508C 2022 Essential Formulary Changes

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.

http://bcbst.com/docs/providers/2022-essential-plus-formulary.pdf

http://bcbst.com/docs/providers/2022-essential-plus-formulary.pdf

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



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.



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



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



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)


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



Tier ChangesDrug Name 2021 Tier Placement 2022 Tier Placement Tier Change

TRINTELLIX Tier 3 Tier 2 +


Step Therapy AddedDrug Name

PENTASA


Prior Authorization RemovedDrug Name

RIBAVIRIN


BlueCross BlueShield of Tennessee (BlueCross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BlueCross does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.BlueCross:• Provides free aids and services to people with disabilities to communicate effectively with us,

such as: (1) qualified interpreters and (2) written information in other formats, such as large print, audio and accessible electronic formats.

• Provides free language services to people whose primary language is not English, such as: (1) qualified interpreters and (2) written information in other languages.

If you need these services, contact a consumer advisor at the number on the back of your Member ID card or call 1-800-565-9140 (TTY: 1-800-848-0298 or 711).If you believe that BlueCross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance (“Nondiscrimination Grievance”). For help with preparing and submitting your Nondiscrimination Grievance, contact a consumer advisor at the number on the back of your Member ID card or call 1-800-565-9140 (TTY: 1-800-848-0298 or 711). They can provide you with the appropriate form to use in submitting a Nondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or email. Address your Nondiscrimination Grievance to: Nondiscrimination Compliance Coordinator; c/o Manager, Operations, Member Benefits Administration; 1 Cameron Hill Circle, Suite 0019, Chattanooga, TN 37402-0019; (423) 591-9208 (fax); [email protected] (email).You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1–800–368–1019, 800–537–7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.

mailto:[email protected]

http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

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21PHM1436400 (11/21)

BlueCross BlueShield of Tennessee 1 Cameron Hill Circle | Chattanooga, TN 37402 | bcbst.com

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508C 2022 Essential Formulary Changes

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