Anthem Blue MedicareRx Standard (PDP) 2019 Formulary (List .
Anthem Blue MedicareRx Standard (PDP)2019 Formulary (List of Covered Drugs)Please read:This document contains information about the drugs we cover in this plan.This formulary was updated on November 1, 2019. For more recentinformation or other questions, please contact Anthem Blue MedicareRxStandard (PDP) Customer Service, at 1-866-755-2776 or, for TTY users,711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving andChristmas) from October 1 through March 31, and Monday to Friday(except holidays) from April 1 through September 30, or visithttps://shop.anthem.com/medicare.S5596 046Y0114 19 35070 I C 013 08/06/2018Basic PDP 19263 v18 1912 1
Note to existing members:This formulary has changed since last year. Please review thisdocument to make sure that it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us,” or “our,” itmeans Anthem Blue Cross and Blue Shield. When it refers to “plan”or “our plan,” it means Anthem Blue MedicareRx Standard (PDP).This document includes a list of the drugs (formulary) for our planwhich is current as of December 1, 2019. For an updated formulary,please contact us. Our contact information, along with the date welast updated the formulary, appears on the front and back coverpages.You must generally use network pharmacies to use your prescriptiondrug benefit. Benefits, formulary, pharmacy network, and/orcopayments/coinsurance may change on January 1, 2020, and fromtime to time during the year.The Formulary, pharmacy network, and/or provider network maychange at any time. You will receive notice when necessary.Effective Date December 1, 20192Basic PDP 19263 v18 1912 1
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 the steps you may taketo request an exception, and you can also findinformation in the section below entitled“How do I request an exception to theAnthem Blue MedicareRx Standard (PDP)’sFormulary?”What is the Anthem Blue MedicareRxStandard (PDP) formulary?A formulary is a list of covered drugs selected by ourplan in consultation with a team of health care providers,which represents the prescription therapies believed tobe a necessary part of a quality treatment program. Ourplan will generally cover the drugs listed in our formularyas long as the drug is medically necessary, theprescription is filled at a plan network pharmacy, andother plan rules are followed. For more information onhow to fill your prescriptions, please review yourEvidence of Coverage.Drugs removed from the market. If the Food andDrug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturerremoves the drug from the market, we willimmediately remove the drug from our formularyand provide notice to members who take the drug.Can the formulary (drug list) change?Generally, if you are taking a drug on our 2019formulary that was covered at the beginning of the year,we will not discontinue or reduce coverage of the drugduring the 2019 coverage year except when a new, lessexpensive generic drug becomes available, when newinformation about the safety or effectiveness of a drugis released, or the drug is removed from the market. (Seebullets below for more information on changes that affectmembers currently taking the drug.) Other types offormulary changes, such as removing a drug from ourformulary, will not affect members who are currentlytaking the drug. It will remain available at the same costsharing for those members taking it for the remainderof the coverage year. We feel it is important that youhave continued access for the remainder of the coverageyear. Below are changes to the drug list that will alsoaffect members currently taking a drug:Other changes. We may make other changes thataffect members currently taking a drug. Forinstance, we may add a generic drug that is not newto market to replace a brand name drug currentlyon the formulary or add new restrictions