2019 Formulary Update
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1 MEDICARE ADVANTAGE BlueShield of Northeastern New York Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January. This document outlines all of the updates to the formulary as of. Medicare beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premiums, and/or copayments/coinsurance may change on January 1, If you would like to receive this material in another format or language, or have questions about this formulary, please call us at (TTY 711). We re available: October 1 March 31 April 1 September 30 8 a.m. to 8 p.m., 7 days a week 8 a.m. to 8 p.m., Monday Friday During non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day. Part D Coverage Decisions and Appeals A coverage decision is a decision we make about your benefits and coverage, or about the amount we will pay for your drugs. Here are examples of coverage decisions you ask us to make about your Part D drugs: Asking us to cover a Part D drug that is not on our list of covered drugs (i.e. the formulary attached) Asking us to waive a restriction on our coverage for a drug (such as limits on the amount of the drug you can receive) Asking to pay a lower cost-sharing amount for a covered, non-preferred drug You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on our list of covered drugs, but we require you to get approval from us before we will cover it for you.) You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment. If you disagree with a coverage decision we have made, you can appeal our decision. If you would like to file an appeal or request an exception to a recent coverage determination, see your Evidence of Coverage for detailed instructions. Y0086_PTD281_C HPMS Approved Formulary File Submission ID , Version 6 NENY_R12071_-02-01
2 If you disagree with our decision to remove or change the tiering structure of the drugs on our list of covered drugs (i.e., the formulary), you may file a grievance with us. You can do so by calling us at (TTY 711). You may also send your grievance to us in writing to: BlueShield of Northeastern New York PO Box 5204 Binghamton, NY Whether you call or write, you should contact customer service right away if you intend to file a grievance. Grievances must be filed within 60 calendar days of. See your Evidence of Coverage for detailed instructions. abiraterone tablet 250mg T5 QL (120 PER 30 Only PA (ZYTIGA) Arikayce suspension for 590mg/8.4 ml T5 nebulization PA (ARIKAYCE): LA azelaic acid gel 15% T2 Braftovi capsule 50mg T5 QL (120 PER 30 Only PA (BRAFTOVI); LA Braftovi capsule 75mg T5 QL (180 PER 30 Only PA (BRAFTOVI); LA clobazam suspension 2.5mg/mL T2 QL (480 PER 30 Only PA (HIGH RISK MEDICATIONS - BENZODIAZEPINES) clobazam tablet 10mg T2 QL (60 PER 30 DAYS); (HIGH RISK MEDICATIONS - BENZODIAZEPINES) 2
3 clobazam tablet 20mg T2 QL (60 PER 30 DAYS); (HIGH RISK MEDICATIONS - BENZODIAZEPINES) colesevelam powder in packet 3.75gram T2 Copiktra capsule 15mg T5 (COPIKTRA); LA Copiktra capsule 25mg T5 (COPIKTRA); LA dalfampridine tablet extended 10mg T5 release 12 hr PA (AMPYRA) daptomycin recon soln 350mg T3 Delstrigo tablet mg T5 dexamethasone tablets,dose pack 1.5mg (51 tabs) T2 dexamethasone tablets,dose pack 1.5mg (35 tabs) T2 dexamethasone tablets,dose pack 1.5mg (21 tabs) T2 dorzolamidetimolol (PF) dropperette 2-0.5% T2 Dupixent syringe 200mg/1.14 ml T5 PA (DUPIXENT) Envarsus XR tablet extended release 24 hr 4mg T4 PA (B VS D) Envarsus XR tablet extended release 24 hr 0.75mg T4 PA (B VS D) Envarsus XR tablet extended release 24 hr 1mg T4 PA (B VS D) Epidiolex solution 100mg/mL T5 (EPIDIOLEX); LA ertapenem recon soln 1gram T2 Granix solution 300mcg/mL T5 PA (GRANIX) Granix solution 480mcg/1.6 ml T5 PA (GRANIX) hydrocortisone butyrate lotion 0.1% T2 3
