MEICARE AVANTAGE BlueCross BlueShield of Western New York 2018 Formulary Update BlueCross BlueShield of Western New York has updated its formulary (drug list) since its original publication in January 2018. 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, 2019. If you would like to receive this material in another format or language, or have questions about this formulary, please call us at 1-800-329-2792 (TTY 711). We re available: October 1 February 14 February 15 September 30 8 a.m. to 8 p.m., 7 days a week 8 a.m. to 8 p.m., Monday Friday uring non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day. R A F T Part Coverage ecisions 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 may ask us to make about your Part drugs: Asking us to cover a Part 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, 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_PT281 Accepted HPMS Approved Formulary File Submission I 00018103, Version 11 WNY_R12071_2018-05-01
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 1-800-329-2792 (TTY 711). You may also send your grievance to us in writing to: BlueCross BlueShield of Western New York PO Box 5204 Binghamton, NY 13902 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. Additions to the Formulary Adacel(Tdap syringe 2 Lf-(2.5-5-3- T3 Adolescent/Adult)(PF) 5mcg)-5Lf/0.5 adapalene-benzoyl peroxide ml gel with pump 0.1-2.5% PA (TOPICAL RETINOI R A F PROUCTS) T PA (B VS ); LA Aliqopa recon soln 60mg T5 aminophylline solution 250mg/10 ml Amnesteem capsule 10mg Amnesteem capsule 20mg Amnesteem capsule 40mg aripiprazole solution 1mg/mL T5 Baxdela recon soln 300mg T5 Benlysta auto-injector 200mg/mL T5 Benlysta syringe 200mg/mL T5 bortezomib recon soln 3.5mg T5 PA (B VS ) Bosulif tablet 400mg T5 QL (30 PER 30 ; (BOSULIF) Bydureon BCise auto-injector 2mg/0.85 ml T3 QL (4 PER 28 ; PA (GLUCAGON-LIKE PEPTIE-1 AGONISTS) Calquence capsule 100mg T5 QL (60 PER 30 ; (CALQUENCE); LA 2
carvedilol phosphate capsule, ER 80mg multiphase 24 hr caspofungin recon soln 50mg T5 PA (B VS ) dactinomycin recon soln 0.5mg PA (B VS ) dapsone gel 5% desogestrel-ethinyl tablet 0.15-0.03mg estradiol doxycycline hyclate tablet 75mg doxycycline hyclate tablet 150mg efavirenz capsule 50mg eletriptan HBr tablet 20mg QL (18 PER 28 eletriptan HBr tablet 40mg QL (18 PER 28 estradiol tablet 10mcg ethynodiol diacetateethinyl tablet 1-35mg-mcg estradiol fluoxetine tablet R 60mg A F T fosamprenavir tablet 700mg T5 Glatiramer syringe 20mg/mL T5 QL (30 PER 30 ; PA (COPAXONE) glatiramer syringe 40mg/mL T5 QL (12 PER 28 ; PA (COPAXONE) Glyxambi tablet 10-5mg T3 QL (30 PER 30 Glyxambi tablet 25-5mg T3 QL (30 PER 30 haloperidol decanoate solution 100mg/mL (1 ml) Havrix (PF) suspension 720 Elisaunit/0.5 T3 ml Havrix (PF) syringe 1,440Elisa T3 unit/ml Humalog Junior KwikPen insulin pen, halfunit 100unit/mL T3 ST (RAPI-ACTING INSULIN-PST) Idhifa tablet 100mg T5 QL (30 PER 30 ; (IHIFA); LA Idhifa tablet 50mg T5 QL (60 PER 30 ; (IHIFA); LA Isibloom tablet 0.15-0.03mg 3