to thebrand name drug or move it to a differentcost-sharing tier. Or we may make changes basedon new clinical guidelines. If we remove drugsfrom our formulary, or add prior authorization,quantity limits and/or step therapy restrictions ona drug or move a drug to a higher cost-sharing tier,we must notify affected members of the change atleast 30 days before the change becomes effective,or at the time the member requests a refill of thedrug, at which time the member will receivea 30-day supply of the drug.New generic drugs. We may immediately removea brand name drug on our Drug List if we arereplacing it with a new generic drug that will appearon the same or lower cost sharing tier and with thesame or fewer restrictions. Also, when adding thenew generic drug, we may decide to keep the brandname drug on our Drug List, but immediatelymove it to a different cost-sharing tier or add newrestrictions. If you are currently taking that brandname drug, we may not tell you in advance beforewe make that change, but we will later provide youwith information about the specific change(s) wehave made.Effective Date December 1, 2019The enclosed formulary is current as of December 1,2019. To get updated information about the drugscovered by our plan, please contact us. Our contactinformation appears on the front and back cover pages.If any other type of approved formulary change(nonmaintenance change) is made during the year, wewill notify you by sending you a list of these changes, orby sending you an updated formulary.3Basic PDP 19263 v18 1912 1
for donepezil. This may be in addition to a standardone-month or three-month supply.How do I use the formulary?There are two ways to find your drug within theformulary:Step Therapy: In some cases, our plan requires you tofirst try certain drugs to treat your medical conditionMedical Conditionbefore we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medicalThe formulary begins on page 8. The drugs in thisformulary are grouped into categories depending on the condition, our plan may not cover Drug B unless youtry Drug A first. If Drug A does not work for you, ourtype of medical conditions that they are used to treat.plan will then cover Drug B.For example, drugs used to treat a heart condition arelisted under the category, “Cardiovascular, Hypertension/You can find out if your drug has any additionalLipids.” If you know what your drug is used for, lookfor the category name in the list that begins on page 8. requirements or limits by looking in the formulary thatbegins on page 8. You can also get more informationThen look under the category name for your drug.about the restrictions applied to specific covered drugsby visiting our website. We have posted onlineAlphabetical Listingdocuments that explain our prior authorization and stepIf you are not sure what category to look under, youtherapy restrictions. You may also ask us to send you ashould look for your drug in the Index that begins oncopy. Our contact information, along with the date wepage 56. The Index provides an alphabetical list of alllast updated the formulary, appears on the front andof the drugs included in this document. Bothback cover pages.brand-name drugs and generic drugs are listed in theYou can ask our plan to make an exception to theseIndex. Look in the Index and find your drug. Next toyour drug, you will see the page number where you can restrictions or limits or for a list of other, similar drugsthat may treat your health condition. See the section,find coverage information. Turn to the page listed in“How do I request an exception to the Anthem Bluethe Index and find the name of your drug in the firstMedicareRx Standard (PDP)'s formulary?” oncolumn of the list.page 5 for information about how to request anexception.What are generic drugs?Our plan covers both brand-name drugs and genericdrugs. A generic drug is approved by the FDA