Formulary LIST OF COVERED DRUGS - Premera Blue Cross
FormularyLIST OF COVERED DRUGSPremera Blue Cross Medicare Advantage HMOPremera Blue Cross Medicare Advantage Classic (HMO)Premera Blue Cross Medicare Advantage Classic Plus (HMO)Premera Blue Cross Medicare Advantage Core (HMO)Premera Blue Cross Medicare Advantage Core Plus (HMO)Premera Blue Cross Medicare Advantage Total Health (HMO)Premera Blue Cross Medicare Advantage Charter Rx (HMO)Premera Blue Cross Medicare Advantage Peak Rx (HMO)Premera Blue Cross Medicare Advantage Sound Rx (HMO)Customer ServiceFor more recent informationor other questions, pleasecontact Premera Blue CrossMedicare Advantage at888-850-8526 (TTY: 711)October 1–March 31,8 a.m. to 8 p.m., 7 days a weekApril 1–Sept 30,8 a.m. to 8 p.m., Mondaythrough Fridaypremera.com/maFILE SUBMISSION ID: 00020386VERSION 16This formulary was updated on 11/25/2020PLEASE READ: This document containsinformation about the drugs we cover in this plan.
Premera Blue Cross Medicare Advantage (HMO)Premera Blue Cross Medicare Advantage Core (HMO)Premera Blue Cross Medicare Advantage Core Plus (HMO)Premera Blue Cross Medicare Advantage Classic (HMO)Premera Blue Cross Medicare Advantage Classic Plus (HMO)Premera Blue Cross Medicare Advantage Total Health (HMO)Premera Blue Cross Medicare Advantage Charter Rx (HMO)Premera Blue Cross Medicare Advantage Peak Rx (HMO)Premera Blue Cross Medicare Advantage Sound Rx (HMO)2020 Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER INTHIS PLAN00020386, Version Number 16i
This formulary was updated on 11/25/2020. For more recent information or other questions, pleasecontact Premera Blue Cross Medicare Advantage Customer Service, at 888-850-8526 or, for TTYusers, 711, Monday -Friday, 8 a.m. to 8 p.m. (7 days a week, 8 a.m. to 8 p.m., from October 1- March31; or visit Premera.com/ma.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,” it means Premera Blue Cross. When itrefers to “plan” or “our plan,” it means Premera Blue Cross Medicare Advantage Plans.This document includes a list of the drugs (formulary) for our plan which is current as of12/01/2020. For an updated formulary, please contact us. Our contact information, along with thedate we last updated the formulary, appears on the front and back cover pages.You must generally use network pharmacies to use your prescription drug benefit. Benefits,formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021,and from time to time during the year.What is the Premera Blue Cross Medicare Advantage (HMO), Premera Blue CrossMedicare Advantage Core (HMO), Premera Blue Cross Medicare Advantage CorePlus (HMO), Premera Blue Cross Medicare Advantage Classic (HMO) , Premera BlueCross Medicare Advantage Classic Plus (HMO), Premera Blue Cross MedicareAdvantage Total Health (HMO), Premera Blue Cross Medicare Advantage Charter Rx (HMO), Premera Blue Cross Medicare Advantage Peak Rx (HMO), Premera BlueCross Medicare Advantage Sound Rx (HMO) Formulary?A formulary is a list of covered drugs selected by Premera Blue Cross Medicare Advantage Plans inconsultation with a team of health care providers, which represents the prescription therapiesbelieved to be a necessary part of a quality treatment program. Premera Blue Cross MedicareAdvantage Plans will generally cover the drugs listed in our formulary as long as the drug ismedically necessary, the prescription is filled at a Premera Blue Cross Medicare Advantage Plansnetwork pharmacy, and other plan rules are followed. For more information on how to fill yourprescriptions, please review your Evidence of Coverage.Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the DrugList during the year, move them to different cost-sharing tiers, or add new restrictions.Changes that can affect you this year: In the below cases, you will be affected by coverage changesduring the year: New generic drugs. We may immediately remove a brand name drug on our Drug List if weare replacing it with a new generic drug that will appear on the same or lower cost sharing tierii
