Capital: 2018 Formulary and Utilization Updates

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

Open/Closed Formularies

  • Newly marketed drugs
  • Drug changing tier status
  • Pharmacy utilization management programs
    • 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.


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The information provided is for informational purposes only and does not constitute legal advice. The information above contains only a summary of the applicable legal provisions and does not purport to cover every aspect of any particular law, regulation or requirement. Depending on the specific facts of any situation, there may be additional or different requirements. This is to be used only as a guide and not as a definitive description of your compliance obligations.