as having What if my drug is not on thethe same active ingredient as the brand-name drug.formulary?Generally, generic drugs cost less than brand-name drugs. If your drug is not included in this formulary (list ofcovered drugs), you should first contact Customer ServiceAre there any restrictions on myand ask if your drug is covered.coverage?If you learn that our plan does not cover your drug, youhave two options:Some covered drugs may have additional requirementsor limits on coverage. These requirements and limitsmay include:You can ask Customer Service for a list of similar drugsthat are covered by our plan. When you receive the list,show it to your doctor and ask him or her to prescribea similar drug that is covered by our plan.Prior Authorization: Our plan requires you or yourphysician to get prior authorization for certain drugs.This means that you will need to get approval from ourplan before you fill your prescriptions. If you don't get You can ask our plan to make an exception and coverapproval, our plan may not cover the drug.your drug. See below for information about how torequest an exception.Quantity Limits: For certain drugs, our plan limits theamount of the drug that our plan will cover. Forexample, our plan provides 30 tablets per prescriptionEffective Date December 1, 20194Basic PDP 19263 v18 1912 1
How do I request an exception to the What do I do before I can talk to myAnthem Blue MedicareRx Standarddoctor about changing my drugs or(PDP)'s formulary?requesting an exception?You can ask our plan to make an exception to ourAs a new or continuing member in our plan you may becoverage rules. There are several types of exceptions that taking drugs that are not on our formulary. Or, you mayyou can ask us to make:be taking a drug that is on our formulary but your abilityto get it is limited. For example, you may need a priorYou can ask us to cover a drug even if it is not on our authorization from us before you can fill yourformulary. If approved, this drug will be covered at aprescription. You should talk to your doctor to decidepredetermined cost-sharing level, and you would not be if you should switch to an appropriate drug that we coverable to ask us to provide the drug at a lower cost-sharing or request a formulary exception so that we will coverlevel.the drug you take. While you talk to your doctor todetermine the right course of action for you, we mayYou can ask us to cover a formulary drug at a lower cover your drug in certain cases during the first 90 dayscost-sharing level. If approved this would lower theyou are a member of our plan.amount you must pay for your drug.For each of your drugs that is not on our formulary, orYou can ask us to waive coverage restrictions or limits if your ability to get your drugs is limited, we will coveron your drug. For example, for certain drugs, our plan a temporary 30-day supply. If your prescription is writtenlimits the amount of the drug that we will cover. If your for fewer days, we will allow refills to provide up to adrug has a quantity limit, you can ask us to waive themaximum 30 day supply of medication. After your firstlimit and cover a greater amount.30-day supply, we will not pay for these drugs, even ifyou have been a member of the plan less than 90 days.Generally, our plan will only approve your request foran exception if the alternative drugs included on theIf you are a resident of a long-term-care facility and, youplan’s formulary, the lower cost-sharing drug orneed a drug that is not on our formulary, or if youradditional utilization restrictions would not be asability to get your drugs is limited, but you are past theeffective in treating your condition and/or would cause first 90 days of membership in our plan, we will coveryou to have adverse medical effects.a 34-day emergency supply of that drug while you pursuea formulary exception.You should contact us to ask us