Commercial Formulary and Utilization Management Program has been updated as a result of the May and August 2017 meetings of the Capital BlueCross Pharmacy & Therapeutics (P&C) Committee.
Opioid use and associated conditions have become a public health priority in the Commonwealth of Pennsylvania, and the United States at large. In response, Capital BlueCross has developed a strategy to reduce opioid use in our network. Capital has included the associated use of benzodiazepines and muscle relaxants in order to offer a comprehensive program that prevents the prescription of dangerous drug combinations, prescribed without medical accepted indications and monitoring.
As part of the prevention strategy, Capital BlueCross modified the Commercial open/closed formulary (not Medicare) to enforce quantity level limits for acute pain diagnoses and procedures. The same limits will apply to the selectively closed formulary beginning January 1, 2018.
- Prior authorization is required*
- Prescriber justification will be reviewed
- Daily dosage limits
Formulary and Utilization Management Program Updates
- Newly marketed drugs
- Drug changing tier status
- Pharmacy utilization management programs
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- Prior authorization
- Quantity level limits
Selectively Closed Formulary
- Addition of Pharmacy Utilization Management Program Updates
- Opioid medications: added prior authorization and quantity level limits
- Non-opioid medications: added prior authorization
- Drug deletions from the formulary
*Prior authorization is also required for non-FDA labeled indications for oral fentanyl, methadone, and medication assisted treatments (MATs), such as Suboxone, Bunavail, Zubsolv, buprenorphine and buprenorphine/naloxone, and immediate-release sublingual or mucosal absorption preparations.