CommercialCoverageHigh impact
BCBSRI pharmacy program April 1, 2021 formulary changes
Blue Cross Blue Shield of Rhode Island·RI·Provider Update
Effective date
Apr 1, 2021
We identified it
Jun 19, 2026
Summary
BCBSRI pharmacy formulary changes effective April 1, 2021 exclude many brand name drugs from coverage when generic equivalents are available, move some drugs to higher copay tiers, add prior authorization requirements, and transfer certain specialty drugs from pharmacy to medical benefit coverage.
Action Required
Immediately: Billing team must update pharmacy benefit billing to exclude brand name drugs listed (ALINIA, HYCODAN, SAPHRIS, ATRIPLA, etc.) and bill for generic equivalents instead. Update prior authorization workflows for CONCERTA, SUPPRELIN LA, and FLUOROURACIL CRE 5%. Reroute specialty drugs (BOTOX, DYSPORT, LUPRON DEPOT, ELIGARD, etc.) from pharmacy billing to medical benefit billing. Update billing software rules and notify providers of formulary changes to prevent claim denials.