for an initial coveragedecision for a formulary or utilization restrictionexception. When you request a formulary orutilization restriction exception you should submita statement from your prescriber or physiciansupporting your request. Generally, we must make ourdecision within 72 hours of getting your prescriber’ssupporting statement. You can request an expedited (fast)exception if you or your doctor believe that your healthcould be seriously harmed by waiting up to 72 hours fora decision. If your request to expedite is granted, we mustgive you a decision no later than 24 hours after we geta supporting statement from your doctor or otherprescriber.During the time when you are getting a temporarysupply of a drug, you should talk to your prescriber orprescribing physician to decide what to do when yoursupply runs out. You can call Customer Service to askfor a list of covered drugs that treat the same medicalcondition. This list can help your doctor find a covereddrug that might work for you while you pursue aformulary exception. Please refer to the Evidence ofCoverage for more information about exceptions.For more informationFor more detailed information about ourplan prescription drug coverage, please review yourEvidence of Coverage and other plan materials.If you have questions about our plan, please contact us.Our contact information, along with the date we lastEffective Date December 1, 20195Basic PDP 19263 v18 1912 1
updated the formulary, appears on the front and backcover pages.(except holidays) from April 1 through September 30TTY/TDD users should call 711.If you have general questions about Medicareprescription drug coverage, please call Medicare at1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call 1-877-486-2048.Or, visit http://www.medicare.gov.MO – Mail Orders: Prescription drugs available throughmail order. Allow up to 14 days from the date theprescription is ordered to process and mail. For first timeusers of the home delivery pharmacy have at least a30-day supply of medication on hand when a request isplaced with home delivery pharmacy.Our plan’s formularyThe formulary on page 8 provides coverage informationabout the drugs covered by our plan. If you have troublefinding your drug in the list, turn to the Index thatbegins on page 56.The first column of the chart lists the drug name.Brand-name drugs are capitalized (e.g., SPIRIVA) andgeneric drugs are listed in lowercase italics (e.g., atenolol).The information in the Requirements/Limits columntells you if our plan has any special requirements forcoverage of your drug.QLL – Quantity Limits: Restricts the frequency,amount or dosage of medication for which you canobtain benefits each time you get a prescription filled(most often set on a monthly basis).PAR – Prior Authorization: The process of obtainingapproval for certain prescriptions before benefits will beapproved. You, your doctor or other network providerwill need to request prior authorization before you fillthe prescription.ST – Step Therapy: The process of first trying a certaindrug or drugs to determine if that drug or those drugswill treat your medical condition before your plan willcover another drug for that condition.B/D PAR – Part B vs. Part D: This drug may becovered under either your Part D prescription drugbenefits or as a Part B drug under your medical benefits,as determined by Medicare.LA – Limited Access: This prescription may be availableonly at certain pharmacies. For more information,consult your Pharmacy Directory or call CustomerService at 1-866-755-2776, 8 a.m. to 8 p.m., seven daysa week (except Thanksgiving and Christmas) fromOctober 1 through March 31, and Monday to FridayEffective Date December 1, 20196Basic PDP 19263 v18 1912 1
