Highmark Blue Cross Blue Shield Of Western New York Formulary 2
Highmark Blue Cross Blue Shield of Western New York Formulary 2 Please bring this guide with you the next time you visit your doctor. If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the Highmark BCBSWNY web site at www.bcbswny.com. CRP2111 0016282.1 MG016282D (Revise Date 07/01/2022) Highmark Blue Cross Blue Shield of Western New York is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association.
TABLE OF CONTENTS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding the symbols used throughout this book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using iii iii this formulary book to help contain costs . iv Save Money on Your Prescription Drugs. . . . . . . . . . . . . . . . . iv Finding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . . . v Section 1 — Therapeutic Drug Categories . . . . . . . . . . 1 Section II — Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 ii
The Highmark Blue Cross Blue Shield of Western New York Formulary 2 is a list of drugs to help guide physicians and pharmacists to select the medication that provides the appropriate treatment for the best price. Introduction Highmark Blue Cross Blue Shield of Western New York has established an independent committee of practicing physicians and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories. Understanding the symbols used throughout this book Throughout this book, you will see certain symbols that indicate a management program is in place for selected medications. The symbols are as follows: Key P z u o step edit applies to this drug. Step therapy means that in order to receive the medication A with a step edit, a preferred medication must be tried first. Specific quantity limits apply. Quantity limits are in place to ensure members receive the appropriate amount of medication not to exceed the maximum allowable daily dosage of medication. Prior authorization required. Prior authorization (also referred to as coverage review) means that a healthcare professional must submit clinical documentation to obtain approval for a member to receive the medication. Prior authorizations ensure medications are being used appropriately. Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month copay. Access restricted to specialty pharmacy. Medications must be obtained through a specialty pharmacy. Custom Home Delivery. The medication should be obtained through the mail service pharmacy. The medication is subject to a retail refill allowance. Affordable Care Act (ACA) Preventive Drug. The medication is included on the ACA Preventive Drug List. iii
Using this formulary book to help contain costs Many employers, benefit sponsors, and individuals may use the formulary to help manage the overall cost of providing prescription drug benefits. The formulary offers a wide range of outpatient medications. Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on the market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed formulary guide the drugs that are most commonly prescribed for our members. If you have any questions regarding coverage of a drug, please call the customer service number on your card. Save Money on Your Prescription Drugs Here’s what you can do to save money: 1. Bring this member guide to your doctor and review the cost-saving information below. 2. Ask your doctor whether a drug listed in this guide is right for you.* Tier 1 Tier 2 Tier 3 Lowest cost to you Highest cost to you The amount you pay for a drug is determined by which medication you purchase and to what tier it is assigned. Some drug plans exclude certain drugs or classes of drugs from coverage. Please check your contract or other plan documents if you have a question about your specific drug coverage. Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost share may vary by plan. Affordable Care Act (ACA) Preventive Drug List The Affordable Care Act (ACA) Preventive Drug List consists of medications that may be covered at 0. They are not subject to any annual deductibles, coinsurance, or copayments. Please refer to your plan documents to confirm if the ACA Preventive Drug List applies to you. We’ve noted any drugs on the ACA Preventive Drug List within this guide. Please consult the key on page iii. This list is reviewed periodically and is subject to change. The presence of a drug on this list does not guarantee coverage. Drugs on this list may require prior authorization, step-edits, and quantity limits. Restrictions may apply to certain brand-name ACA medications with generic equivalents. Other restrictions may apply according to U.S. Preventive Services Task Force (USPSTF) recommendations, which define ACA coverage requirements. These restrictions may be based on age, dose, diagnosis, and others as recommended by USPSTF. Both prescription and over-the-counter (OTC) products are eligible to be covered when prescribed by a licensed health care provider and require a valid prescription. * Some plan designs require that you use a Tier 1 generic drug if a generic is available. Disclaimer: The Highmark Blue Cross Blue Shield of Western New York Medication Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the Highmark Blue Cross Blue Shield of Western New York Formulary 2. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability. iv
Contraceptive Coverage under New York Insurance Law Contraceptives (for members whose benefits align with contraceptive coverage requirements under New York Insurance Law): All tier 1 contraceptives are covered at a 0 copayment. Brand-name contraceptives without a generic equivalent are covered at a 0 copayment. Brand-name contraceptives with a generic equivalent are covered at the copayment based on your plan design unless deemed medically necessary by the prescriber. The prescriber must designate “DAW” (Dispense as Written) on the prescription in order for the brand-name contraceptive with a generic equivalent to be considered medically necessary and covered at a 0 copayment. Both prescription and over-the-counter (OTC) products are covered only when prescribed by a licensed health care provider and require a valid prescription. Please refer to your plan documents to confirm your cost share for contraceptives. Cost share may vary by plan. Contraceptives may include implantable rods, intrauterine devices (IUD), shots/injections, oral contraceptives, patches, vaginal contraceptive rings, diaphragms, sponges, cervical caps, condoms, spermicides, and emergency contraceptives. Please see the “Women’s Health” section of this guide for specific product examples. Custom Home Delivery: Members must obtain maintenance medications at mail-order after retail allowance is exhausted for members with Custom Home Delivery Benefit. Finding Medications in the Guide This guide lists medications two different ways: Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis) Locate a category and drug on the guide and you will see the tier and copayment for that drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a generic or brand-name medication, look at the name of the drug. Generic medications are lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair). Section 2: Alphabetically by drug name. Use this list to find your drug. Questions? Please call Pharmacy Services at 1 800 939-3751 if you have any questions about the Highmark Blue Cross Blue Shield of Western New York Formulary 2. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com. v
