2021 Formulary For Group MedicareBlue Rx Standard Plan
2021FORMULARY(List of covered drugs)MedicareBlueSM Rx (PDP) StandardEffective January 1, 2021Please read: This document contains information about the drugs we cover in this plan.Formulary ID: 00021208 Version 11This formulary was updated on 5/1/2021. For more recent information or other questions,please contact MedicareBlue Rx customer service.Call 1-866-434-2037, 8 a.m. to 8 p.m., daily, Central and Mountain times(TTY hearing impaired users call 711)Visit YourMedicareSolutions.comS5743 082620NN01 C
Note to existing members: This formularyhas changed since last year. Please review thisdocument to make sure it still contains the drugsyou take.When this drug list (formulary) refers to “we,” “us”or “our,” it means Blue Cross and Blue Shield.When it refers to “plan” or “our plan,” it meansMedicareBlue Rx.This document includes a list of the drugs(formulary) for our plan which is current as of May1, 2021. For an updated formulary, please contactus. Our contact information, along with the date welast updated the formulary, appears on the front andback cover pages.You must generally use network pharmacies to useyour prescription drug beneft. Benefts, formulary,pharmacy network, and/or copayments/coinsurancemay change on January 1, 2022, and from time totime during the year.WHAT IS THE MEDICAREBLUE RXFORMULARY?A formulary is a list of covered drugs selectedby MedicareBlue Rx in consultation with ateam of health care providers, which representsthe prescription therapies believed to be anecessary part of a quality treatment program.MedicareBlue Rx will generally cover the drugslisted in our formulary as long as the drug ismedically necessary, the prescription is flled at aMedicareBlue Rx network pharmacy, and other planrules are followed. For more information on how tofll your prescriptions, please review your Evidenceof Coverage.CAN THE FORMULARY (DRUG LIST) CHANGE?Most changes in drug coverage happen on January1, but MedicareBlue Rx may add or remove drugson the Drug List during the year, move them todifferent cost-sharing tiers, or add new restrictions.We must follow Medicare rules in making thesechanges.Changes that can affect you this year: In thebelow cases, you will be affected by coveragechanges during the year: New generic drugs. We may immediatelyremove a brand-name drug on our Drug List if weare replacing it with a new generic drug that willappear on the same or lower cost-sharing tier andwith the same or fewer restrictions. Also, whenadding the new generic drug, we may decide tokeep the brand-name drug on our Drug List, butimmediately move it to a different cost-sharingtier or add new restrictions. If you are currentlytaking that brand-name drug, we may not tell youin advance before we make that change, but wewill later provide you with information about thespecific change(s) we have made. If we make such a change, you or yourprescriber can ask us to make an exceptionand continue to cover the brand-name drugfor you. The notice we provide you will alsoinclude information on how to request anexception, and you can also find informationin the following section entitled “How do Irequest an exception to the MedicareBlue RxFormulary?”Drugs removed from the market. If the Food andDrug Administration deems a drug on our formularyto be unsafe or the drug’s manufacturer removesthe drug from the market, we will immediatelyremove the drug from our formulary and providenotice to members who take the drug.Other changes. We may make other changesthat affect members currently taking a drug. Forinstance, we may add a generic drug that is notnew to market to replace a brand-name drugcurrently on the formulary or add new restrictionsto the brand-name drug or move it to a differentcost-sharing tier, or both. Or, we may make changesbased on new clinical guidelines. If we removedrugs from our formulary, or add prior authorization,quantity limits and/or step therapy restrictions on adrug, or move a drug to a higher cost-sharing tier,we must notify affected members of the change1
at least 30 days before the change becomeseffective, or at the time the member requests arefll of the drug, at which time the member willreceive a 30-day supply of the drug. If we make these other changes, you or yourprescriber can ask us to make an exceptionand continue to cover the brand-name drug foryou. The notice we provide you will also includeinformation on how to request an exception,and you can also find information in thefollowing section entitled “How do I request anexception to the MedicareBlue Rx Formulary?”Changes that will not affect you if you arecurrently taking the drug. Generally, if you aretaking a drug on our 2021 formulary that wascovered at the beginning of the year, we will notdiscontinue or reduce coverage of the