Cost-sharing for a one-month supply of a covered Part D prescription drugduring the Initial Coverage Stage:Cost-Sharing Tier 1: Preferred GenericNetwork Pharmacy with preferred cost-sharing (30-day supply)or Mail-Order Pharmacy** (30-day supply) 1.00Network Pharmacy with standard cost-sharing (30-day supply)or Long-Term-Care Pharmacy (34-day supply) 11.00Cost-Sharing Tier 2: GenericNetwork Pharmacy with preferred cost-sharing (30-day supply)or Mail-Order Pharmacy** (30-day supply) 5.00Network Pharmacy with standard cost-sharing (30-day supply)or Long-Term-Care Pharmacy (34-day supply) 15.00Cost-Sharing Tier 3: Preferred BrandNetwork Pharmacy with preferred cost-sharing (30-day supply)or Mail-Order Pharmacy** (30-day supply) 30.00Network Pharmacy with standard cost-sharing (30-day supply)or Long-Term-Care Pharmacy (34-day supply) 39.00Cost-Sharing Tier 4: Nonpreferred DrugsNetwork Pharmacy with preferred cost-sharing (30-day supply)or Mail-Order Pharmacy** (30-day supply)40%Network Pharmacy with standard cost-sharing (30-day supply)or Long-Term-Care Pharmacy (34-day supply)50%Cost-Sharing Tier 5: Specialty Tier*Network Pharmacy with preferred cost-sharing (30-day supply)or Mail-Order Pharmacy** (30-day supply)25%Network Pharmacy with standard cost-sharing (30-day supply)or Long-Term-Care Pharmacy (34-day supply)25%Cost-Sharing Tier 6: Select Care DrugsNetwork Pharmacy with preferred cost-sharing (30-day supply)or Mail-Order Pharmacy** (30-day supply) 0.00Network Pharmacy with standard cost-sharing (30-day supply)or Long-Term-Care Pharmacy (34-day supply) 8.00Please refer to our Evidence of Coverage for more information on cost sharing.The amount you pay will depend if you qualify for low-income subsidy (LIS), also known as Medicare's "ExtraHelp" program.Network Pharmacy with preferred cost-sharing – A network pharmacy that offers covered drugs to members ofour plan that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing.* A long-term supply is not available for drugs in the Tier 5: Specialty Tier** Mail-Order Pharmacy – Mail-order service allows you to order a 30–90-day supply of drugs. The drugsavailable through our plan’s mail-order service are marked as “mail-order” drugs in our drug list.Effective Date December 1, 20197Basic PDP 19263 v18 1912 1
Covered Medications by Therapeutic CategoryLegendGeneric drugs are shown in lowercase italic (e.g., atenolol).Brand-name drugs are shown in capital letters (e.g., SPIRIVA).QLL – Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtainbenefits each time you get a prescription filled (most often set on a monthly basis).PAR – Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will beapproved. You, your doctor or other network provider will need to request prior authorization before you fill theprescription.ST – Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugswill treat your medical condition before your plan will cover another drug for that condition.B/D PAR – Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits oras a Part B drug under your medical benefits, as determined by Medicare.LA – Limited Access: This prescription may be available only at certain pharmacies. For more information, consultyour Pharmacy Directory or call Customer Service at 1-866-755-2776, 8 a.m. to 8 p.m., seven days a week (exceptThanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) fromApril 1 through September 30. TTY/TDD users should call 711.MO – Mail Orders: Prescription drugs available through mail order. Allow up to 14 days from the date theprescription is ordered to process and mail. For first time users of the home delivery pharmacy have at least a 30-daysupply of medication on hand when a request is placed with home delivery pharmacy.Drug NameAnti - Infectivesabacavir oral solutionDrug RequirementsTier /Limits4524MO; QLL (960 per30 days)MO; QLL (60 per30 days)MO; QLL (30 per30 days)MO; QLL (60 per30 days)B/D PAR; MOMOMO24MOB/D PAR; MO4454PAR; MOMOMOMO; QLL (180 per30 days)abacavir oral vudineABELCETacyclovir oral capsuleacyclovir oral suspension 