NetResults formulary — Noncovered drugs with preferred alternatives
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Lists prescription drugs that are noncovered under the NetResults formulary for Blue Cross Blue Shield - Wyoming and provides preferred generic or brand alternatives where available; governs pharmacy coverage and affects providers, pharmacies, and plan members.
No material clinical or coverage changes in this revision.
Noncovered Drugs and Coverage Stance
Noncovered drugs
Coverage stance
Providers should use listed preferred alternatives or confirm coverage exceptions with the plan.
Standard Noncovered Drugs
Products are classified into coverage categories with rationale and preferred alternatives
Rationale statements describe reasons for noncoverage and recommend talking to your doctor or pharmacist about alternatives.
Noncovered — OTC Alternatives
Noncovered with over-the-counter alternatives
Document advises talking to your pharmacist or doctor about OTC options and lists prescription alternatives where applicable.
Noncovered — High Cost
Noncovered due to high costs
Providers should consider generics or preferred alternatives identified in the formulary when selecting therapy.
Noncovered products and preferred alternatives
Medications listed below are designated Noncovered due to high costs; preferred generics or alternative brands are listed where applicable.
See formulary sections for full enumerated lists by therapeutic class.
When a preferred alternative is listed, coverage is expected for that alternative subject to plan rules; prior authorization requirements may still apply.
If a drug is not listed on the NetResults formulary it is not covered by the health plan. This document lists many noncovered medications and identifies covered alternatives where available; providers and pharmacies should confirm formulary status and select listed alternatives or pursue coverage exceptions with the plan when appropriate.
Examples of categories excluded from coverage include: brand drugs when a generic equivalent is available (rationale: brand names are not covered if a generic exists), bulk powders and other non-FDA-approved ingredients used in compounding, drugs deemed not safe or effective by the plan's Pharmacy & Therapeutics Committee, institutional packs packaged for use or redistribution by institutions, and repackaged medications. Talk to the member's clinician or pharmacist about FDA‑approved, appropriately packaged, or generic alternatives.
Coverage for specific items may vary by benefit design. Benefit‑specific coverage means some products listed as noncovered here could be paid under a different benefit (for example, the medical benefit) or may have exceptions based on the member's plan — verify the member's benefit documents or contact the plan for applicability.
Examples and Codes for Noncovered Products
| OPZELURA | Topical: atopic dermatitis, Noncovered = OPZELURA |
| VTAMA | Topical: atopic dermatitis, Noncovered = VTAMA |
| ZORYVE CREAM 0.15% | Topical: atopic dermatitis, Noncovered = ZORYVE CREAM 0.15% |
| TAVALISSE | Thrombocytopenia Agents, Nonpreferred brand alternatives = TAVALISSE |
| OLPRUVA | Urea Cycle Disorder, Noncovered = OLPRUVA |
| CEQUA | Dry eyes, Noncovered = CEQUA |
| EYSUVIS | Dry eyes, Noncovered = EYSUVIS |
| QBREXZA PAD | Excessive sweating, Noncovered = QBREXZA PAD |
| ABSORICA LD | Acne agents: retinoids & retinoid like agents, Noncovered = ABSORICA LD |
| AKLIEF | Acne agents: retinoids & retinoid like agents, Noncovered = AKLIEF |
What Providers Should Do / Authorization and Substitution Expectations
Formulary determines coverage and use preferred alternatives
NetResults is the formulary that determines coverage for this plan. If a drug is not listed on the NetResults formulary, it will not be covered by the health plan. Providers should review the formulary for covered alternatives and consider prescribing generics or preferred brands when available.
- NetResults governs coverage; nonformulary drugs are not covered.
- When a noncovered product has covered alternatives listed, consider the preferred alternative first.
- Quarterly formulary reviews occur; verify current status before prescribing.