Jadenu Sprinkle granules in packet 90mg T5 PA (EXJAE/JAENU) Jadenu Sprinkle granules in packet 360mg T5 PA (EXJAE/JAENU) Jadenu Sprinkle granules in packet 180mg T5 PA (EXJAE/JAENU) Juluca tablet 50-25mg T5 Kadcyla recon soln 160mg T5 (KACYLA) Klor-Con packet 20mEq T1 lanthanum tablet,chewable 500mg lanthanum tablet,chewable 1,000mg lanthanum tablet,chewable 750mg Lartruvo solution 10mg/mL (19 ml) T5 PA (B VS ); LA Levonorgestrel/ethinyl estradiol Lupron epot-ped (3 month) tablets,dose pack,3 month 0.15 mg-20 mcg/0.15 mg-25 mcg 4 syringe kit 30mg T5 R A F (LEUPROLIE T(LONG ACTING)) (LYNPARZA) Lynparza tablet 100mg T5 Lynparza tablet 150mg T5 (LYNPARZA) meropenem recon soln 1gram mesalamine tablet,delayed release (R/EC) 1.2gram methotrexate sodium solution 25mg/mL (10 ml) (PF) methylphenidate HCl capsule,er 30mg biphasic 50-50 morphine syringe 5mg/mL PA (B VS ) QL (400 PER 30 moxifloxacin drops 0.5% Mylotarg recon soln 4.5 mg (1 mg/mlinitial T5 conc) PA (B VS ); LA Nerlynx tablet 40mg T5 LA Opdivo solution 100mg/10 ml T5 (OPIVO) oseltamivir suspension for 6mg/mL reconstitution
oxaliplatin recon soln 100mg PA (B VS ) paroxetine mesylate capsule 7.5mg (menopausal symptoms) QL (30 PER 30 peg 3350-electrolytes recon soln 240-22.72-6.72-5.84 gram piperacillintazobactam recon soln 2.25gram potassium chloride solution 2mEq/mL prasugrel tablet 10mg prasugrel tablet 5mg Prevymis solution 240mg/12 ml T5 Prevymis solution 480mg/24 ml T5 Prevymis tablet 240mg T5 Prevymis tablet 480mg T5 ProFeno tablet R 600mg A F T Radicava piggyback 30mg/100 ml T5 Rituxan concentrate 10mg/mL T5 (RITUXAN) scopolamine base patch 3 day 1mg over 3 days sevelamer carbonate tablet 800mg Soliqua 100/33 insulin pen 100 unit- T3 33mcg/mL Stelara solution 45mg/0.5 ml T5 testosterone solution in metered pump w/app 30 mg/actuation(1.5 ml) timolol maleate drops, once daily 0.5% tramadol tramadol tramadol tablet, ER multiphase 24 hr tablet, ER multiphase 24 hr tablet, ER multiphase 24 hr 300mg (matrix delivery) Treanda recon soln 25mg T5 5 PA (STELARA) PA (TOPICAL TESTOSTERONE PROUCTS) QL (30 PER 30 ; PA (LONG ACTING OPIOIS) 200mg QL (30 PER 30 ; PA (LONG ACTING OPIOIS) 100mg QL (30 PER 30 ; PA (LONG ACTING OPIOIS) PA (B VS )
Trelegy Ellipta blister with device 100-62.5-25mcg T3 QL (60 PER 30 Trisenox solution 2mg/mL T5 PA (B VS ) Twinrix (PF) syringe 720 Elisa unit-20 T3 mcg/ml Vaqta (PF) suspension 50unit/mL T3 Vaqta (PF) suspension 25unit/0.5 ml T3 Verzenio tablet 50mg T5 QL (240 PER 30 ; New Starts Only PA (VERZENIO); LA Verzenio tablet 100mg T5 QL (120 PER 30 ; New Starts Only PA (VERZENIO); LA Verzenio tablet 150mg T5 QL (80 PER 30 ; (VERZENIO); LA Verzenio tablet R 200mg A T5 F QL (60 TPER 30 ; (VERZENIO); LA vigabatrin powder in packet 500mg T5 LA Vyxeos recon soln 44-100mg T5 PA (B VS ) Xatmep solution 2.5mg/mL T5 PA (B VS ) Xuriden granules in packet 2gram T5 Zenpep capsule,delayed 20,000-63,000- T3 release(r/ec) 84,000 unit Altavera (28) tablet 0.15-0.03mg Alunbrig tablet 90mg T5 QL (60 PER 30 ; (ALUNBRIG) Alunbrig tablet 180mg T5 QL (30 PER 30 ; (ALUNBRIG) Alunbrig tablets,dose pack 90 mg (7)-180 mg (23) atazanavir capsule 150mg atazanavir capsule 200mg atazanavir capsule 300mg T5 6 T5 QL (30 PER 30 ; (ALUNBRIG)
Eliquis tablets,dose pack 5mg (74 tabs) T3 Enskyce tablet 0.15-0.03mg estradiol cream 0.01% (0.1 mg/gram) Fasenra syringe 30mg/mL T5 PA (FASENRA) fluticasone-salmeterol aerosol powder 113- T1 QL (60 PER 30 breath activated 14mcg/actuation fluticasone-salmeterol aerosol powder 232- T1 QL (60 PER 30 breath activated 14mcg/actuation fluticasone-salmeterol aerosol powder 55- T1 QL (60 PER 30 breath activated 14mcg/actuation Herceptin recon soln 150mg T5 PA (B VS ) Kurvelo tablet 0.15-0.03mg levonorgestrel-ethinyl tablet 0.15-0.03mg estradiol medroxyprogesterone syringe 150mg/mL Roweepra tablet R 750mg A F T Roweepra tablet 500mg Selzentry solution 20mg/mL T3 Shingrix (PF) suspension for 50mcg/0.5 ml T3 reconstitution Tamiflu capsule 75mg T3 Tamiflu capsule 30mg T3 Tamiflu capsule 45mg T3 tenofovir disoproxil tablet 300mg T5 fumarate Xigduo XR tablet, IR - ER, 2.5-1,000mg T3 QL (60 PER 30 biphasic 24hr Zenpep capsule,delayed 40,000-126,000- T5 release(r/ec) 168,000 unit abacavir solution 20mg/mL Biktarvy tablet 50-200-25mg T5 igox tablet 250mcg igox tablet 125mcg efavirenz capsule 200mg T5 efavirenz tablet 600mg T5 7