200mg/5 mlacyclovir oral tabletacyclovir sodium 50 mg/mlintravenous solutionadefoviralbendazoleALBENZAALINIA ORALSUSPENSION FORRECONSTITUTION5Drug NameDrug RequirementsTier /LimitsALINIA ORAL TABLET4amantadine hcl oral capsuleamantadine hcl oral solutionamantadine hcl oral tabletAMBISOMEamikacin injection solution1,000 mg/4 ml, 500 mg/2 mlamoxicillin oral capsuleamoxicillin oral suspension forreconstitutionamoxicillin oral tabletamoxicillin oral tablet,chewable 125 mg, 250 mgamoxicillin-pot clavulanateoral suspension forreconstitutionamoxicillin-pot clavulanateoral tablet 250-125 mgamoxicillin-pot clavulanateoral tablet 500-125 mg, 875125 mg22344MO; QLL (6 per30 days)MOMOMOB/D PAR; MOMO22MOMO22MOMO3MO4MO3MOYou can find information on what the symbols and abbreviations on this table mean by going to the Legend onpage number 8.Basic PDP 19263 v18 1912 18Effective Date December 1, 2019
Drug NameDrug RequirementsTier /Limitsamoxicillin-pot clavulanateoral tablet extended release 12hramoxicillin-pot clavulanateoral tablet,chewableamphotericin bampicillin oral capsule 250mgampicillin oral capsule 500mgampicillin sodium injectionampicillin sodiumintravenousampicillin-sulbactaminjection recon soln 1.5 gram,3 gramampicillin-sulbactaminjection recon soln 15 gramampicillin-sulbactamintravenous recon soln 1.5gramampicillin-sulbactamintravenous recon soln 3 gramAPTIVUS ORALCAPSULEAPTIVUS ORALSOLUTIONatazanavir oral capsule 150mg, 200 mgatazanavir oral capsule ithromycin intravenousazithromycin oral packetazithromycin oral suspensionfor reconstitutionazithromycin oral tablet 250mg, 250 mg (6 pack), 500mg, 600 mgaztreonamBARACLUDE ORALSOLUTION422B/D PAR; MOMO44MO4MO444MO5443MO; QLL (120 per30 days)QLL (380 per 30days)MO; QLL (60 per30 days)MO; QLL (30 per30 days)PAR; MOMOMO; QLL (30 per30 days)MOMOMO2MO45MOPAR; MO555545Drug NameDrug RequirementsTier /LimitsBICILLIN C-RBICILLIN L-ABIKTARVY445MOMOMO; QLL (30 per30 days)CAPASTATcaspofungin intravenous reconsoln 50 mgcaspofungin intravenous reconsoln 70 mgCAYSTONcefaclor oral capsulecefaclor oral suspension forreconstitution 125 mg/5 mlcefaclor oral suspension forreconstitution 250 mg/5 ml,375 mg/5 mlcefaclor oral tablet extendedrelease 12 hrcefadroxil oral capsulecefadroxil oral suspension forreconstitution 250 mg/5 ml,500 mg/5 mlcefadroxil oral tabletcefazolin in dextrose (iso-os)intravenous piggyback 1gram/50 ml, 2 gram/50 mlcefazolin injection recon soln1 gram, 500 mgcefazolin injection recon soln10 gram, 100 gram, 20gram, 300 gcefazolin intravenouscefdinircefepime in dextrose,iso-osmintravenous piggyback 1gram/50 mlcefepime in dextrose,iso-osmintravenous piggyback 2gram/100 mlcefepime injectioncefotaxime injection recon soln1 gram, 500 mgcefoxitin intravenous reconsoln 1 gram, 2 gram45B/D PAR4B/D PAR543PAR; MO; LAMOMO33MO32MOMO34MOMO4MO4434MO4MO44MO4MOYou can find information on what the symbols and abbreviations on this table mean by going to the Legend onpage number 8.Basic PDP 19263 v18 1912 19Effective Date December 1, 2019
Drug NameDrug RequirementsTier /Limitscefoxitin intravenous reconsoln 10 gramcefpodoximecefprozil oral suspension forreconstitution 125 mg/5 mlcefprozil oral suspension forreconstitution 250 mg/5 mlcefprozil oral tabletceftazidime injection reconsoln 1 gram, 2 gramceftazidime injection reconsoln 6 gramceftriaxone in dextrose,iso-osceftriaxone injection reconsoln 1 gram, 2 gram, 250 mg,500 mgceftriaxone injection reconsoln 10 gram, 100 gramceftriaxone intravenouscefuroxime axetil oral tabletcefuroxime sodium injectionrecon soln 750 mgcefuroxime sodiumintravenous recon soln 1.5gramcefuroxime sodiumintravenous recon soln 7.5gramcephalexin oral capsule 250mg, 500 mgcephalexin oral suspension forreconstitutioncephalexin oral tabletchloramphenicol sod succinatechloroquine phosphateCIMDUO4ciprofloxacin hcl oral tablet100 mgciprofloxacin hcl oral tablet250 mg, 500 mg, 750 