Section I — Therapeutic drug categories TIER TIER Allergy/Cough & Cold Antihistamines & Decongestants brompheniramine/ phenylephrine brompheniramine/ pseudoephedrine Pz carbinoxamine o cetirizine clemastine cyproheptadine dexchlorpheniramine diphenhydramine hydroxyzine HCl hydroxyzine pamoate zo levocetirizine loratadine loratadine-D pseudoephedrine Semprex-D zo Clarinex-D zo desloratadine z Grastek z Odactra z Oralair z Palforzia z Ragwitek Expectorant & Cough Products benzonatate guaifenesin/codeine hydrocodone/chlorpheniramine hydrocodone/homatropine promethazine/codeine promethazine/DM promethazine/phenylephrine/ codeine pseudoephedrine/codeine Cardec/DM Guaifenesin DM Hycodan Rondec DM/TR Vituz Mucolytic Agents acetylcysteine inh soln. Nasal Medications azelastine nasal spray budesonide nasal spray Clarispray Flonase Allergy Relief Flonase Sensimist zo fluticasone nasal spray ipratropium nasal spray z Nasacort Allergy 24HR Rhinocort Allergy triamcinolone nasal spray Atrovent Nasal Spray Pzo Beconase AQ Dymista zo flunisolide nasal spray zo mometasone nasal spray Pzo Nasacort AQ Pzo Omnaris Pzo Qnasl zo Xhance Pzo Zetonna Alzheimer Agents 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 3 3 3 3 3 3 3 3 3 3 donepezil ergoloid mesylates galantamine galantamine ER memantine memantine ER rivastigmine rivastigmine patch Namzaric 1 1 1 1 1 1 1 1 2 K-Phos Alkalinizers potassium citrate Oracit Analgesics phenazopyridine Anticholinergics z oxybutynin z oxybutynin ER z Oxytrol for Women z solifenacin z tolterodine z tolterodine ER 2 zo zo zo zo zo zo zo z Bladder/Kidney Acidifiers 1 3 1 1 1 1 1 1 1 z trospium z trospium ER z Myrbetriq z Toviaz Pz Detrol Pz Detrol LA Pz Ditropan XL Pz Enablex Pz Gelnique Pz Oxytrol Pz Sanctura Pz Sanctura XR Cholinergic Agents Urecholine Miscellaneous Pz Gemtesa z Jynarque P Tarpeyo tiopronin Blood Anticoagulants/antithrombotics anagrelide aspirin 325mg OTC aspirin 81mg OTC o aspirin-dipyridamole o clopidogrel o dipyridamole enoxaparin fondaparinux sodium heparin jantoven o prasugrel ticlopidine warfarin o Brilinta Coumadin Eliquis Fragmin Xarelto Bevyxxa zo Durlaza Innohep z Pradaxa z Savaysa zo Zontivity Other Blood Modifiers o calcitonin-salmon inj. o cilostazol deferasirox pentoxifylline z trientine z Actimmune Aranesp Epogen Fulphila Leukine Neulasta Procrit z Promacta z Revlimid Zarxio Alprolix z Cablivi deferiprone z Doptelet Eloctate z Endari Exjade Ferriprox Granix Hemlibra Jadenu Jivi o Miacalcin inj. Mircera z Mulpleta Neupogen Nivestym P Nyvepria Omontys z Oxbryta z Pyrukynd P Releuko Retacrit z Tavalisse P Udenyca P Ziextenzo z Zontivity KEY: P A step edit applies to this drug. z Specific Quantity Limits Apply. Prior Authorization Required. u Included in Tablet-Splitting Program TIER Cancer Drugs 1 1 2 2 3 3 3 3 3 3 3 3 Alkylating Agents cyclophosphamide Alkeran CeeNu Emcyt Hexalen Leukeran Myleran Antimetabolites capecitabine mercaptopurine methotrexate Purixan z Inqovi Onureg Trexall z Xatmep Hormones anastrozole bicalutamide exemestane flutamide letrozole leuprolide megestrol tamoxifen Fareston z Nubeqa Miscellaneous z abiraterone acetate z erlotinib etoposide z everolimus (generic Afinitor) hydroxyurea z imatinib z lapatinib nilutamide z sunitinib temozolomide z Arcalyst z Bosulif z Cabometyx z Caprelsa z Cometriq z Cotellic z Erivedge z Gilotrif Hycamtin capsule z Ibrance z Iclusig z Imbruvica z Inlyta Intron A z Iressa z Jakafi z Lenvima z Lonsurf z Lynparza Lysodren Matulane z Mekinist Mesnex z Nexavar z Ninlaro z Odomzo z Pomalyst z Sprycel z Stivarga z Sylatron z Synribo z Tafinlar z Tagrisso z Tasigna Thalomid z Valchlor z Verzenio z Votrient z Xalkori z Xtandi z Zelboraf z Zolinza z Zydelig z Zykadia Pz Afinitor z Alecensa z Alunbrig z Ayvakit z Balversa z Besremi z Braftovi z Brukinsa 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 3 