Policies & Regulations
Premium Formulary drug program changes

​Effective July 1, 2024, changes will be made affecting the Premium Formulary drug program. 

The Premium Formulary is managed by an independent pharmacy benefits management (PBM) company. It includes all therapeutic categories and provides physicians with prescribing options. The formulary is reviewed biannually to add new drugs and to remove brand-name drugs when a generic equivalent becomes available. 

Premium Formulary – key updates 

  • Dermatological agents – Rhofade® cream will move to an Excluded Status, with preferred agent Mirvaso® gel moving to the Preferred Brand tier. 
  • Ophthalmic Agents, Alphagan® P 0.1% and Prolensa® 0.07% – new generic launches. Generics for these products have been added to the Generic tier, and brand-name products will move to an Excluded Status. 

 

Utilization Management – key updates 

Utilization Management strategies for select drugs in categories such as opioids among others will be enhanced with new or revised Quantity Limits and/or prior authorization edits.  

  • Cardiology: Heart Failure/Hypertension – A new prior authorization will be required for CaroSpir® to better manage this costly product promoting use of lower cost formulary alternatives first. 
  • Dermatology: Beta Blockers – A new prior authorization will be required for Hemangeol® to better manage this costly product by validating diagnosis and appropriate age of use. 
  • Oncology (oral) – A new prior authorization will be required for Xatmep® solution to better manage this costly product by validating trial of generic equivalent in a solid dosage form unless patient is unable to swallow a solid dosage form due to age, physical impairment, dysphagia, or use of feeding tube/NG tube. 
  • Fanapt® pak – new quantity limit of 2 starter packs per 365 days. 

Health Care Reform (HCR) list – key updates 

Members need a prescription from their provider to receive Over-the-Counter (OTC) medications on the HCR Preventive Care Medication List at $0 cost-share. 

  • Age edits for aspirin and bowel prep agents will be added to better align our criteria with the U.S. Preventative Services Task Force recommendations for these products: 
    • Aspirin for preeclampsia: Max age limit of 55 years of age. 
    • Bowel prep ag​ents for colonoscopies: New age edit of 45 – 75 years of age. 
  • OTC oral contraceptive Opill® will be added to the HCR Preventive Medication List upon launch. 

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For more information on the Premium Formulary, visit the Independence Blue Cross and Independence Administrators websites.​ 


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