and with the same or fewer restrictions. Also, when adding the new generic drug, we maydecide to keep the brand name drug on our Drug List, but immediately move it to a differentcost-sharing tier or add new restrictions. If you are currently taking that brand name drug, wemay not tell you in advance before we make that change, but we will later provide you withinformation about the specific change(s) we have made.o If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will alsoinclude information on how to request an exception, and you can also find informationin the section below entitled “How do I request an exception to the Premera Blue CrossMedicare Advantage (HMO), Premera Blue Cross Medicare Advantage Core (HMO),Premera Blue Cross Medicare Advantage Core Plus (HMO), Premera Blue CrossMedicare Advantage Classic (HMO) , Premera Blue Cross Medicare Advantage ClassicPlus (HMO), Premera Blue Cross Medicare Advantage Total Health (HMO), PremeraBlue Cross Medicare Advantage Charter Rx (HMO), Premera Blue Cross MedicareAdvantage Peak Rx (HMO), or Premera Blue Cross Medicare Advantage Sound Rx(HMO) Formulary?” Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who takethe drug. Other changes. We may make other changes that affect members currently taking a drug.For instance, we may add a generic drug that is not new to market to replace a brand namedrug currently on the formulary or add new restrictions to the brand name drug or move it to adifferent cost-sharing tier, or both. Or we may make changes based on new clinicalguidelines. If we remove drugs from our formulary, add prior authorization, quantity limitsand/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, wemust notify affected members of the change at least 30 days before the change becomeseffective, or at the time the member requests a refill of the drug, at which time the memberwill receive a 30-day supply of the drug.o If we make these other changes, you or your prescriber can ask us to make anexception and continue to cover the brand name drug for you. The notice we provideyou will also include information on how to request an exception, and you can also findinformation in the section below entitled “How do I request an exception to thePremera Blue Cross Medicare Advantage (HMO), Premera Blue Cross MedicareAdvantage Core (HMO), Premera Blue Cross Medicare Advantage Core Plus (HMO),Premera Blue Cross Medicare Advantage Classic (HMO) , Premera Blue CrossMedicare Advantage Classic Plus (HMO), Premera Blue Cross Medicare AdvantageTotal Health (HMO), Premera Blue Cross Medicare Advantage Charter Rx (HMO),Premera Blue Cross Medicare Advantage Peak Rx (HMO), or Premera Blue CrossMedicare Advantage Sound Rx (HMO) Formulary?”Changes that will not affect you if you are currently taking the drug. Generally, if you are taking adrug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue oriii
reduce coverage of the drug during the 2020 coverage year except as described above. This meansthese drugs will remain available at the same cost-sharing and with no new restrictions for thosemembers taking them for the remainder of the coverage year.The enclosed formulary is current as of 10/01/2020. To get updated information about the drugscovered by Premera Blue Cross Medicare Advantage Plans, please contact us. Our contactinformation appears on the front and back cover pages. We will update print formularies in theevent of mid-year non-maintenance formulary changes.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categoriesdepending on the type of medical conditions that they are used to treat. For example, drugs usedto treat a heart condition are listed under the category, “Cardiovascular”. If you know what yourdrug is used for, look for the category name in the list that begins below. Then look under thecategory name for your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index thatbegins on page 60. The Index provides an alphabetical list of all of the drugs included in thisdocument. Both brand name drugs and generic drugs are listed in the Index. Look in the Indexand find your drug. Next to your drug, you will see the page number where you can find coverageinformation. Turn to the page listed in the Index and find the name of your drug in the firstcolumn of the list.What are generic drugs?Premera Blue Cross Medicare Advantage Plans cover both brand name drugs and generic drugs.A generic drug is approved by the FDA as having the same active ingredient as the brand namedrug. Generally, generic drugs cost less than brand name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirementsand limits may include: Prior Authorization: Premera Blue Cross Medicare Advantage Plans requires you or yourphysician to get prior authorization for certain drugs. This means that you will need to getapproval from Premera Blue Cross Medicare Advantage Plans before you fill youriv