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 2 2 2 2 2 2 1 1 1 2 3 3 3 3 1 1 1 1 1 1 1 1 2 3 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 z z z z z z Pz z z z Pz z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z Calquence Copiktra Daurismo Erleada Exkivity Fotivda Gavreto Gleevec Idhifa Inrebic Kesimpta Kisqali Kisqali Femara Co-Pack Koselugo Lorbrena Lumakras Mektovi Nerlynx Orgovyx Pemazyre Piqray Qinlock Retevmo Rozlytrek Rubraca Rydapt Scemblix Siklos Sutent Tabrecta Talzenna Tarceva Tazverik Temodar Tepmetko Tibsovo Truseltiq Tukysa Turalio Tykerb Ukoniq Venclexta Vitrakvi Vizimpro Vonjo Welireg Xgeva z Xospata z Xpovio z Yonsa z Zejula Pz Zytiga Rexinoids bexarotene Targretin gel Diabetes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 2 Please refer to your plan documents to confirm your cost share for diabetic drugs. Cost share may vary by plan. Antidiabetic Agents, Injectable Basaglar 2 z Bydureon 2 z Byetta 2 Humalog insulin 2 Humulin (all types) 2 Lantus 2 Lyumjev 2 z Ozempic 2 z Soliqua 2 z Symlin 2 Toujeo 2 z Trulicity 2 z Victoza 2 Pz Adlyxin 3 P Admelog 3 P Apidra 3 P Fiasp 3 P Insulin Lispro 3 P Levemir 3 P Novolin 3 P Novolog 3 P Semglee 3 Pz Tanzeum 3 P Tresiba 3 z Xultophy 3 Antidiabetic Agents, Glucose Elevating Agents acarbose 1 chlorpropamide 1 z glimepiride 1 glipizide 1 z glipizide ER 1 Access restricted to specialty pharmacy. o Custom Home Delivery. ACA Preventive Drug 1 TIER
Section I — Therapeutic drug categories (cont’d) TIER z z z z z z z z z z z z z z z z z z z z z z z z Pz Pz P P P P z P P z z z glipizide/metformin glyburide glyburide micronized metformin metformin ER (generic Glucophage XR) metformin/glyburide nateglinide pioglitazone/metformin repaglinide tolazamide tolbutamide Avandamet Avandaryl Avandia Duetact Farxiga Glucagon Glyxambi Invokamet Invokamet XR Invokana Janumet Janumet XR Januvia Jardiance Jentadueto Jentadueto XR Juvisync Rybelsus Synjardy Tradjenta Trijardy XR Xigduo XR Afrezza Baqsimi Fortamet Glumetza Kazano Kombiglyze XR metformin ER (except generic Glucophage XR) miglitol Nesina Qtern Onglyza Oseni repaglinide/metformin Segluromet Steglatro Steglujan Diabetic Supplies TIER 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Please refer to your plan documents to confirm your cost share for diabetic supplies. Cost share may vary by plan. Miscellaneous Omnipod V-Go Diabetic Test Strips Test Strips other than OneTouch require prior authorization. P OneTouch Test Strips P Accu-Chek P Ascensia Breeze P Contour P Freestyle P Precision P TRUEtest P TRUEtrack Ear Anti-infective Agents acetic acid otic acetic acid/aluminum acetate ciprofloxacin otic ofloxacin otic Domeboro Xtoro Anti-infective/Anti-inflammatory combinations acetic acid HC otic ciprofloxacin/dexamethasone neomycin/polymyxin/HC otic Cipro HC Eye Antiallergy Agents (Eye) azelastine ophth cromolyn ophth olopatadine ophth Alomide 1 1 1 1 3 3 1 1 1 3 1 1 1 2 bepotastine Bepreve ketotifen opthalmic solution olopatadine 0.2% drop Pazeo Zaditor o Zerviate Anti-infective Agents bacitracin ophth bacitracin/polymyxin ciprofloxacin ophth erythromycin ophth gatifloxacin gentamicin ophth moxifloxacin 0.5% (generic Vigamox) neomycin/bacitracin/poly B ofloxacin ophth polymyxin B/TMP sulfacetamide 10% tobramycin soln Tobrex ointment Azasite Besivance Ciloxan Tobrex solution Anti-inflammatory fluorometholone ophth loteprednol loteprednol etabonate susp prednisolone acetate prednisolone sod phosphate FML Forte FML S.O.P. Lotemax ointment Lotemax SM Pred Mild Flarex Lotemax gel Maxidex Anti-inflammatory/Anti-infective combinations dexameth/neomycin/poly B neomycin/bacitracin/poly B/HC sulfacetamide/prednisolone ophth tobramycin/dexameth Tobradex ointment Maxitrol ophth Pred-G Zylet Antiviral z famciclovir ophth trifluridine