Formulary changes
The chart below indicates current and future changes to the formulary used by Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. These changes may include the removal of a drug from the formulary or a change in copayment or coinsurance level. Changes will be posted 60 days before a change takes place and will remain displayed until the revised formulary is published on an annual basis.
| Drug Name | Change Type | Reason for Change | Alternative Options | Estimated Cost of Alternative |
|---|---|---|---|---|
| Depakote ER 250, 500 mg extended-release tablets | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Divalproex sodium 250, 500 mg extended-release tablets | Generic divalproex sodium is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Imitrex 25, 50, 100 mg tablets | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Sumatriptan succinate 25, 50, 100 mg tablets | Generic sumatriptan succinate tablets are covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Keppra oral solution 100 mg/ml | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Levetiracetam oral solution 100 mg/ml | Generic levetiracetam is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Keppra 1000 mg tablets | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Levetiracetam 1000 mg tablets | Generic levetiracetam is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Topamax 25, 50, 100, 200 mg tablets | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Topiramate 25, 50, 100, 200 mg tablets | Generic topiramate is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Topamax Sprinkle 15, 25 mg capsules | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Topiramate 15, 25 mg capsules | Generic topiramate is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Depakote 125, 250, 500 mg tablets | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Divalproex sodium 125, 250, 500 mg tablets | Generic divalproex sodium is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Depakote Sprinkle 125 mg capsules | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Divalproex sodium 125 mg capsules | Generic divalproex sodium is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Diamox 500 mg capsules | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Acetazolamide 500 mg capsules | Generic acetazolamide is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Keppra 250, 500, 750 mg tablets | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Levetiracetam 250, 500, 750 mg tablets | Generic levetiracetam is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| PhosLo 667 mg capsules | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Calcium acetate 667 mg capsules | Generic calcium acetate is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| TobraDex ophthalmic suspension | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Tobramycin-dexamethasone ophthalmic suspension | Generic tobramycin-dexamethasone is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Videx EC 125 mg capsules | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Didanosine 125 mg capsules | Generic didanosine is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Wellbutrin XL 150 mg tablets | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Bupropion 150 mg extended-release (24 hr) tablets | Generic bupropion extended-release is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
| Zerit 15, 20, 30, 40 mg capsules | Formulary tier increase from Tier 2 to Tier 3 | Generic equivalent became available | Stavudine 15, 20, 30, 40 mg capsules | Generic stavudine is covered at the Tier 1 cost-sharing amount. However, your drug costs will depend on your specific prescription drug plan. |
Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS), a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS do not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association.
The information on this page regarding Blue Medicare Rx Plans is current as of 08/17/07.
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The information on this page is current as of 07/01/09.
© , Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.