Capital BlueCross Prescription Drug Changes

The 2017 updates are results of the most recent Capital BlueCross Pharmacy & Therapeutics (P&T) Committee meetings, held in May 2016 and August 2016. These updates include January 1, 2017 changes to the open/closed and selectively closed formularies. Impacted members will be notified prior to changes.

These formulary updates reflect the decisions from quarterly P&T Committee meetings in the following categories (These updates do not apply to Medicare.):

  •  Newly Marketed Drugs
  •  Products Changing Tier Status
  •  Pharmacy Utilization Management Programs:
    • Prior Authorization
    • Enhanced Prior Authorization
    • Quantity Level Limit

Effective January 1, 2017, the selectively closed formulary will consist of three tiers of medications: Generic, Brand Preferred, and Brand Nonpreferred. Currently, the selectively closed formulary operates as a two-tier generic formulary but will be changing to a one-tier generic formulary starting January 1, 2017.

Please note that the open/closed formulary will continue to operate with four tiers of medications: Generic Preferred, Generic Nonpreferred, Brand Preferred, and Brand Non-preferred.

Not all benefits utilizing the open/closed formulary have separate cost shares for generic drugs. For benefits that have one cost share for generic drugs, that cost share is applied to generic preferred and generic nonpreferred drugs. For generic specialty drugs, one cost share is applied to generic preferred and generic nonpreferred specialty drugs when applicable.

Formulary updates are communicated via BenefitFOCUS, Simply-Well, and the Provider Administrative Bulletin. Quarterly Formulary Update-Decision Summaries by Quarter for the open/closed formulary and the selectively closed formulary can also be found on the Capital’s Drug Formulary webpage




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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.