Beta-Blockers (Eye) o betaxolol HCl o carteolol o levobunolol o metipranolol o timolol o Betoptic-S o Istalol Carbonic Anhydrase Inhibitors o brinzolamide o dorzolamide 2% eye drops o dorzolamide/timolol eye drops o Azopt Miotics o pilocarpine Phospholine Iodide z Vuity Miscellaneous Cystaran z Restasis z Xiidra z Cequa Cystadrops z Oxervate Po Rhopressa oz Rocklatan Pz Tyrvaya Mydriatics atropine sulfate ophth homatropine tropicamide NSAIDs bromfenac diclofenac flurbiprofen ophth Nevanac Acular PF Prolensa KEY: P A step edit applies to this drug. z Specific Quantity Limits Apply. Prior Authorization Required. u Included in Tablet-Splitting Program TIER 3 3 3 3 3 3 3 Prostaglandin Analogues/Prostamines o bimatoprost 0.03% o latanoprost o Lumigan 0.01% o Xelpros P Izba P Rescula Po Travatan Z o travoprost (generic Travatan Z) Po Vyzulta Po Xalatan Po Zioptan Sympathomimetics o brimonidine o Alphagan P 0.1% Upneeq Vasoconstrictors naphazoline phenylephrine ophth 1 1 1 1 1 1 1 1 1 1 1 1 2 3 3 3 3 Gout z z Pz z Pz z 1 1 1 1 1 2 2 2 2 2 3 3 3 Heart allopurinol colchicine (generic Colcrys) colchicine/probenecid probenecid Mitigare Duzallo febuxostat Gloperba Uloric Zurampic Angiotensin Converting Enzyme Inhibitors o benazepril o captopril o enalapril o fosinopril o lisinopril o moexipril o perindopril o quinapril o ramipril o trandolapril Pzo enalapril oral solution Pzo Epaned zo Qbrelis Angiotensin II Antagonists zo eprosartan 600mg zo irbesartan zo losartan zo olmesartan zo telmisartan zo valsartan Pzo Atacand Pzo Avapro Pzo Benicar Pzo Cozaar Pzo Diovan Pzo Edarbi Pzo Micardis Pz Prexxartan Anti-Adrenergic Blockers Centrally Acting o clonidine, oral, patch z droxidopa o guanfacine methyldopa midodrine z Northera Anti-Adrenergic Blockers Peripheral o doxazosin o prazosin o terazosin o Cardura XL Antiarrhythmics o amiodarone digoxin o disopyramide dofetilide o flecainide o mexiletine procainamide o propafenone o propafenone SR o quinidine gluconate quinidine sulfate SR o sotalol Lanoxin o Multaq Lanoxin 62.5mcg o Norpace CR 1 1 1 1 2 3 3 3 1 1 1 1 1 1 1 2 3 1 1 1 3 1 2 3 2 2 2 3 3 3 3 3 3 1 1 1 1 1 1 2 3 3 TIER 1 1 2 2 3 3 3 3 3 3 3 1 2 3 1 1 1 1 1 1 2 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 3 3 3 1 1 1 1 1 1 3 3 3 3 3 3 3 3 1 1 1 1 1 3 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 2 2 3 3 Antilipidemics zuo atorvastatin calcium o cholestyramine o colestipol zo ezetimibe o fenofibrate (generic) o fenofibric acid, tab o gemfibrozil zuo lovastatin o niacin ER Po niacin IR 500mg tablet niacin (OTC) zo niacin/simvastatin zuo pravastatin zo rosuvastatin zuo simvastatin Advicor o Colestid z Kynamro zo Praluent zo Repatha zo Altoprev zuo Crestor o colesevelam z Epanova zo Ezallor zo ezetimibe-simvastatin o Fenofibrate (brand) zo fenofibric acid, capsule DR zo fluvastatin z Juxtapid zuo Lescol zo Lescol XL zuo Lipitor o Livalo zo Nexletol zo Nexlizet z Nikita z omega-3 acid ethyl esters z Omtryg zuo Pravachol Pzo Roszet Vascepa zuo Zocor zo Zypitamag Beta Blockers o acebutolol o atenolol o betaxolol o bisoprolol o carvedilol o carvedilol ER o labetalol o metoprolol o metoprolol ER o metoprolol/HCTZ o nadolol nebivolol o pindolol o propranolol o timolol o Innopran XL o Bystolic Hemangeol Calcium Channel Blockers o amlodipine o cartia XT o diltia XT o diltiazem o diltiazem CD/SR/ER/XR o felodipine ER o isradipine o nicardipine o nifediac CC o nifedical XL o nifedipine o nifedipine SR o nimodipine o nisoldipine o verapamil/SR Pzo Conjupri Dynacirc/CR P Katerzia o Nymalize Combination Anti-Hypertensive o aliskiren zo amlodipine/atorvastatin o amlodipine/benazepril zo amlodipine/valsartan o atenolol/chlorthalidone o benazepril/HCTZ o bisoprolol/HCTZ Access restricted to specialty pharmacy. o Custom Home Delivery. ACA Preventive Drug 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 3 3 1 1 1 1 1 1 1
