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Formulary Updates: November 2020 P&T Committee Meeting

Horizon BCBSNJ’s Pharmacy and Therapeutics (P&T) Committee meets quarterly to review new drugs, drug classes, clinical indications, therapeutic advantages, chemical entities and safety information to help ensure that our formularies encourage the use of safe, effective and affordable drugs by our members.

The tables below outline changes determined for our Commercial and Medicare Formularies at the P&T Committee meeting held in November 2020.


COMMERCIAL FORMULARY

Brand Name Generic Name Prior Authorization (Y/N)
Trijardy XR® empagliflozin, linagliptin and metformin Y
Oriahnn™ elagolix, estradiol and norethindrone acetate Y
Qinlock™ ripretinib Y
Tukysa® tucatinib Y
Retevmo™ selpercatinib Y
Tabrecta™ capmatinib Y
Zeposia® ozanimod Y

Added to Preferred Status following re-evaluation

Brand Name Generic Name Prior Authorization (Y/N)
Retacrit® epoetin alfa-epbx injection Y

Added to Non-Preferred Status following re-evaluation

Brand Name Generic Name Prior Authorization (Y/N)
Procrit® epoetin alfa injection Y

Remaining in Non-Preferred Status following review

Brand Name Generic Name Prior Authorization (Y/N)
Consensi™ amlodipine and celecoxib Y
Arazlo™ tazarotene Y
Reditrex™ methotrexate injection Y
Bynfezia Pen™ octreotide acetate injection Y
Dayvigo® lemborexant Y
Tabrecta™ capmatinib Y
Xcopr® ozanimod N
Isturisa® osilodrostat Y

MEDICARE FORMULARY

Added to the Medicare Formulary

Brand Name Generic Name Prior Authorization (Y/N)
Fintepla® fenfluramine Y
Tivicay® dolutegravir N
Darzalex Faspro™ daratumumab-hyaluronidase-fihj Y
Phesgo™ pertuzumab-trastuzumab-hyaluronidase-zzxf Y
Rukobia™ fostemsavir tromethamine N
Tabrecta™ capmatinib Y
Zepzelca™ lurbinectedin Y
Pemazyre® pemigatinib Y
Retevmo™ selpercatinib Y
Trodelvy™ sacituzumab govitecan-hziy Y
Qinlock™ ripretinib Y

Not covered in the Medicare Formulary

Brand Name Generic Name Prior Authorization (Y/N)
Ortikos™ budesonide n/a
Dayvigo® lemborexant n/a
Zeposia® ozanimod n/a
Evrysdi™ risdiplam n/a
Licart™ diclofenac epolamine patch n/a
Ferriprox® Twice-A-Day deferiprone n/a
Dojolvi™ triheptanoin n/a
Avsola™ infliximab-axxq n/a
Twirla® levonorgestrel-ethinyl estradiol patch n/a
Lyumjev™ insulin lispro-aabc n/a
Oriahnn™ elagolix-estradiol-norethindrone n/a
Fensolvi® euprolide n/a
Mycapssa® octreotide n/a
Bynfezia Pen™ octreotide n/a
Nexlizet™ bempedoic acid-ezetimibe n/a
Breztri Aerosphere™ budesonide-glycopyrrolate-formoterol n/a
Phexxi™ lactic acid-citric acid-potassium bitartrate gel n/a
Kynmobi™ apomorphine n/a
Zilxi™ minocycline micronized n/a
Helidac™ metronidazole-tetracycline w/bismuth subsalicylate n/a

FORMULARY INFORMATION AVAILABLE ONLINE

This document contains prescription brand name drugs that are registered marks or trademarks of pharmaceutical manufacturers that are not affiliated with either Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association.

Published on: March 3, 2021, 10:47 a.m. ET
Last updated on: July 8, 2021, 06:40 a.m. ET