drug duringthe 2021 coverage year except as describedpreviously. This means these drugs will remainavailable at the same cost-sharing and with nonew restrictions for those members taking themfor the remainder of the coverage year. You willnot get direct notice this year about changes thatdo not affect you. However, on January 1 of thenext year, such changes would affect you, and itis important to check the Drug List for the newbenefit year for any changes to drugs.The enclosed formulary is current as of May 1,2021. To get updated information aboutthe drugs covered by MedicareBlue Rx, pleasecontact us. Our contact information appears onthe front and back cover pages. In the event of anymid-year non-maintenance formulary changes, theformulary will be updated monthly and posted onour website. To view the most recent formulary,visit YourMedicareSolutions.com.HOW DO I USE THE FORMULARY?There are two ways to fnd your drug within theformulary.2Medical conditionThe formulary begins on page 7. The drugs in thisformulary are grouped into categories dependingon the type of medical conditions that they areused to treat. For example, drugs used to treata heart condition are listed under the category,“Cardiovascular.” If you know what your drug isused for, look for the category name in the list thatbegins on page 7. Then look under the categoryname for your drug.Alphabetical listingIf you are not sure what category to look under, youshould look for your drug in the Index at the back ofthis booklet. The Index provides an alphabetical listof all of the drugs included in this document. Bothbrand-name drugs and generic drugs are listed inthe Index. Look in the Index and fnd your drug.Next to your drug, you will see the page numberwhere you can fnd coverage information. Turn tothe page listed in the Index and fnd the name ofyour drug in the frst column of the list.WHAT ARE GENERIC DRUGS?MedicareBlue Rx covers both brand-name drugsand generic drugs. A generic drug is approved bythe FDA as having the same active ingredient as thebrand-name drug. Generally, generic drugs cost lessthan brand-name drugs.ARE THERE ANY RESTRICTIONS ON MYCOVERAGE?Some covered drugs may have additionalrequirements or limits on coverage. Theserequirements and limits may include: Prior authorization: MedicareBlue Rx requiresyou or your physician to get prior authorization forcertain drugs. This means that you will need toget approval from MedicareBlue Rx before youfill your prescriptions. If you don’t get approval,MedicareBlue Rx may not cover the drug.
Quantity limits: For certain drugs,MedicareBlue Rx limits the amount of the drugthat MedicareBlue Rx will cover. For example,MedicareBlue Rx provides 30 capsules perprescription for glimepiride. This may be in additionto a standard one-month or three-month supply. Step therapy: In some cases, MedicareBlue Rxrequires you to first try certain drugs to treat yourmedical condition before we will cover anotherdrug for that condition. For example, if Drug Aand Drug B both treat your medical condition,MedicareBlue Rx may not cover Drug B unless youtry Drug A first. If Drug A does not work for you,MedicareBlue Rx will then cover Drug B.You can fnd out if your drug has any additionalrequirements or limits by looking in the formulary thatbegins on page 7. You can also get more informationabout the restrictions applied to specifc covereddrugs by visiting our website. We have posted onlinedocuments that explain our prior authorization andstep therapy restrictions. You may also ask us tosend you a copy. Our contact information, along withthe date we last updated the formulary, appears onthe front and back cover pages.You can ask MedicareBlue Rx to make an exceptionto these restrictions or limits, or for a list of other,similar drugs that may treat your health condition.See the section, “How do I request an exception tothe MedicareBlue Rx formulary?” in the followingsection for information about how to request anexception.WHAT IF MY DRUG IS NOT ON THEFORMULARY?If your drug is not included in this formulary (list ofcovered drugs), you should frst contact customerservice and ask if your drug is covered. If you learnthat MedicareBlue Rx does not cover your drug, youhave two options: You can ask customer service for a list of similardrugs that are covered by MedicareBlue Rx. Whenyou receive the list, show it to your doctor andask him or her to prescribe a similar drug that iscovered by MedicareBlue Rx. You can ask MedicareBlue Rx to make anexception and cover your drug. See below forinformation about how to request an exception.HOW DO I REQUEST AN EXCEPTION TO THEMEDICAREBLUE RX FORMULARY?You can ask MedicareBlue Rx to make an exceptionto our coverage rules. There are several types ofexceptions that you can ask us to make. You can ask us to cover a drug even