Section I — Therapeutic drug categories (cont’d) Pzo candesartan/HCTZ o captopril/HCTZ o enalapril/HCTZ o fosinopril/HCTZ zo irbesartan/HCTZ o lisinopril/HCTZ zo losartan/HCTZ o methyldopa/HCTZ o metoprolol/HCTZ zo olmesartan/HCTZ o propranolol/HCTZ o quinapril/HCTZ zo telmisartan/HCTZ zo valsartan/HCTZ Pzo Tekturna HCT zo amlodipine/olmesartan zo amlodipine/valsartan/HCTZ Pz Amturnide Pzo Atacand HCT Pzo Avalide zo Azor Pzo Benicar HCT zo Byvalson Pzo Diovan HCT Pzo Edarbyclor zo Exforge HCT Pzo Hyzaar Pzo Micardis HCT zo olmesartan/amlodipine/HCTZ zo Prestalia Pzo Tekturna zo telmisartan/amlodipine o trandolapril/verapamil zo Tribenzor Diuretics o acetazolamide o acetazolamide ER o amiloride o amiloride/HCTZ o bumetanide o chlorothiazide o chlorthalidone o furosemide o hydrochlorothiazide o indapamide o methazolamide o methyclothiazide o metolazone o spironolactone o spironolactone/HCTZ o torsemide o triamterene/HCTZ zo Carospir o Kerendia Miscellaneous Cardiovascular Agents zo eplerenone z icatibant o ranolazine ER z tolvaptan z Berinert z Cinryze zo Entresto z Ruconest z Samsca 15mg Pz Consensi zo Corlanor z Firazyr z Haegarda z Orladeyo o Ranexa z Samsca 30mg z Takhzyro Vecamyl zo Verquvo z Vyndamax z Vyndaqel Pulmonary Arterial Hypertension z alyq z ambrisentan z bosentan z sildenafil 20 mg tab z tadalafil (generic Adcirca) z Tracleer tab for susp z Tyvaso z Uptravi z Adempas epoprostenol Pz Letairis z Opsumit TIER 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 1 1 1 1 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 2 2 2 3 3 3 3 Orenitram Pz Revatio Pz sildenafil suspension Pz Tracleer tab veletri Pz Ventavis Vasodilators diazoxide oral suspension o hydralazine o isosorbide dinitrate o isosorbide mononitrate o isosorbide mononitrate SA o isoxsuprine o minoxidil oral nitroglycerin pumpspray nitroglycerin SR nitroglycerin transdermal patch o Dilatrate SR Nitrostat SL tabs Gonitro Minitran NitroDur patches HIV - Antivirals TIER TIER Huntington’s Disease 3 3 3 3 3 3 z z z tetrabenazine Austedo Ingrezza 1 3 3 azathioprine cyclosporine everolimus (generic Zortress) gengraf mycophenolate mofetil mycophenolic acid sirolimus tacrolimus Astagraf XL Cellcept Neoral Prograf Sandimmune Empaveli Envarsus XR Lupkynis Rezurock Zortress 1 1 1 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 Immunosuppressants 1 1 1 1 1 1 1 1 1 1 2 2 3 3 3 z z z Infection Non-Nucleoside Reverse Transcriptase Inhibitor efavirenz 1 efavirenz/emtricit/tenofovr df 1 etravirine 1 Edurant 2 Rescriptor 2 Viramune, XR 2 Atripla 3 Intelence 3 Nucleoside Analog Reverse Transcriptase Inhibitor Combination abacavir/lamivudine/zidovudine 1 efavirenz/lamivu/tenofovr diop 1 emtricitabine/tenofovir disop 1 lamivudine/zidovudine 1 tenofovir 300mg 1 Biktarvy 2 Cimduo 2 Complera 2 Descovy 2 Dutrebis 2 Odefsey 2 Stribild 2 Triumeq 2 Viread 150mg, 200mg, 250mg, 40mg/ scoop powder 2 Symfi 3 Symfi Lo 3 Truvada 3 Nucleoside Reverse Transcriptase Inhibitors abacavir-lamivudine 1 didanosine 1 emtricitabine 1 lamivudine tabs 1 stavudine 1 zidovudine 1 Emtriva solution 2 Epivir solution 2 Videx 2 Ziagen 2 Other maraviroc 1 Fuzeon 2 Genvoya 2 Isentress 2 Juluca 2 Selzentry 25mg, 7mg tab, 20mg/ml soln 2 Tivicay 2 Tybost 2 Vitekta 2 Selzentry 150mg, 300mg 3 Protease Inhibitors atazanavir 1 ritonavir tablet 1 Aptivus 2 Crixivan 2 Evotaz 2 Invirase 2 Lexiva 2 Norvir capsule, solution 2 Prezcobix 2 Prezista 2 Viracept 2 Protease Inhibitors Combinations lopinavir-ritonavir 1 Kaletra 3 TIER Antibacterial Agents/Antibiotics amoxicillin 1 amoxicillin-clavulanate ER 1 ampicillin 1 azithromycin suspension 1 azithromycin tablets 1 cefaclor 1 cefadroxil 1 cefdinir 1 cefpodoxime 1 cefprozil 1 cefuroxime 1 