prescriptions. If you don’t get approval, Premera Blue Cross Medicare Advantage Plans maynot cover the drug. Quantity Limits: For certain drugs, Premera Blue Cross Medicare Advantage Plans limits theamount of the drug that Premera Blue Cross Medicare Advantage Plans will cover. Forexample, Premera Blue Cross Medicare Advantage Plans provides 30 tablets per prescriptionfor desvenlafaxine. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Premera Blue Cross Medicare Advantage Plans requires you tofirst try certain drugs to treat your medical condition before we will cover another drug forthat condition. For example, if Drug A and Drug B both treat your medical condition, PremeraBlue Cross Medicare Advantage Plans may not cover Drug B unless you try Drug A first. IfDrug A does not work for you, Premera Blue Cross Medicare Advantage Plans will then coverDrug B.You can find out if your drug has any additional requirements or limits by looking in the formularythat begins on page 1. You can also get more information about the restrictions applied to specificcovered drugs by visiting our web site. We have posted online documents that explain our priorauthorization and step therapy restrictions. You may also ask us to send you a copy. Our contactinformation, along with the date we last updated the formulary, appears on the front and back coverpages.You can ask Premera Blue Cross Medicare Advantage Plans to make an exception to theserestrictions or limits or for a list of other, similar drugs that may treat your health condition. See thesection, “How do I request an exception to the Premera Blue Cross Medicare Advantage Plans’formulary?” on page vii for information about how to request an exception.What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contactCustomer Service and ask if your drug is covered.If you learn that Premera Blue Cross Medicare Advantage Plans do not cover your drug, you havetwo options: You can ask Customer Service for a list of similar drugs that are covered by Premera BlueCross Medicare Advantage Plans. When you receive the list, show it to your doctor and askhim or her to prescribe a similar drug that is covered by Premera Blue Cross MedicareAdvantage Plans.v
You can ask Premera Blue Cross Medicare Advantage Plans to make an exception and coveryour drug. See below for information about how to request an exception.How do I request an exception to the Premera Blue Cross Medicare Advantage(HMO), Premera Blue Cross Medicare Advantage Core (HMO), Premera Blue CrossMedicare Advantage Core Plus (HMO), Premera Blue Cross Medicare AdvantageClassic (HMO), Premera Blue Cross Medicare Advantage Classic Plus (HMO),Premera Blue Cross Medicare Advantage Total Health (HMO), Premera Blue CrossMedicare Advantage Charter Rx (HMO), Premera Blue Cross Medicare AdvantagePeak Rx (HMO), or Premera Blue Cross Medicare Advantage Sound Rx (HMO)Formulary?You can ask Premera Blue Cross Medicare Advantage Plans to make an exception to our coveragerules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will becovered at a pre-determined cost-sharing level, and you would not be able to ask us toprovide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not onthe specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certaindrugs, Premera Blue Cross Medicare Advantage Plans limit the amount of the drug that wewill cover. If your drug has a quantity limit, you can ask us to waive the limit and cover agreater amount.Generally, Premera Blue Cross Medicare Advantage Plans will only approve your request for