if it is noton our formulary. If approved, this drug will becovered at a pre-determined cost-sharing level,and you would not be able to ask us to provide thedrug at a lower cost-sharing level. You can ask us to cover a formulary drug at alower cost-sharing level if this drug is not on thespecialty tier. If approved this would lower theamount you must pay for your drug. You can ask us to waive coverage restrictionsor limits on your drug. For example, for certaindrugs, MedicareBlue Rx limits the amount of thedrug that we will cover. If your drug has a quantitylimit, you can ask us to waive the limit and cover agreater amount.Generally, MedicareBlue Rx will only approve yourrequest for an exception if the alternative drug isincluded on the plan’s formulary, the lower costsharing drug or additional utilization restrictionswould not be as effective in treating your conditionand/or would cause you to have adverse medicaleffects.You should contact us to ask us for an initialcoverage decision for a formulary, tiering orutilization restriction exception. When you requesta formulary, tiering or utilization restrictionexception you should submit a statement fromyour prescriber or physician supporting yourrequest. Generally, we must make our decision3
within 72 hours of getting your prescriber’ssupporting statement. You can request anexpedited (fast) exception if you or your doctorbelieve that your health could be seriously harmedby waiting up to 72 hours for a decision. If yourrequest to expedite is granted, we must give youa decision no later than 24 hours after we get asupporting statement from your doctor or otherprescriber.WHAT DO I DO BEFORE I CAN TALK TO MYDOCTOR ABOUT CHANGING MY DRUGS ORREQUESTING AN EXCEPTION?As a new or continuing member in our plan youmay be taking drugs that are not on our formulary.Or, you may be taking a drug that is on ourformulary but your ability to get it is limited. Forexample, you may need a prior authorization fromus before you can fll your prescription. You shouldtalk to your doctor to decide if you should switchto an appropriate drug that we cover or requesta formulary exception so that we will cover thedrug you take. While you talk to your doctor todetermine the right course of action for you, wemay cover your drug in certain cases during thefrst 90 days you are a member of our plan.For each of your drugs that is not on our formularyor if your ability to get your drugs is limited, wewill cover a temporary 30-day supply. If yourprescription is written for fewer days, we’ll allowreflls to provide up to a maximum 30-day supplyof medication. After your frst 30-day supply, wewill not pay for these drugs, even if you have beena member of the plan less than 90 days.If you are a resident of a long-term care facility andyou need a drug that is not on our formulary, or ifyour ability to get your drugs is limited, but you arepast the frst 90 days of membership in our plan,we will cover a 31-day emergency supply of thatdrug while you pursue a formulary exception.If you have a level of care change, such as beingdischarged from a hospital to your home or4from a long-term care facility to your home or asimilar change in care setting, you may have to fllnew prescriptions for the drugs you were takingin the hospital or long-term care facility. We haveprocesses in place to make sure you can continuetaking your prescriptions and not have a gap in yourdrug therapy.If you are not a resident of a long-term carefacility and have a level of care change, such asbeing discharged from a hospital to your home,a transition fll of each of your drugs will be providedautomatically at your pharmacy. If you are a residentof a long-term care facility and have a level of carechange, such as being discharged from the longterm care facility to your home, your pharmacy willsubmit a request to allow you to get up to a 30day supply of each of your drugs. Your pharmacistshould be able to tell when he or she electronicallyfles your claim that the prescription is the resultof a level of care change. If the pharmacist cannottell that from your claim, he or she can call thePharmacy Help Desk and obtain the necessarypermission to fll your prescription. That phonenumber is on the back of your member ID card.FOR MORE INFORMATIONFor more detailed information about yourMedicareBlue Rx prescription drug coverage, pleasereview your Evidence of Coverage and other planmaterials.If you have questions about MedicareBlue Rx,please contact us. Our contact information, alongwith the date we last updated the formulary,appears on the front and back cover pages.If you have general questions about Medicareprescription drug coverage, please call Medicare at1-800-MEDICARE (1-800-633-4227) 24 hours aday, seven days a week. TTY users should call1-877-486-2048. Or, visit medicare.gov.