cephalexin 1 ciprofloxacin 1 clarithromycin susp 1 clarithromycin tabs 1 clindamycin 1 dicloxacillin 1 doxycycline 1 ery-tab 250mg, 333mg 1 erythromycin base 1 erythromycin DR 1 erythromycin ethylsuccinate 1 erythromycin stearate 1 erythromycin/sulfisoxazole 1 levofloxacin 1 minocycline 1 nitrofurantoin 1 ofloxacin 1 penicillin VK 1 sulfamethoxazole/trimethoprim 1 tetracycline 1 Ketek 2 Zmax 2 Baxdela 3 Biaxin XL 3 cefixime 3 Ceftin 3 Cleocin 3 z doxycycline hyclate 50mg, 75mg, 150mg tab 3 erythromycin estolate 3 erythromycin suspension 3 Factive 3 z Lymepak 3 Minocin 3 moxifloxacin 3 Noroxin 3 PCE 3 Spectracef 3 Vibramycin 3 Antifungals clotrimazole lozenge 1 fluconazole 1 flucytosine 1 griseofulvin 1 z itraconazole 1 ketoconazole 1 nystatin 1 Pz oxiconazole 1 z terbinafine 1 z voriconazole 1 z Noxafil 2 Pz Oxistat lotion 2 z Posaconazole 2 z Sporanox suspension 2 z Brexafemme 3 z Cresemba 3 Ecoza 3 Pz Ertaczo 3 KEY: P A step edit applies to this drug. z Specific Quantity Limits Apply. Prior Authorization Required. u Included in Tablet-Splitting Program Lamisil Oral Luzu Oravig Pz Oxistat cream Pz Tolsura Antimalarials atovaquone/proguanil HCl chloroquine phosphate mefloquine pyrimethamine Primaquine quinine sulfate Antituberculosis o ethambutol o isoniazid o pyrazinamide o rifabutin o rifampin Coartem o Rifater o Rifamate o Sirturo Antivirals z acyclovir oral o amantadine z famciclovir ganciclovir moderiba oseltamivir ribapak ribasphere ribavirin rimantadine z valacyclovir valganciclovir tablets z Epclusa Epivir-HBV solution z Harvoni z Hepsera z Mavyret Pegasys Relenza z Sovaldi Victrelis Pz Viekira Baraclude solution entecavir tablets Pz Ledipasvir/Sofosbuvir z Livtencity z Molnupiravir z Paxlovid P Peg-Intron z Prevymis tablets Rebetol Ribatab Pz Sitavig Pz Sofosbuvir/Velpatasvir z Tyzeka valganciclovir solution z Valtrex z Vemlidy z Vosevi z Xofluza Pz Zepatier Other Anti-Infectives atovaquone dapsone tablets z linezolid methenamine combination metronidazole neomycin nitrofurantoin paromomycin pentamidine inhal powder trimethoprim tinidazole tobramycin ampule/neb vancomycin caps Firvanq z Sivextro Tobi Podhaler Bethkis Cayston z Dificid Flagyl/ER z Impavido z Kitabis Pak Macrodantin Tobi Vancocin z Xifaxan z Access restricted to specialty pharmacy. o Custom Home Delivery. ACA Preventive Drug 3 3 3 3 3 3 1 1 1 1 2 3 1 1 1 1 1 2 2 3 3 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 3 3 3 3 3 3 3 3 3 3
Section I — Therapeutic drug categories (cont’d) TIER TIER Men’s Health Impotence zo sildenafil citrate 25mg, 50mg, 100mg zo tadalafil (generic Cialis) zo vardenafil zo vardenafil ODT z Caverject z MUSE Pzo Cialis z Edex Pz Levitra Pzo Staxyn Pzo Stendra Pzo Viagra Male Hormones testosterone cypionate testosterone enanthate z testosterone gel z testosterone pump Androderm patch Android fluoxymesterone Pz Axiron Pz Fortesta Pz Jatenzo Pz Natesto P Striant Pz Testim Pz Testosterone gel (brand) Pz Vogelxo Pz Xyosted Prostate Health zo alfuzosin zo dutasteride o dutasteride/tamsulosin zo finasteride 5mg o tamsulosin Pz Entadfi o silodosin Mental Health Antidepressants amitriptyline amitriptyline/ chlordiazepoxide amitriptyline/perphenazine amoxapine bupropion bupropion 12HR bupropion 24HR u citalopram clomipramine desipramine desvenlafaxine succinate ER doxepin duloxetine u escitalopram u fluoxetine 10mg and 20mg tablet fluoxetine capsule u fluvoxamine tablet imipramine maprotiline u mirtazapine nefazodone nortriptyline u paroxetine phenelzine protriptyline u sertraline tranylcypromine trazodone u venlafaxine venlafaxine ER Viibryd z citalopram 30mg Desvenlafaxine ER Desvenlafaxine Fumarate ER P Drizalma Sprinkle Fetzima fluoxetine 60mg tablet fluvoxamine ER capsule Forfivo Khedezla zu Oleptro ER paroxetine suspension Pexeva Sarafem