anexception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug. oradditional utilization restrictions would not be as effective in treating your condition and/or wouldcause you to have adverse medical effects.You should contact us to ask us for an initial coverage decision for a formulary, tier, or utilizationrestriction exception. When you request a formulary, tier or utilization restriction exception youshould submit a statement from your prescriber or physician supporting your request. Generally,we must make our decision within 72 hours of getting your prescriber’s supporting statement. Youcan request an expedited (fast) exception if you or your doctor believe that your health could beseriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, wemust give you a decision no later than 24 hours after we get a supporting statement from yourdoctor or other prescriber.vi
What do I do before I can talk to my doctor about changing my drugs or requestingan exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary.Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example,you may need a prior authorization from us before you can fill your prescription. You should talk toyour doctor to decide if you should switch to an appropriate drug that we cover or request aformulary exception so that we will cover the drug you take. While you talk to your doctor todetermine the right course of action for you, we may cover your drug in certain cases during the first90 days you are a member of our plan.For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, wewill cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refillsto provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will notpay for these drugs, even if you have been a member of the plan less than 90 days.If you are a resident of a long-term care facility and you need a drug that is not on our formulary or ifyour ability to get your drugs is limited, but you are past the first 90 days of membership in our plan,we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.Premera Blue Cross assures that members with level of care changes have access to transitionsupplies of medications as required. Please see the Premera Blue Cross Transition Policy on ourwebsite (premera.com/ma) for more information.For more informationFor more detailed information about your Premera Blue Cross Medicare Advantage Plansprescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Premera Blue Cross Medicare Advantage Plans, please contact us. Ourcontact information, along with the date we last updated the formulary, appears on the front andback cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1800-MEDICARE (1-800-633-4227) 24 hours a day/ 7 days a week. TTY users should call 1-877-4862048. Or, visit http://www.medicare.gov.Premera Blue Cross Medicare Advantage Plans’ FormularyThe formulary below provides coverage information about the drugs covered by Premera Blue CrossMedicare Advantage Plans. If you have trouble finding your drug in the list, turn to the Index thatbegins on page 60.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA)and generic drugs are listed in lower-case italics (e.g., metformin hcl).vii
The information in the Requirements/Limits column tells you if Premera Blue Cross MedicareAdvantage Plans have any special requirements for coverage of your drug.COVERAGE NOTES lization Management RestrictionsPAPriorAuthorizationRestrictionYou (or your physician) are required to get priorauthorization from Premera Blue Cross MedicareAdvantage Plans before you fill your prescription for thisdrug. Without prior approval, Premera Blue Cross MedicareAdvantage Plans may not cover this drug.B/DPriorAuthorization todetermine Part Bversus Part DcoverageThis drug may be covered under Medicare Part B or Ddepending on the circumstances. Information may need tobe submitted describing the use and setting of the drug tomake the determination.QLQuantity LimitRestrictionPremera Blue Cross Medicare Advantage Plans limits theamount of this drug that is covered per prescription, orwithin a specific time frame.STStep TherapyRestrictionBefore Premera Blue Cross Medicare Advantage Plans willprovide coverage for this drug, you must first try anotherdrug to treat your medical condition. This drug may only becovered if the other drug does not work for you.Other Special Requirements for CoverageLALimited AccessDrugThis prescription may be available only at certainpharmacies. For more information consult your PharmacyDirectory or call Customer Service888-850-8526 (TTY/ TDD: 711)April 1 – September 30, Monday – Friday, 8 a.m. to 8 p.m.October 1 – March 31, 7 days a week, 8 a.m. to 8 p.m.NMNon-Mail OrderNot available at our mail-order pharmacies.viii
