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Highmark Blue Shieldof NortheasternNew YorkFormulary 2Please bring this guidewith you the next timeyou visit your doctor.If you have questions about your prescription drug benefit,visit the Pharmacy Services section of the Highmark BSNENY web site atwww.bsneny.com.CRP2206 0016282.1 MG016282E(Revise Date 07/01/2022)Highmark Blue Shield of Northeastern 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 CONTENTSIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Understandingthe symbols usedthroughout this book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Usingiiiiiithis formulary book to help contain costs . ivSave Money on Your Prescription Drugs. . . . . . . . . . . . . . . . .ivFinding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . . . vSection 1 — Therapeutic Drug Categories . . . . . . . . . .1Section II — Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8ii
The Highmark Blue Shield of Northeastern 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.IntroductionHighmark Blue Shield of Northeastern 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 yourpatients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluatesmedications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeuticcategories.Understandingthe symbols used throughout this bookThroughout this book, you will see certain symbols that indicate a management program is in place for selectedmedications. The symbols are as follows: KeyP z u o step edit applies to this drug. Step therapy means that in order to receive the medicationAwith a step edit, a preferred medication must be tried first. Specific quantity limits apply. Quantity limits are in place to ensure members receive theappropriate amount of medication not to exceed the maximum allowable daily dosage ofmedication. Prior authorization required. Prior authorization (also referred to as coverage review)means that a healthcare professional must submit clinical documentation to obtainapproval for a member to receive the medication. Prior authorizations ensure medicationsare being used appropriately. Included in tablet-splitting program. The medication can be cut in half to obtain the dailydose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet ofsimvastatin 40mg). A member will receive a 1-month supply for half their regular 1-monthcopay. Access restricted to specialty pharmacy. Medications must be obtained through a specialtypharmacy. Custom Home Delivery. The medication should be obtained through the mail servicepharmacy. The medication is subject to a retail refill allowance. Affordable Care Act (ACA) Preventive Drug. The medication is included on the ACAPreventive Drug List.iii
Usingthis formulary book to help contain costsMany employers, benefit sponsors, and individuals may use the formulary to help manage theoverall cost of providing prescription drug benefits. The formulary offers a wide range of outpatientmedications.Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs onthe market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printedformulary guide the drugs that are most commonly prescribed for our members. If you have anyquestions regarding coverage of a drug, please call the customer service number on your card.Save Money on Your Prescription DrugsHere’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 1Tier 2Tier 3Lowest cost to you Highest cost to youThe amount you pay for a drug is determined by which medication you purchase and to what tier it isassigned. Some drug plans exclude certain drugs or classes of drugs from coverage. Please check yourcontract 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. Costshare may vary by plan.Affordable Care Act (ACA) Preventive Drug ListThe 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 plandocuments 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 onpage 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 priorauthorization, step-edits, and quantity limits. Restrictions may apply to certain brand-name ACAmedications with generic equivalents. Other restrictions may apply according to U.S. Preventive