mgciprofloxacin in 5 % dextroseclarithromycinclindamycin hclclindamycin in 5 % dextrose3MOMO; QLL (30 per30 OMOMOMO42MO3MO3425MODrug NameDrug RequirementsTier /Limitsclindamycin phosphateinjection solution 150 mg/mlclindamycin phosphateintravenous solution 600 mg/4 mlclotrimazole mucousmembranecolistin (colistimethate na)COMPLERA4MO4MO3MO45CRIXIVAN ORALCAPSULE 200 MGCRIXIVAN ORALCAPSULE 400 MGDAPSONE ORALDAPTOMYCININTRAVENOUS RECONSOLN 350 MGdaptomycin intravenous reconsoln 500 mgDARAPRIMDELSTRIGO435MOMO; QLL (30 per30 days)MO; QLL (360 per30 days)MO; QLL (180 per30 days)MOMO5MODESCOVY5dicloxacillindidanosine oral capsule,delayed release(dr/ec) 200 mgdidanosine oral capsule,delayed release(dr/ec) 250 mg,400 mgDOVATO34doxy-100doxycycline hyclateintravenousdoxycycline hyclate oralcapsuledoxycycline hyclate oral tablet100 mg, 150 mg, 20 mg, 75mgdoxycycline monohydrate oralcapsule 100 mg, 50 mgdoxycycline monohydrate oraltablet 100 mg, 50 mg, 75 mg4444545MO; QLL (30 per30 days)MO; QLL (30 per30 days)MOQLL (60 per 30days)MO; QLL (30 per30 days)MO; QLL (30 per30 days)MO4MO4MO2MO4MOYou can find information on what the symbols and abbreviations on this table mean by going to the Legend onpage number 8.Basic PDP 19263 v18 1912 110Effective Date December 1, 2019
Drug NameDrug RequirementsTier /LimitsEDURANT5efavirenz oral capsule 200 mg4efavirenz oral capsule 50 mg4efavirenz oral tablet5EMTRIVA ORALCAPSULEEMTRIVA ORALSOLUTIONentecavirEPCLUSA4EPIVIR HBV ORALSOLUTIONERYTHROCININTRAVENOUS RECONSOLN 500 MGerythromycin ethylsuccinateoral tableterythromycin oral capsule,delayed release(dr/ec)erythromycin oral tabletethambutolEVOTAZ3famciclovir oral tablet 125mg, 250 mgfamciclovir oral tablet 500mgfluconazole in nacl (iso-osm)intravenous piggyback 200mg/100 mlfluconazole in nacl (iso-osm)intravenous piggyback 400mg/200 mlfluconazole oral suspension forreconstitutionfluconazole oral tabletflucytosine oral capsule 250mgflucytosine oral capsule 500mg3455MO; QLL (30 per30 days)MO; QLL (120 per30 days)MO; QLL (360 per30 days)MO; QLL (30 per30 days)MO; QLL (30 per30 days)MO; QLL (850 per30 days)PAR; MOPAR; MO; QLL(30 per 30 days)MO4MO4MO4MO435MOMOMO; QLL (30 per30 days)MO; QLL (60 per30 days)MO; QLL (21 per7 days)MO3443MO24MOMO5MODrug NameDrug RequirementsTier /Limitsfosamprenavir5FUZEONSUBCUTANEOUSRECON SOLNganciclovir sodiumintravenous recon solngentamicin injectiongentamicin sulfate (ped) (pf)GENVOYA5griseofulvin microsize oralsuspensiongriseofulvin ultramicrosizeHARVONI ORALTABLET 90-400 MGhydroxychloroquineimipenem-cilastatinintravenous recon soln 250mgimipenem-cilastatinintravenous recon soln 500mgINTELENCE ORALTABLET 100 MGINTELENCE ORALTABLET 200 MGINTELENCE ORALTABLET 25 MGINVIRASE ORALTABLETISENTRESS HD3ISENTRESS ORALPOWDER IN PACKETISENTRESS ORALTABLETISENTRESS ORALTABLET,CHEWABLE 100MGISENTRESS ORALTABLET,CHEWABLE 25MGisoniazid oral solutionisoniazid oral tablet4MO; QLL (120 per30 days)MO; QLL (60 per30 days)4B/D PAR; MO445MOMOMO; QLL (30 per30 days)MO4533MOPAR; MO; QLL(28 per 28 days)MOMO4MO5MO; QLL (120 per30 days)MO; QLL (60 per30 days)MO; QLL (480 per30 days)MO; QLL (120 per30 days)MO; QLL (60 per30 days)MO; QLL (180 per30 days)MO; QLL (120 per30 days)MO; QLL (180 per30 days)5445553MO; QLL (720 per30 days)31MOMOYou can find information on what the symbols and abbreviations on this table mean by going to the Legend onpage number 8.Basic PDP 19263 v18 1912 111Effective Date December 1, 2019