Drug Payment Stages and Drug TiersThe amount you pay for a covered drug will depend on: Drug payment stage. There are different stages of drug coverage in your plan. The amountyou pay will depend on the coverage stage you’re in. Drug tier. There are five drug tiers. Each tier has a copay and/or co-insurance amount. Thechart below shows the differences between the tiers.Please take a look at your Evidence of Coverage for more information about drug coverage andcopay or coinsurance amounts for each tier.Drug TierIncludesCost Sharing Tier 1:Tier 1 is the lowest tier and includes preferred generic drugsPreferred GenericCost Sharing Tier 2:Tier 2 includes generic drugsGenericCost Sharing Tier 3:Preferred BrandCost Sharing Tier 4:Non-Preferred DrugsTier 5:Specialty TierTier 3 includes preferred brand drugs and non-preferred genericdrugs.Tier 4 includes non-preferred brand drugs and non-preferred genericdrugsTier 5 is the highest tier. It contains very high cost brand and genericdrugs, which may require special handling and/or close monitoring.Extra HelpMembers who qualify will receive Extra Help for prescription drugs, copays, and coinsurance. Pleaseread the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs”(LIS Rider), to learn about your costs. You can also call customer service. Our contact informationappears on the front and back cover pages.ix
PREMERA CY20 5T STND eff 12/01/2020Drug NameDrug Tier Requirements/LimitsANALGESICSGOUTallopurinol tabcolchicine w/ probenecidCOLCRYSMITIGAREprobenecid12332QL (120 tabs / 30 days)QL (60 caps / 30 days)NSAIDScelecoxib CAPS 50mgcelecoxib CAPS 100mgcelecoxib CAPS 200mgcelecoxib CAPS 400mgdiclofenac potassiumdiclofenac sodium TB24; TBECdiflunisal TABSec-naproxenetodolacetodolac erflurbiprofen TABS 100mgibu tab 600mgibu tab 800mgibuprofen SUSPibuprofen TABS 400mg, 600mg, 800mgmeloxicam TABSnabumetone TABSnaproxen TABS 250mg, 375mg, 500mgnaproxen drnaproxen sodium TABS 275mg, 550mgpiroxicam CAPSsulindac TABS2222222222211211112222QLQLQLQLQL(240 caps / 30 days)(120 caps / 30 days)(60 caps / 30 days)(30 caps / 30 days)(120 tabs / 30 days)22224QLQLQLQL(400 tabs(360 tabs(180 tabs(2700 mLOPIOID ANALGESICSacetaminophen w/ codeine 300-15mgacetaminophen w/ codeine 300-30mgacetaminophen w/ codeine 300-60mgacetaminophen w/ codeine solnbutorphanol tartrate SOLN 1mg/ml,2mg/mlnalbuphine hcl SOLNtramadol hcl tab 50 )days)422QL (240 tabs / 30 days)QL (240 tabs / 30 days)22QL (360 tabs / 30 days)QL (360 tabs / 30 days)OPIOID ANALGESICS, CIIendocet 2.5-325mgendocet 5-325mgPA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available atmail-order B/D - Covered under Medicare B or D LA - Limited Access1
Drug Nameendocet 7.5-325mgendocet 10-325mgfentanyl citrate LPOPDrug Tier225fentanyl patch 12 mcg/hr2fentanyl patch 25 mcg/hr2fentanyl patch 50 mcg/hr2fentanyl patch 75 mcg/hr2fentanyl patch 100 mcg/hr2hydroco/apap tab 5-325mghydroco/apap tab 7.5-325hydroco/apap tab 10-325mghydrocodone-acetaminophen 7.5-325mg/15mlhydrocodone-ibuprofen tab 7.5-200 mghydromorphone hcl LIQDhydromorphone hcl SOLN 10mg/ml,50mg/5ml, 500mg/50mlhydromorphone hcl TABSHYSINGLA ER2222Requirements/LimitsQL (240 tabs / 30 days)QL (180 tabs / 30 days)QL (120 lozenges / 30days), PAQL (10 patches / 30days), PAQL (10 patches / 30days), PAQL (10 patches / 30days), PAQL (10 patches / 30days), PAQL (10 patches / 30days), PAQL (240 tabs / 30 days)QL (180 tabs / 30 days)QL (180 tabs / 30 days)QL (2700 mL / 30 days)224QL (150 tabs / 30 days)QL (600 mL / 30 days)B/D23methadone hcl SOLN 5mg/5ml, 10mg/5ml2methadone hcl 5mg2methadone hcl 10mg2methadone hcl