ServicesTask Force (USPSTF) recommendations, which define ACA coverage requirements. These restrictionsmay be based on age, dose, diagnosis, and others as recommended by USPSTF. Both prescription andover-the-counter (OTC) products are eligible to be covered when prescribed by a licensed health careprovider 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 Shield of Northeastern New York Medication Guide is subject to change, as we regularlyreview medications and existing therapies for inclusion in the Highmark Blue Shield of Northeastern 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 LawContraceptives (for members whose benefits align with contraceptive coverage requirements underNew York Insurance Law): All tier 1 contraceptives are covered at a 0 copayment. Brand-namecontraceptives without a generic equivalent are covered at a 0 copayment. Brand-name contraceptiveswith a generic equivalent are covered at the copayment based on your plan design unless deemedmedically necessary by the prescriber. The prescriber must designate “DAW” (Dispense as Written) onthe prescription in order for the brand-name contraceptive with a generic equivalent to be consideredmedically 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 validprescription. Please refer to your plan documents to confirm your cost share for contraceptives. Costshare may vary by plan.Contraceptives may include implantable rods, intrauterine devices (IUD), shots/injections, oralcontraceptives, patches, vaginal contraceptive rings, diaphragms, sponges, cervical caps, condoms,spermicides, and emergency contraceptives. Please see the “Women’s Health” section of this guide forspecific product examples.Custom Home Delivery: Members must obtain maintenance medications at mail-order after retail allowance isexhausted for members with Custom Home Delivery Benefit.Finding Medications in the GuideThis 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 thatdrug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is ageneric or brand-name medication, look at the name of the drug. Generic medications arelower 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 theHighmark Blue Shield of Northeastern New York Formulary 2. For the most up-to-date version of theGuide, visit the Pharmacy Services section of our web site at www.bsneny.com.v
Section I — Therapeutic drug categoriesTIERTIERAllergy/Cough & ColdAntihistamines & Decongestantsbrompheniramine/ phenylephrinebrompheniramine/ ydroxyzine HClhydroxyzine stek zOdactra zOralair zPalforzia zRagwitekExpectorant & Cough / codeinepseudoephedrine/codeineCardec/DMGuaifenesin DMHycodanRondec DM/TRVituzMucolytic Agentsacetylcysteine inh soln.Nasal Medicationsazelastine nasal spraybudesonide nasal sprayClarisprayFlonase Allergy ReliefFlonase Sensimistzofluticasone nasal sprayipratropium nasal sprayzNasacort Allergy 24HRRhinocort Allergytriamcinolone nasal sprayAtrovent Nasal SprayPzo Beconase AQDymistazoflunisolide nasal sprayzomometasone nasal sprayPzo Nasacort AQPzo OmnarisPzo Qnasl zoXhancePzo ZetonnaAlzheimer 113333333333donepezilergoloid mesylatesgalantaminegalantamine ERmemantinememantine ERrivastigminerivastigmine patchNamzaric111111112K-PhosAlkalinizerspotassium gicszoxybutyninzoxybutynin ERzOxytrol for Womenzsolifenacinztolterodineztolterodine 1ztrospiumztrospium ERzMyrbetriqzToviazPzDetrolPzDetrol LAPzDitropan XLPzEnablexPzGelniquePzOxytrolPzSancturaPzSanctura XRCholinergic AgentsUrecholineMiscellaneous PzGemtesa zJynarque PTarpeyo lide aspirin 325mg OTC aspirin 81mg noxaparinfondaparinux lazaInnohepzPradaxazSavaysazoZontivityOther Blood Modifiersocalcitonin-salmon inj.ocilostazol deferasiroxpentoxifylline ztrientine zActimmune Aranesp Epogen Fulphila LeukineNeulasta Procrit zPromacta zRevlimid Zarxio Alprolix zCablivi deferiprone zDoptelet Eloctate zEndari Exjade Ferriprox Granix Hemlibra Jadenu JivioMiacalcin inj. Mircera zMulpleta Neupogen Nivestym PNyvepria Omontys zOxbryta zPyrukyndPReleuko Retacrit zTavalisse P Udenyca P ZiextenzozZontivityKEY: P A step edit applies to this drug.z Specific Quantity Limits Apply. Prior Authorization Required.u Included in Tablet-Splitting