Nonformulary, brand/generic, and OTC denial risks
Requests for nonformulary drugs may be denied or result in full out-of-pocket cost. When a generic equivalent exists, brand-name drug requests are typically not covered. For drugs listed as having over-the-counter alternatives, coverage requests for the prescription product may be denied in favor of OTC options.
- Nonformulary coverage risk: drugs not on NetResults will not be covered and may lead to claim denial or member paying full price.
- Brand vs Generic denial risk: brand-name medications are not covered when a generic equivalent is available.
- OTC alternative denial risk: prescription items with effective OTC alternatives may be denied; discuss OTC options with patient.
Prescribe preferred alternatives and substitute to generics first
Some noncovered drugs have listed preferred alternatives; providers should substitute to listed generics or preferred brands when possible. The formulary highlights preferred alternatives and stepwise options to help manage costs and ensure access.
- Preferred-alternative expectation: prescribe listed generics or preferred brands instead of noncovered products when available.
- Preferred substitution expectation: substitute to generic equivalents or preferred brands before requesting coverage for nonpreferred products.
- Use preferred alternatives first: formulary implies stepping to preferred generics/brands prior to noncovered choices.
Prior review / Prior authorization may be required
Prior authorization or other prior review may be required for some products, and additional restrictions can apply. Submitting a prior review or restricted access medicine request does not guarantee payment.
- Prior authorization may be required for restricted access medicines or nonpreferred products.
- Additional restrictions and prior review processes may apply — check plan-specific requirements.
- Successful claim adjudication is not a guarantee of payment.
Formulary change notifications — verify current status
The formulary is reviewed quarterly and updates (including new noncovered drugs and covered alternatives) are communicated to affected members. Always verify the current formulary status before prescribing to avoid coverage issues.
- Formulary change notifications are sent each quarter to affected members.
- Verify current formulary status prior to prescribing as changes may not be effective until stated effective date (e.g., July 1, 2026).
Documentation, member guide, and rationale notes
Refer to the member guide for detailed benefit design, out-of-pocket costs, prior review and restricted access medicine requests, and applicable exclusions. Documentation supporting medical necessity may be required for prior authorization requests.
- Documentation and member guide: consult the member guide for benefit details and exclusions.
- Rationale/documentation notes: many noncovered categories include rationale (e.g., generic available, non‑FDA approved) — include supporting documentation when requesting exceptions.
- Contact your Prime Therapeutics representative for more information.
Formulary Background and Management
NetResults is the payer's formulary, managed by Prime Therapeutics, intended to promote clinically appropriate, lower‑cost medication options by designating certain products as noncovered and identifying preferred generic or brand alternatives. The formulary determines which drugs are covered; if a drug is not on NetResults it will not be covered and providers should use listed alternatives or confirm coverage exceptions with the plan.
Key Terms and Definitions
Preferred Alternatives and Step Expectations
| Step | Requirement |
|---|---|
| 1 | Preferred alternatives are identified for many noncovered drugs; prescribers are expected to consider these lower‑cost options prior to using noncovered agents. |
| Step | Requirement |
|---|---|
| 1 | Encourage substitution to listed generics or preferred brand alternatives where available; high‑cost branded products are listed as noncovered with generics preferred. |
| Step | Requirement |
|---|---|
| 1 | Formulary directs use of generics and preferred brand alternatives where listed products are noncovered, indicating step to those alternatives prior to coverage of non‑preferred products. |
Adalimumab / Biosimilar Guidance
Preferred adalimumab biosimilars listed; HUMIRA/nonpreferred adalimumab noncovered
Certain adalimumab products and HUMIRA are listed as noncovered while specific adalimumab biosimilars (ADALIMUMAB-AATY, ADALIMUMAB-ADAZ, HADLIMA, SIMLANDI) are listed as preferred alternatives — consider those preferred biosimilars when treating indications covered on the formulary.
- Noncovered: HUMIRA and certain adalimumab products
- Preferred alternatives: ADALIMUMAB-AATY, ADALIMUMAB-ADAZ, HADLIMA, SIMLANDI
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