Sertraline capsules Trintellix Antimanic Agents lithium carbonate Antipsychotic Agents aripiprazole chlorpromazine clozapine 1 1 1 1 2 2 3 3 3 3 3 3 1 1 1 1 2 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 fluphenazine haloperidol loxapine z olanzapine perphenazine z quetiapine z quetiapine fumarate ER z risperidone z risperidone m-tab thioridazine thiothixene trifluoperazine z ziprasidone caps z Latuda z Saphris z Abilify Mycite z Caplyta z Fanapt Fazaclo z Lybalvi z Nuplazid z olanzapine/fluoxetine z paliperidone z Rexulti z Secuado P Versacloz z Vraylar z Zyprexa z Zyprexa Zydis Anxiolytics, Sedatives, and Hypnotics alprazolam/ER buspirone chloral hydrate chlordiazepoxide clorazepate diazepam estazolam z eszopiclone flurazepam lorazepam meprobamate oxazepam temazepam triazolam z zaleplon z zolpidem z zolpidem ER z Hetlioz z Xyrem Pz Ambien Pz Ambien CR Ativan Pz Belsomra z Dayvigo Pz Edluar Pz Intermezzo Librium P Loreev XR Pz Quviviq P ramelteon P Rozerem Pz Silenor Somnote Pz Sonata z Xywav Pz zolpidem ER sublingual tablet Pz Zolpimist Cerebral Stimulants z armodafin
Highmark Blue Cross Blue Shield of Western New York is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. CRP2111_0016282.1 MG016282D Highmark Blue Cross Blue Shield of Western New York Formulary 2 Please bring this guide with you the next time you visit your doctor.
HIGHMARK HEALTH 2019 CORPORATE PROFILE 6. Headquarters: Highmark Inc., doing business as Highmark Blue Cross Blue Shield in the 42 counties of western and northeastern Pennsylvania and as Highmark Blue Shield elsewhere in the state — Pittsburgh, Pennsylvania Highmark West Virginia Inc., doing business as
Blue Shield 65 Plus Choice Plan (HMO) X Blue Shield of California Blue Shield Inspire (HMO) X Blue Shield of California Blue Shield Medicare (PPO) Blue Shield Promise X Blue Shield of California AdvantageOptimum Plan (HMO) Blue Shield Promise X Blue Shield of California AdvantageOpt
Health benefits or health benefit administration may be provided by Highmark Blue Cross Blue Shield, Highmark Choice Company and Highmark Senior Health Company, all of which are independent licensees of the Blue Cross Blue Shield Association. This information is not a complete description of benefits. Call the phone number on the back
Highmark Inc. ("Highmark") was created in 1996 by the consolidation of Pennsylvania Blue Shield and Blue Cross of Western Pennsylvania. In recent years, Highmark has acquired BlueCross BlueShield of Delaware and Mountain State Blue Cross Blue Shield. Highmark currently serves 5.2 million members.
Health benefits or health benefit administration may be provided by Highmark Blue Shield, Highmark Choice Company and Highmark Senior Health Company, all of which are independent licensees of the Blue Cross Blue Shield Association. This information is not a complete description of benefits. Call the phone number on the back
Blue Cross and Blue Shield of Alabama is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield Association permits us to use the Blue Cross and Blue Shield service marks in the state of Alabama.
Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark Blue Cross Blue Shield of Western New York y BlueCross BlueShield of Western New York son nombres comerciales de Highmark Western y Northeastern New York Inc., un licenciatario independiente de Blue Cross Blue Shield Association.
Abrasive Jet machining can be employed for machining super alloys and refractory from materials. This process is based on surface erosion process. The process parameters that control metal removal rate are air quality and pressure, Abrasive grain size, nozzle material, nozzle diameter, stand of distance between nozzle tip and work surface. INTRODUCTION: Abrasives are costly but the abrasive .