4 itraconazole solution 10mg/mL T2 ketoprofen capsule 25mg T2 Lenvima capsule 4mg T5 (LENVIMA) Lenvima capsule 12 mg/day (4mg x 3) T5 (LENVIMA) Lokelma powder in packet 5gram T3 Lokelma powder in packet 10gram T3 Lorbrena tablet 25mg T5 (LORBRENA) Lorbrena tablet 100mg T5 (LORBRENA) mafenide acetate packet 50gram T2 Mektovi tablet 15mg T5 QL (180 PER 30 Only PA (MEKTOVI); LA molindone tablet 10mg T2 molindone tablet 25mg T2 molindone tablet 5mg T2 Mondoxyne NL capsule 100mg T2 Mondoxyne NL capsule 75mg T2 morphine capsule,extend.release pellets 40mg T2 QL (90 PER 30 DAYS); PA (LONG ACTING OPIOIDS) Mulpleta tablet 3mg T5 PA (MULPLETA) nafcillin recon soln 2gram T2 Nuplazid tablet 10mg T5 (NUPLAZID) Nuplazid capsule 34mg T5 (NUPLAZID) 4
5 gel in metered-dose pump Orkambi granules in packet mg T5 QL (56 PER 28 DAYS); PA (ORKAMBI) Orkambi granules in packet mg T5 QL (56 PER 28 DAYS); PA (ORKAMBI) Pifeltro tablet 100mg T5 sotalol tablet 120mg T2 Syeda tablet mg T2 Symtuza tablet mg T5 tadalafil tablet 5mg T2 QL (30 PER 30 DAYS); PA (cialis) tadalafil tablet 2.5mg T2 QL (30 PER 30 DAYS); PA (cialis) Talzenna capsule 0.25mg T5 (TALZENNA) Talzenna capsule 1mg T5 (TALZENNA) 10 mg/0.5 gram/actuation gel in metered-dose pump gel in packet gel in packet mg/1.25gram (1.62 %) 1.62 % (20.25mg/1.25 gram) 1.62 % (40.5mg/2.5 gram) 5 T2 QL (120 PER 30 T2 QL (150 PER 30 T2 QL (37.5 PER 30 T2 QL (150 PER 30 Tibsovo tablet 250mg T5 (TIBSOVO) vancomycin recon soln 750mg T2 Vizimpro tablet 15mg T5 QL (30 PER 30 DAYS); (VIZIMPRO)
6 Vizimpro tablet 30mg T5 QL (30 PER 30 DAYS); (VIZIMPRO) Vizimpro tablet 45mg T5 QL (30 PER 30 DAYS); (VIZIMPRO) Xarelto tablet 2.5mg T3 Xofluza tablet 20mg T3 Xofluza tablet 40mg T3 Xolair syringe 150mg/mL T5 QL (6 PER 28 DAYS); PA (XOLAIR); LA Xolair syringe 75mg/0.5 ml T5 QL (5 PER 28 DAYS); PA (XOLAIR); LA Zortress tablet 1mg T5 PA (B VS D) Deletions Drug Name Dosage Dosage Form Reason for Change Alternative Drug Alternative Drug Tier Effective Date No deletions Please consult with your physician to determine if the alternative drug listed here is appropriate for you. If you have any questions regarding the BlueShield of Northeastern New York Medicare Part D formulary, please contact the customer service number on the back of your member ID card. Changes from Previous Month s Formulary Drug Name Dosage Form Strength Previous Tier buprenorphine patch weekly 15mcg/hour T3; QL (4 PER 28 buprenorphine patch weekly 10mcg/hour T3; QL (4 PER 28 Current Tier T2; PA (LONG T2; QL (4 PER 28 Effective Date 6
7 Changes from Previous Month s Formulary Drug Name Dosage Form Strength Previous Tier buprenorphine patch weekly 20mcg/hour T3; QL (4 PER 28 buprenorphine patch weekly 5mcg/hour T3; QL (4 PER 28 morphine tablet 100mg T2; QL (60 PER 30 extended release Current Tier T2; QL (4 PER 28 T2; QL (4 PER 28 T2; QL (120 PER 30 Effective Date BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association. 7
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Pharmacy Updates Summary
All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 04/15/2015 Effective date: 05/15/2015 Therapeutic Classes reviewed: Testosterone replacement
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NOTIFICATION OF CHANGES The following summary describes changes to the 2018 Presbyterian Senior Care (HMO)/(HMO-POS), Presbyterian MediCare PPO and formularies. The formulary may change at any time. You