Erleada tablet 60mg T5 (ERLEAA) haloperidol lactate syringe 5mg/mL isotretinoin capsule 10mg isotretinoin capsule 20mg isotretinoin capsule 40mg isotretinoin capsule 30mg Levonorgestrel/ethinyl estradiol-ethinyl estradiol tablets,dose pack,3 month 0.10 mg-20 mcg(84)/10 mcg (7) memantine capsule,sprinkle,er 24hr 14mg PA (MEMANTINE) memantine capsule,sprinkle,er 21mg PA (MEMANTINE) 24hr memantine capsule,sprinkle,er 28mg PA (MEMANTINE) 24hr memantine capsule,sprinkle,er 7mg PA (MEMANTINE) 24hr R A F T methotrexate sodium solution (INJ) 25mg/mL PA (B VS ) minocycline tablet extended 115mg T5 release 24 hr minocycline tablet extended 65mg T5 release 24 hr naloxone syringe 0.4mg/mL Natroba suspension 0.9% T3 Nolix cream 0.05% Qvar RediHaler HFA aerosol breath activated 80mcg/actuation T3 Qvar RediHaler HFA aerosol 40mcg/actuation T3 breath activated sodium tablet 500mg T5 phenylbutyrate sumatriptan-naproxen tablet 85-500mg Symdeko tablets, sequential 100-150 mg T5 (d)/150 mg (n) Symproic tablet 0.2mg T3 trientine capsule 250mg T5 PA (SYPRINE) Videx EC capsule,delayed release(r/ec) 125mg 8 T4 QL (56 PER 28 ; PA (SYMEKO)
Zenpep capsule,delayed 25,000-79,000- T3 release(r/ec) 105,000 unit Zenpep capsule,delayed 5,000-17,000- T3 release(r/ec) 24,000 unit eletions rug Name osage osage Form Reason for Change Alternative rug Alternative rug Tier Effective ate No deletions No deletions 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 BlueCross BlueShield of Western New York Medicare Part formulary, please contact the customer R service number A on the F back of your Tmember I card. Changes from Previous Month s Formulary Previous Tier Current Tier rug Name osage Form Strength & Limitations & Limitations Effective ate buprenorphine HCl tablet 2mg ; QL (100 PER 30 buprenorphine HCl tablet 8mg ; QL (25 PER 30 Enbrel recon soln 25mg (1 ml) T5; QL (16 PER 28 T5; QL (8 PER 28 ; PA (ENBREL) ; PA (ENBREL) hydrocodoneacetaminophen tablet 10-300mg ; QL (360 PER 30 ; QL (390 PER 30 hydrocodoneacetaminophen tablet 5-300mg ; QL (360 PER 30 ; QL (390 PER 30 hydrocodoneacetaminophen tablet 7.5-300mg ; QL (360 PER 30 ; QL (390 PER 30 leuprolide kit 1mg/0.2 ml ; PA (B VS ) megestrol suspension 625mg/5 ml T4; PA (MEGACE) ; PA (MEGACE) megestrol tablet 20mg T4; New Starts Only PA (MEGACE) ; New Starts Only PA (MEGACE) megestrol tablet 40mg T4; New Starts Only PA (MEGACE) ; New Starts Only PA (MEGACE) 9
Changes from Previous Month s Formulary rug Name osage Form Strength Previous Tier & Limitations Current Tier & Limitations Effective ate megestrol suspension 400 mg/10 ml(40 mg/ml) T4; PA (MEGACE) ; PA (MEGACE) valacyclovir tablet 1gram ; QL (30 PER 30 ; QL (120 PER 30 valacyclovir tablet 500mg ; QL (30 PER 30 ; QL (60 PER 30 Vicodin tablet 5-300mg ; QL (360 PER 30 ; QL (390 PER 30 Vicodin ES tablet 7.5-300mg ; QL (360 PER 30 ; QL (390 PER 30 Vicodin HP tablet 10-300mg ; QL (360 PER 30 ; QL (390 PER 30 No changes tiagabine tablet 2mg T4 tiagabine tablet 4mg T4 BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract R A F T and enrollment depends on contract renewal. A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association. The formulary may change at any time. You will receive notice when necessary. 10