Drug NameDrug RequirementsTier /Limitsitraconazole oral capsuleivermectin oralJULUCA425KALETRA ORALTABLET 100-25 MGKALETRA ORALTABLET 200-50 MGketoconazole orallamivudine oral solution4lamivudine oral tablet 100mglamivudine oral tablet 150mglamivudine oral tablet 300mglamivudine-zidovudine4levofloxacin in d5wintravenous piggyback 250mg/50 mllevofloxacin in d5wintravenous piggyback 500mg/100 ml, 750 mg/150 mllevofloxacin intravenouslevofloxacin oral solutionlevofloxacin oral tabletLEXIVA ORALSUSPENSIONLEXIVA ORAL TABLET4linezolid in dextrose 5%linezolid oral suspension forreconstitutionlinezolid oral tablet44linezolid-0.9% nemmethenamine hippuratemethenamine mandelate344252434444424554Drug NameDrug RequirementsTier /LimitsPAR; MOMOMO; QLL (30 per30 days)MO; QLL (300 per30 days)MO; QLL (120 per30 days)MOMO; QLL (960 per30 days)MOmetro i.v.metronidazole in nacl (iso-os)metronidazole oral tablet 250mgmetronidazole oral tablet 500mgminocycline oral capsuleminocycline oral tabletmorgidox oral capsule 50 mgNEBUPENTneomycinnevirapine oral suspension441MOMOMO2MO232324MO; QLL (60 per30 days)MO; QLL (30 per30 days)MO; QLL (60 per30 days)nevirapine oral tablet3nevirapine oral tabletextended release 24 hr 100mgnevirapine oral tabletextended release 24 hr 400mgnitrofurantoin macrocrystaloral capsule 100 mg, 50 mgnitrofurantoin monohyd/mcrystNORVIR ORALPOWDER IN PACKETNORVIR ORALSOLUTIONNORVIR ORAL TABLET4MOMOMOB/D PAR; MOMOQLL (1200 per 30days)MO; QLL (60 per30 days)MONOXAFIL ORALSUSPENSIONnystatin oral suspensionnystatin oral tabletODEFSEY5oseltamiviroxacillin in dextrose(iso-osm)intravenous piggyback 1gram/50 mloxacillin injection recon soln1 gramoxacillin injection recon soln2 gram34MOMOMOMOMO; QLL (1800per 30 days)MO; QLL (120 per30 days)PAR; MO; QLL(1800 per 30 days)PAR; MO; QLL(56 per 28 days)MO; QLL (480 per30 days)MOMOMOMO4MO; QLL (30 per30 days)3PAR; MO3PAR; MO4MO; QLL (360 per30 days)MO; QLL (480 per30 days)MO; QLL (360 per30 days)PAR; MO44335MOMOMO; QLL (30 per30 days)MO44MOYou can find information on what the symbols and abbreviations on this table mean by going to the Legend onpage number 8.Basic PDP 19263 v18 1912 112Effective Date December 1, 2019
Drug NameDrug RequirementsTier /LimitsparomomycinPASERpenicillin g potassiumpenicillin v potassiumPENTAMpentamidine azobactamintravenous recon soln 2.25gram, 3.375 gram, 4.5 gram,40
Nov 01, 2019 · Anthem Blue MedicareRx Standard (PDP)’s Formulary?” Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and pr
for Blue Cross MedicareRx StandardSM (PDP), Blue Cross MedicareRx PlusSM (PDP), and Blue Cross MedicareRx GoldSM (PDP) Available in California This plan is a PDP with a Medicare contract.Anthem Blue Cross Life and Health Insurance Company (Anthem) has contracted with the Centers for M edica
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Anthem Blue Cross Anthem Blue Cross MedicareRx (PDP) EvidEncE of covEragE This booklet is your Evidence of Coverage (EOC). For questions regarding your coverage please call customer service, Monday through Friday, from from 8 a.m. to 9 p.m. ET, excep
Blue Cross MedicareRx (PDP) network pharmacies. Once I am a member of Blue Cross MedicareRx (PDP), I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Anthem Blue
Blue MedicareRx Value (PDP) Blue MedicareRx Plus (PDP) Blue MedicareRx Enhanced (PDP) 21KCKSS5726 Thank you for your interest in our Prescription Drug plans. Blue Cross and Blue Shield of Kansas City offers prescription drug plans designed to help you with your specific drug
Anthem Blue MedicareRx Premier (PDP). There are different types of Medicare plans. Anthem Blue MedicareRx Premier (PDP) is a Medicare prescription drug plan (PDP). Like all Medicare plans, this Medicare prescription drug plan is approved by Medicare and run by a private company. Se
Anthem Blue Cross Life and Health Insurance Company is a PDP plan with a Medicare contract. Enrollment in Anthem Blue Cross Life and Health Insurance Company depends on . Blue Cross MedicareRx (PDP) with Senior Rx Plus provides you with outpatient prescription benefits to help you live
Blue MedicareRxSM Premier (PDP) offered by ANTHEM INSURANCE CO. & BCBSMA & BCBSRI & BCBSVT/Blue MedicareRxSM (PDP) Annual Notice of Changes for 2021 You are currently enrolled as a member of Blue MedicareRx Premier. Next year, there will be some changes to the plan’s