intensol2morphine ext-rel tab2morphine sul inj 1mg/mlMORPHINE SULFATE SOLN 2mg/ml,4mg/ml, 5mg/ml, 8mg/ml, 10mg/mlmorphine sulfate SOLN 4mg/ml, 8mg/ml,10mg/mlmorphine sulfate TABSmorphine sulfate oral soln 10mg/5mlmorphine sulfate oral soln 20mg/5mlmorphine sulfate oral soln 100mg/5mlNUCYNTA ER44QL (180 tabs / 30 days)QL (30 tabs / 30 days),PAQL (450 mL / 30 days),PAQL (90 tabs / 30 days),PAQL (90 tabs / 30 days),PAQL (90 mL / 30 days),PAQL (90 tabs / 30 days),PAB/DB/D4B/D22223QLQLQLQLQLPA(180 tabs / 30 days)(900 mL / 30 days)(900 mL / 30 days)(180 mL / 30 days)(60 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 Access2
Drug Nameoxycodone hcl CAPSoxycodone hcl CONCoxycodone hcl SOLNoxycodone hcl TABSoxycodone w/ acetaminophenoxycodone w/ acetaminophenoxycodone w/ acetaminophenoxycodone w/ acetaminophen2.5-325mg5-325mg7.5-325mg10-325mgDrug Tier22222222Requirements/LimitsQL (180 caps / 30 days)QL (180 mL / 30 days)QL (900 mL / 30 days)QL (180 tabs / 30 days)QL (360 tabs / 30 days)QL (360 tabs / 30 days)QL (240 tabs / 30 days)QL (180 tabs / 30 days)ANESTHETICSLOCAL ANESTHETICSlidocainelidocainelidocainelidocainehcl (local anesth.)inj 0.5%inj 1%inj 1.5% preservative free (pf)2222B/DB/DB/DB/DANTI-INFECTIVESANTI-BACTERIALS - MISCELLANEOUSamikacin sulfate SOLNgentamicin in salinegentamicin sulfate SOLNneomycin sulfate TABSparomomycin sulfate CAPSstreptomycin sulfate SOLRSULFADIAZINE TABStobramycin NEBU 300mg/5mltobramycin inj 1.2 gm/30mltobramycin inj 1.2gmtobramycin inj 10mg/mltobramycin inj 80mg/2mltobramycin sulfate SOLN2222254525222NM, PAANTI-INFECTIVES - MISCELLANEOUSalbendazole TABSALINIAatovaquone SUSPaztreonamCAYSTONclindamycin cap 75mgclindamycin cap 300mgclindamycin hcl cap 150 mgclindamycin phosphate in d5wCLINDAMYCIN PHOSPHATE IN NACLclindamycin phosphate injclindamycin soln 75mg/5mlcolistimethate sodium SOLRdapsone TABS55525111242222NM, LA, PAPA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available atmail-order B/D - Covered under Medicare B or D LA - Limited Access3
Drug NameDrug Tierdaptomycin5EMVERM5ertapenem sodium2imipenem-cilastatin2ivermectin TABS2linezolid in sodium chloride4linezolid inj2linezolid susp5linezolid tab 600mg2meropenem2methenamine hippurate2metronidazole TABS1metronidazole in nacl2nitrofurantoin macrocrystal 50mg, 100mg3nitrofurantoin monohyd macro3pentamidine isethionate inh2pentamidine isethionate inj2praziquantel TABS2SIVEXTRO5sulfamethoxazole-trimethop ds1sulfamethoxazole-trimethoprim inj2sulfamethoxazole-trimethoprim susp2sulfamethoxazole-trimethoprim tab 400180mgSYNERCID5tigecycline5trimethoprim TABS1vancomycin hcl CAPS 125mg2vancomycin hcl CAPS 250mg52vancomycin hcl SOLR 1gm, 5gm, 10gm,500mg, 750mgVANCOMYCIN IN NACL4Requirements/LimitsQL (12 tabs / 365 days)B/DQL (120 caps / 30 days)QL (240 caps / 30 days)ANTIFUNGALSABELCETAMBISOMEamphotericin b SOLRcaspofungin acetatefluconazole SUSRfluconazole TABS 50mg, 100mg, 200mgfluconazole TABS 150mgfluconazole inj nacl 200fluconazole inj nacl 400flucytosine CAPSgriseofulvin microsizegriseofulvin ultramicrosize552522122522B/DB/DB/DPA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available atmail-order B/D - Covered under Medicare B or D LA - Limited Access4
Drug Nameitraconazole CAPSketoconazole TABSmicafungin sodiumMYCAMINENOXAFIL SUSPnystatin TABSposaconazoleterbinafine hcl TABSvoriconazole SOLRvoriconazole SUSRvoriconazole TABS 50mgvoriconazole TABS 200mgDrug Tier225552515525Requirements/LimitsPAPAQL (630 mL / 30 days)QL (93 tabs / 30 days)QL (90 tabs / year)PAPAANTIMALARIALSatovaquone-proguanil hclchloroquine phosphate TABSCOARTEMmefloquine hclprimaquine phosphate 26.3mgPRIMAQUINE PHOSPHATE 26.3mgquinine sulfate MNMNMNMNMNMNMNMNMNMNMNMNMNMNMNMNMNMANTIRETROVIRAL AGENTSabacavir sulfateAPTIVUSatazanavir sulfateCRIXIVANdidanosineEDURANTefavirenz CAPS 50mgefavirenz CAPS 200mgefavirenz TABSemtricitabineEMTRIVAfosamprenavir tab 700 mgFUZEONINTELENCE 25mgINTELENCE 100mg, 200mgINVIRASEISENTRESS CHEW 25mgISENTRESS CHEW 100mgISENTRESS PACKISENTRESS TABSISENTRESS HDlamivudineLEXIVA SUSPnevirapine susp 50 mg/5mlPA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available atmail-order B/D - Covered under Medicare B or D LA - Limited Access5
