZOLMITRIPTAN 5 MG SPRAY
ANNOVERA VAGINAL RING
Formulary Additions
2022 Essential Formulary Changes | Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur.6
2022 Essential and Essential Plus Drug List
New Prior Authorizations and Quantity Limits
Drug Name
ATOMOXETINE METADATE
CLONIDINE ER METHAMPHETAMINE
DAYTRANA METHYLPHENIDATE
DEXMETHYLPHENIDATE METHYLPHENIDATE ER
DEXMETHYLPHENIDATE ER MYDAYIS
DEXTROAMPHETAMINE PROCENTRA
DEXTROAMPHETAMINE ER QUILLICHEW
DEXTROAMPHETAMINE-AMPHETAMINE QUILLIVANT
DEXTROAMPHETAMINE-AMPHETAMINE ER VYVANSE
GUANFACINE ER ZENZEDI
Drug Name
ABIRATERONE IMBRUVICA SUTENT
AFINITOR INLYTA TAFINLAR
ALECENSA IRESSA TAGRISSO
BALVERSA JAKAFI TALZENNA
BOSULIF LAPATINIB TASIGNA
CABOMETYX LENVIMA THALOMID
CALQUENCE LYNPARZA TIBSOVO
COPIKTRA MEKINIST UKONIQ
ERIVEDGE NEXAVAR VENCLEXTA
ERLEADA NINLARO VERZENIO
ERLOTINIB NUBEQA VITRAKVI
EVEROLIMUS POMALYST VOTRIENT
FARYDAK REVLIMID XOSPATA
GAVRETO RUBRACA XTANDI
IBRANCE SPRYCEL ZEJULA
IMATINIB STIVARGA ZYDELIG
Quantity Limits Added to Oncology Medications
New Prior Authorizations and Quantity Limits on ADHD Medications(Prior Authorizations required for members 19 years and older)
Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. | 2022 Essential Formulary Changes 7
New Quantity Limits on Insulin ProductsDrug Name
ADEMLOG INSULIN LISPRO NOVOLOG
APIDRA LANTUS SOLIQUA
FIASP LEVEMIR TOUJEO
HUMALOG LYUMJEV TRESIBA
HUMULIN NOVOLIN
New Quantity Limits on Medications that Treat Inflammatory Conditions
Drug Name
ACTEMRA KEVZARA RINVOQ TREMFYA
CIMZIA KINERET SIMPONI XELJANZ
COSENTYX OLUMIANT SKYRIZI XELJANZ XR
ENBREL ORENCIA STELARA ZEPOSIA
HUMIRA OTEZLA TALTZ
New Quantity LimitsDrug Name
XIFAXAN
New Prior Authorizations and Quantity Limits on GLP-1 Agonists
Drug Name
BYDUREON OZEMPIC TRULICITY
BYETTA RYBELSUS
New Prior Authorizations and Quantity Limits on Multiple Sclerosis Medications
Drug Name
AUBAGIO EXTAVIA MAYZENT
AVONEX GILENYA PLEGRIDY
BETASERON GLATIRAMER REBIF
COPAXONE GLATOPA VUMERITY
DIMETHYL FUMARATE KESIMPTA ZEPOSIA
2022 Essential Formulary Changes | Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur.8
2022 Essential and Essential Plus Drug List
Tier ChangesDrug Name 2021 Tier Placement 2022 Tier Placement Tier Change
TRINTELLIX Tier 3 Tier 2 +
2022 Essential and Essential Plus Drug List
Step Therapy AddedDrug Name
PENTASA
2022 Essential and Essential Plus Drug List
Prior Authorization RemovedDrug Name
RIBAVIRIN
Please check the 2022 Essential and Essential Plus Guidebooks often, as additional changes may occur. | 2022 Essential Formulary Changes 9
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21PHM1436400 (11/21)
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