The tables below show your share of the cost for 30-day and 90-day supplies from network pharmaciesoffering preferred and standard cost sharing.MedicareBlue Rx Standard (PDP) 0 annual deductible on tier 1 (preferred generic) and tier 2(generic) drugs 445 annual deductible on tier 3 (preferred brand), tier 4 (nonpreferred drug) and tier 5 (specialty) drugs30-day supplies cost sharingDrug tiers and tier names30-day supply – preferredretail cost sharing30-day supply – standardretail cost sharingTier 1: Preferred generic drugs 1 copay 10 copayTier 2: Generic drugs 7 copay 15 copayTier 3: Preferred brand drugs 29 copay 46 copayTier 4: Non-preferred drugs31% coinsurance36% coinsuranceTier 5: Specialty drugs25% coinsurance25% coinsuranceDrug tiers and tier names90-day supply – preferredretail, mail order orextended day supply costsharing90-day supply – standardretail, mail order or extendedday supply cost sharingTier 1: Preferred generic drugs 2 copay 20 copayTier 2: Generic drugs 14 copay 30 copayTier 3: Preferred brand drugs 87 copay 138 copayTier 4: Non-preferred drugs31% coinsurance36% coinsuranceTier 5: Specialty drugsNot availableNot available90-day supplies cost sharingCost sharing tier 1: Preferred genericThis tier is the lowest tier and generally contains the lowest cost generics.Cost sharing tier 2: GenericThis tier contains generics.Cost sharing tier 3: Preferred brandThis tier contains preferred brand drugs and non-preferred generic drugs.Cost sharing tier 4: Non-preferred drugsThis tier contains non-preferred brand drugs and non-preferred generic drugs.Cost sharing tier 5: Specialty tierThis tier contains very high cost brand and some generic drugs, which may require special handling and/orclose monitoring.5
MEDICAREBLUE RX FORMULARYThe formulary that begins on page 7 providescoverage information about the drugs covered byMedicareBlue Rx. If you have trouble fnding yourdrug in the list, turn to the Index at the back of thisbooklet.The frst column of the chart lists the drugname. Brand-name drugs are capitalized (e.g.,JANUVIA) and generic drugs are listed in lowercase italics (e.g., glipizide). The information inthe Requirements/Limits column tells you ifMedicareBlue Rx has any special requirements forcoverage of your drug.The key below can assist you as you look for theinformation for your drug.KEYUpper case BRAND-NAMELower case italics generic1 Tier 1: Preferred generic drugs2 Tier 2: Generic drugs3 Tier 3: Preferred brand drugs4 Tier 4: Non-preferred drugs5 Tier 5: Specialty drugsB/D Drugs that may be covered by MedicarePart B or Medicare Part D depending on thecircumstanceLA Limited accessNM Not available by mail orderPA Prior authorizationQL Quantity limitsST Step therapy6
