Changes to the 2018 BlueCross Secure SM (HMO) & BlueCross Total SM (PPO) Formularies BlueCross BlueShield of South Carolina may add or remove drugs from the formulary during the year. If we remove drugs from our formulary; or add prior authorization, quantity limits and/or step therapy restrictions on a drug; and/or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, however, we will immediately remove the drug from our formulary. This table outlines upcoming changes to our formulary. Name of Affected Drug ACETIC ACID 2% IN ALUMINUM ACETATE OTIC SOLN ACYCLOVIR SODIUM INJ 500MG AMINOSYN II INJ 7% BROMFENAC OPHTH SOLN 0.09% BUPHENYL TAB 500MG CIPROFLOXACIN INJ 400MG CIPROFLOXACN INJ 200MG Description of Change Reason for Change Alternative Drug * ACETIC ACID OTIC SOLN 2% Alternative Drug Effective Tier Date ACYCLOVIR SODIUM INJ Tier 2 7/1/2018 50MG/ML AMINOSYN-HBC INJ 7% Tier 4 3/1/2018 BROMFENAC SODIUM OPHTH SOLN 0.09% (ONCE-DAILY) SODIUM PHENYLBUTYRATE TAB 500 MG CIPROFLOXACN INJ 400MG IN D5W CIPROFLOXACN INJ 200MG IN D5W Tier 5 6/1/2018 Tier 2 8/1/2018 Tier 2 8/1/2018 * Alternative drugs are drugs in the same therapeutic category/class or cost-sharing tier as the affected drug. Only your physician can determine if the alternate here is appropriate for you given the individualized nature of the drug therapy. Please consult your physician as to whether this is an appropriate drug for you. BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Y0012_Web2018, Formulary Change Notice Update: 09/2018 Revision 01-03/2017 1
CLINDAMAX GEL 1% COPAXONE INJ 40MG/ML COREG CR CAP DESMOPRESSIN SOLN 0.01% DIDANOSINE CAP 125 MG DOCEFREZ INJ 20MG ESTRACE VAGINAL CREAM 0.01% GAVILYTE-H KIT GENGRAF CAP 50MG GENTAMICIN INJ 10MG/ML GLEOSTINE CAP 5MG ISTALOL OPHTH SOLN 0.5% LORTAB TAB 10-325MG LORTAB TAB 5-325MG LORTAB TAB 7.5-325 MENOMUNE INJ A/C/Y/W METHOTREXATE INJ 100/4ML CLINDAMYCIN PHOSPHATE GEL 1% GLATIRAMER INJ Tier 5 6/1/2018 40MG/ML CARVEDILOL PHOSPHATE ER 24HR CAP DESMOPRESSIN SPR Tier 2 9/1/2018 0.01% VIDEX EC CAP 125MG Tier 4 5/1/2018 DOCETAXEL INJ 80MG/4ML Tier 5 3/1/2018 ESTRADIOL VAGINAL CREAM 0.01% GAVILYTE-G SOL CYCLOSPORINE MODIFIED CAP 50 MG GENTAMICIN INJ 40MG/ML Tier 2 5/1/2018 GLEOSTINE CAP 10MG Tier 4 9/1/2018 TIMOLOL MALEATE OPHTH SOLN 0.5% (ONCE- DAILY) ACETAMINOPHEN TAB 10-325 MG ACETAMINOPHEN TAB 5-325 MG ACETAMINOPHEN TAB 7.5-325 MG MENACTRA INJ Tier 3 3/1/2018 METHOTREXATE INJ 50MG/2ML Tier 2 7/1/2018 2
METHOTREXATE INJ 200/8ML MORPHINE SULATE INJ 15MG/ML NECON TAB 10/11-28 NEVIRAPINE SUSP 50MG/5ML NYATA OXYCODONE W/ ACETAMINOPHEN SOLN 5-325 MG/5ML RELPAX TAB RENVELA PAK RENVELA TAB 800MG REYATAZ CAP SABRIL PACK 500MG SUSTIVA CAP 200MG SUSTIVA CAP 50MG TAMIFLU SUSP 6MG/ML TRANSDERM-SC PATCH 1.5MG TRIKLO CAP 1GM TRISENOX SOL 10MG/10ML VIGAMOX DROPS 0.5% METHOTREXATE INJ 50MG/2ML Tier 2 7/1/2018 MORPHINE SULFATE IV Tier 4 3/1/2018 SOLN PF 10 MG/ML NECON TAB 7/7/7 VIRAMUNE SUSP Tier 4 6/1/2018 50MG/5ML NYSTATIN POW 100000 Tier 2 4/1/2018 OXYCODONE HCL SOLN 5 MG/5ML ELETRIPTAN TAB SEVELAMER CARBONATE PACKET SEVELAMER CARBONATE TAB 800 MG ATAZANAVIR CAP Tier 5 6/1/2018 VIGABATRIN POWDER Tier 5 6/1/2018 PACK 500MG EFAVIRENZ CAP 200 MG Tier 5 6/1/2018 EFAVIRENZ CAP 50 MG OSELTAMIVIR PHOSPHATE SUSP 6 MG/ML SCOPOLAMINE PATCH Tier 4 6/1/2018 OMEGA-3-ACID ETHYL ESTERS CAP 1 GM TRISENOX INJ 12MG/6ML Tier 5 5/1/2018 MOXIFLOXACIN HCL OPHTH SOLN 0.5% 3
ZAZOLE CREAM 0.8% ZIAGEN SOLN 20MG/ML ZOLEDRONIC INJ 4MG TERCONAZOLE VAGINAL CREAM 0.8% ABACAVIR SOLN 20MG/ML ZOLEDRONIC INJ 4MG/5ML What to Do if You Disagree with a Coverage Decision If we deny your request for a drug that you haven t received, or deny your request to pay you back for a drug that you have received, we will send you a letter explaining our decision. If you disagree with our decision, you can request an appeal within 60 calendar days from the date of our first decision. You can request a standard or fast (expedited) appeal. We will automatically give you a fast appeal if your physician tells us that waiting for a standard decision may seriously jeopardize your life or health. You can request an appeal by calling 855-204-2744 (TTY users should call 711). Your doctor needs to give us a statement explaining that the drug you need is medically necessary to treat your condition if you or your doctor believe that: You need a drug that isn t on our list of covered drugs (formulary) The Plan should waive a coverage rule or limit on a drug that you need You can t take any of the drugs on our preferred tier for your condition, and you would like us to cover a non-preferred drug at the preferred cost-sharing amount Your doctor can mail the statement to: Or fax it to 855-633-7673. CVS/Caremark Part D Appeals Department P.O. Box 152000, MC109 Phoenix, AZ, 85072-2000 CVS/Caremark is an independent company that administers pharmacy benefits on behalf of BlueCross. The Formulary may change at any time. You will receive notice when necessary. 4
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