Drug Namenevirapine tab 100mg ernevirapine tab 200mgnevirapine tab 400mg erNORVIR PACKNORVIR SOLNPIFELTROPREZISTA SUSPDrug Tier2224455PREZISTA TABS 75mg4PREZISTA TABS 150mg5PREZISTA TABS 600mg5PREZISTA TABS 800mg5REYATAZ PACKritonavirRUKOBIASELZENTRY SOLNSELZENTRY TABS 25mgSELZENTRY TABS 75mg, 150mg, 300mgstavudinetenofovir disoproxil fumarateTIVICAY 10mgTIVICAY 25mg, 50mgTIVICAY PDTROGARZOTYBOSTVIRACEPTVIREAD POWDVIREAD TABS 150mg, 200mg, 250mgzidovudine cap 100mgzidovudine syp 50mg/5mlzidovudine tab MNMNMQL (400 mL / 30 days),NMQL (480 tabs / 30 days),NMQL (240 tabs / 30 days),NMQL (60 tabs / 30 days),NMQL (30 tabs / 30 days),NMNMNMNMNMNMNMNMNMNMNMNMNM, ROVIRAL COMBINATION AGENTSabacavir sulfate-lamivudineabacavir COMPLERADELSTRIGODESCOVYDOVATOPA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available atmail-order B/D - Covered under Medicare B or D LA - Limited Access6
Drug NameDrug Tierefavirenz-emtricitabine-tenofovir disoproxil5fumarateefavirenz-lamivudine-tenofovir disoproxil5fumarateemtricitabine-tenofovir disoproxil fumarate5EVOTAZGENVOYAJULUCAKALETRA TAB 100-25MGKALETRA TAB EFSEYPREZCOBIXSTRIBILDSYMFISYMFI LOSYMTUZATEMIXYSTRIUMEQTRUVADA TAB 100-1505554522555555555TRUVADA TAB 133-2005TRUVADA TAB 167-2505TRUVADA TAB 200-3005Requirements/LimitsNMNMQL (30NMNMNMNMNMNMNMNMNMNMNMNMNMNMNMNMQL (30NMQL (30NMQL (30NMQL (30NMtabs / 30 days),tabs / 30 days),tabs / 30 days),tabs / 30 days),tabs / 30 days),ANTITUBERCULAR AGENTScycloserine CAPSethambutol hcl TABSisoniazid TABSisoniazid syp 50mg/5mlPASER D/RPRIFTINpyrazinamide TABSrifabutinrifampin CAPS; SOLRSIRTUROTRECATOR52124422254LA, PAANTIVIRALSacyclovir CAPS; TABSacyclovir SUSPacyclovir sodium122B/DPA - 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 Tieradefovir dipivoxil5BARACLUDE SOLN5entecavir2EPCLUSA5EPIVIR HBV SOLN4famciclovir TABS2ganciclovir sodium2HARVONI5lamivudine (hbv)2MAVYRET5oseltamivir phosphate CAPS 30mg2oseltamivir phosphate CAPS 45mg, 75mg2oseltamivir phosphate SUSR2PEGASYS5PEGASYS PROCLICK5RELENZA DISKHALER3ribavirin 200mg2rimantadine hydrochloride2valacyclovir hcl TABS2valganciclovir hcl5VEMLIDY5VOSEVI5Requirements/LimitsNMNMNMNM, PANMB/DNM, PANMNM, PAQL (168 caps / year)QL (84 caps / year)QL (1080 mL / year)NM, PANM, PAQL (6 inhalers / year)NMNMNM, PACEPHALOSPORINScefaclorCEFACLOR MONOHYDRATE ERcefadroxil CAPScefadro
What are generic drugs? Premera Blue Cross Medicare Advantage Plans cover both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage?
The UCare formulary is a list of generic and brand drugs that are covered by this plan(s). To be covered, the drug must be on our formulary. The most current list of covered drugs can be found on the UCare . Express Scripts for review/copay override. Contraceptives Women u
Express Scripts Medicare (PDP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION . ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN. Formulary ID Number: 19057, v5. This formulary was updated on 08/24/2018. For more recent information or to price a medication,
Express Scripts Medicare (PDP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION . ABOUT THE DRUGS WE COVER IN THIS PLAN . Formulary ID Number: 19155, Version 5 . This formulary was updated on 09/27/2018. For more recent information or
Oct 19, 2017 · Express Scripts Medicare (PDP) 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION . ABOUT THE DRUGS WE COVER IN THIS PLAN . Formulary File Submission ID: 17070, V18. This formulary was updated on 10/19/2017. For more recent informa
UPMC for Life Dual (HMO SNP) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00016312, Version Number 17.
Pharmacy Benefit Dimensions Prescription Drug Plan . Part D Formulary . 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINSINFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN . HPMS Approved Formulary File Submission ID 00019368, Version Number 33. This formulary was updated on December 1, 2019.
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
WellCare Reserve (HMO D-SNP), WellCare Select (HMO D-SNP), WellCare Summit (PPO) Comprehensive Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believe