CLEARSTONE CY21 SSG SELECT STANDARDeff 05/01/2021Drug NameDrug Tier Requirements/LimitsANALGESICSGOUTallopurinol TABS 100mg, 300mgcolchicine TABS .6mgcolchicine w/ probenecid tab 0.5-500 mgMITIGARE CAPS .6mgprobenecid TABS 500mg24333QL (120 tabs / 30 days)QL (60 caps / 30 days)NSAIDScelecoxib CAPS 50mgcelecoxib CAPS 100mgcelecoxib CAPS 200mgcelecoxib CAPS 400mgdiclofenac potassium TABS 50mgdiclofenac sodium TB24 100mgdiclofenac sodium TBEC 25mg, 50mg,75mgdiflunisal TABS 500mgec-naproxen TBEC 375mg, 500mgflurbiprofen TABS 100mgibu TABS 600mg, 800mgibuprofen SUSP 100mg/5mlibuprofen TABS 400mg, 600mg, 800mgmeloxicam TABS 7.5mg, 15mgnabumetone TABS 500mg, 750mgnaproxen TABS 250mg, 375mg, 500mgnaproxen TBEC 375mg, 500mgsulindac TABS 150mg, 200mg3333332QLQLQLQLQL(240 caps / 30 days)(120 caps / 30 days)(60 caps / 30 days)(30 caps / 30 days)(120 tabs / 30 days)32323212122OPIOID ANALGESICS, LONG-ACTINGfentanyl PT72 12mcg/hr, 25mcg/hr,50mcg/hr, 75mcg/hr, 100mcg/hrhydrocodone bitartrate T24A 20mg,30mg, 40mg, 60mg, 80mg, 100mg,120mgHYSINGLA ER T24A 20mg, 30mg, 40mg,60mg, 80mg, 100mg, 120mgmethadone hcl SOLN 5mg/5ml, 10mg/5ml4methadone hcl TABS 5mg, 10mg3methadone hcl intensol CONC 10mg/ml3morphine sulfate TBCR 15mg, 30mg,60mg, 100mg, 200mg3333QL (10 patches / 30days), PAQL (30 tabs / 30 days),PAQLPAQLPAQLPAQLPAQLPA(30 tabs / 30 days),(450 mL / 30 days),(90 tabs / 30 days),(90 mL / 30 days),(90 tabs / 30 days),PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available atmail-order B/D - Covered under Medicare B or D LA - Limited Access7
Drug NameDrug Tier Requirements/LimitsOPIOID ANALGESICS, SHORT-ACTINGacetaminophen w/ codeine soln 120-12mg/5mlacetaminophen w/ codeine tab 300-15 mgacetaminophen w/ codeine tab 300-30 mgacetaminophen w/ codeine tab 300-60 mgendocet tab 2.5-325mgendocet tab 5-325mgendocet tab 7.5-325mgendocet tab 10-325mgfentanyl citrate LPOP 200mcg, 600mcg,800mcg, 1200mcg, 1600mcgfentanyl citrate LPOP 400mcg3QL (2700 mL / 30 days)33333335hydrocodone-acetaminophen soln 7.5-325mg/15mlhydrocodone-acetaminophen tab 5-325 mghydrocodone-acetaminophen tab 7.5-325mghydrocodone-acetaminophen tab 10-325mghydrocodone-ibuprofen tab 7.5-200 mghydromorphone hcl LIQD 1mg/mlhydromorphone hcl TABS 2mg, 4mg, 8mgmorphine sulfate SOLN 1mg/ml, 4mg/ml,8mg/ml, 10mg/mlMORPHINE SULFATE SOLN 2mg/ml,4mg/ml, 5mg/ml, 8mg/ml, 10mg/mlmorphine sulfate SOLN 10mg/5mlmorphine sulfate SOLN 20mg/5mlmorphine sulfate SOLN 100mg/5mlmorphine sulfate TABS 15mg, 30mgnalbuphine hcl SOLN 10mg/ml, 20mg/mloxycodone hcl SOLN 5mg/5mloxycodone hcl TABS 5mg, 10mg, 15mg,20mg, 30mgoxycodone w/ acetaminophen tab 2.5-325mgoxycodone w/ acetaminophen tab 5-325mgoxycodone w/ acetaminophen tab 7.5-325mgoxycodone w/ acetami
You must generally use network pharmacies to use your prescription drug beneft. Benefts, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year. WHAT IS THE MEDICAREBLUE RX FORMULARY? A formulary is a list of covered drugs selected by MedicareBlue Rx in consultation with a
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MDwise Formulary Introduction – Hoosier Healthwise (HHW) HHW members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on the type of medical
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