ProgramTIERCancer Drugs112233333333Alkylating eranMyleranAntimetabolites capecitabinemercaptopurinemethotrexatePurixan zInqovi OnuregTrexall zXatmepHormones anastrozolebicalutamide exemestaneflutamide letrozole leuprolidemegestrol tamoxifenFareston zNubeqaMiscellaneous zabiraterone acetate zerlotinibetoposide zeverolimus (generic Afinitor)hydroxyurea zimatinib zlapatinibnilutamide zsunitinib temozolomide zArcalyst zBosulif zCabometyx zCaprelsa zCometriq zCotellic zErivedge zGilotrif Hycamtin capsule zIbrance zIclusig zImbruvica zInlyta Intron A zIressa zJakafi zLenvima zLonsurf zLynparzaLysodrenMatulane zMekinistMesnex zNexavar zNinlaro zOdomzo zPomalyst zSprycel zStivarga zSylatron zSynribo zTafinlar zTagrisso zTasigna Thalomid zValchlor zVerzenio zVotrient zXalkori zXtandi zZelboraf zZolinza zZydelig zZykadia Pz Afinitor zAlecensa zAlunbrig zAyvakit zBalversa zBesremi zBraftovi 22222222233333333 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 vretoGleevecIdhifaInrebicKesimptaKisqaliKisqali Femara erbUkoniqVenclextaVitrakviVizimproVonjoWelireg Xgeva zXospata zXpovio zYonsa zZejula Pz ZytigaRexinoids bexarotene Targretin 333333333333312Please refer to your plan documents to confirm yourcost share for diabetic drugs. Cost share may varyby plan.Antidiabetic Agents, InjectableBasaglar2zBydureon2zByetta2Humalog insulin2Humulin (all types)2Lantus2Lyumjev2zOzempic2zSoliqua2 log3PApidra3PFiasp3PInsulin um3PTresiba3zXultophy3Antidiabetic Agents, Glucose Elevating de1zglipizide ER1 Access restricted to specialty pharmacy.o Custom Home Delivery. ACA Preventive Drug1TIER
Section I — Therapeutic drug categories (cont’d)TIERzzzzzzzzzzzzzzzzzzzzzzzz e micronizedmetforminmetformin ER (generic Glucophage tInvokamet XRInvokanaJanumetJanumet XRJanuviaJardianceJentaduetoJentadueto XRJuvisyncRybelsusSynjardyTradjentaTrijardy XRXigduo XRAfrezzaBaqsimiFortametGlumetzaKazanoKombiglyze XRmetformin ER (except genericGlucophage orminSeglurometSteglatroSteglujanDiabetic 33333333333Please refer to your plan documents to confirm yourcost share for diabetic supplies. Cost share mayvary by plan.MiscellaneousOmnipodV-GoDiabetic Test StripsTest Strips other than OneTouch require priorauthorization.POneTouch Test StripsPAccu-ChekPAscensia ackEarAnti-infective Agentsacetic acid oticacetic acid/aluminum acetateciprofloxacin oticofloxacin oticDomeboroXtoroAnti-infective/Anti-inflammatory combinationsacetic acid HC HC oticCipro HCEyeAntiallergy Agents (Eye)azelastine ophthcromolyn ophtholopatadine fen opthalmic solutionolopatadine 0.2% dropPazeoZaditoroZerviateAnti-infective Agentsbacitracin ophthbacitracin/polymyxinciprofloxacin ophtherythromycin ophthgatifloxacingentamicin ophthmoxifloxacin 0.5% (generic Vigamox)neomycin/bacitracin/poly Bofloxacin ophthpolymyxin B/TMPsulfacetamide 10%tobramycin solnTobrex ointmentAzasiteBesivanceCiloxanTobrex solutionAnti-inflammatoryfluorometholone ophthloteprednolloteprednol etabonate suspprednisolone acetateprednisolone sod phosphateFML ForteFML S.O.P.Lotemax ointmentLotemax SMPred MildFlarexLotemax gelMaxidexAnti-inflammatory/Anti-infective combinationsdexameth/neomycin/poly Bneomycin/bacitracin/poly B/HCsulfacetamide/prednisolone ophthtobramycin/dexamethTobradex ointmentMaxitrol ophthPred-GZyletAntiviralzfamciclovir ophthtrifluridineBeta-Blockers (Eye)obetaxolol optic-SoIstalolCarbonic Anhydrase Inhibitorsobrinzolamideodorzolamide 2% eye dropsodorzolamide/timolol eye dropsoAzoptMioticsopilocarpinePhospholine Iodide zVuityMiscellaneousCystaranzRestasiszXiidrazCequa Cystadrops zOxervatePoRhopressa ozRocklatanPzTyrvayaMydriaticsatropine sulfate acflurbiprofen ophthNevanacAcular PFProlensaKEY: P A step edit applies to this drug.z Specific Quantity Limits Apply. Prior Authorization Required.u Included in Tablet-Splitting ProgramTIER3333333Prostaglandin Analogues/Prostaminesobimatoprost 0.03%olatanoprostoLumigan 0.01%oXelprosPIzbaPResculaPoTravatan Zotravoprost (generic Travatan onidineoAlphagan P 0.1%UpneeqVasoconstrictorsnaphazolinephenylephrine ophth11111111111123333Goutz zPzzPz z1111122222333Heartallopurinolcolchicine (generic allofebuxostatGloperbaUloricZurampicAngiotensin Converting Enzyme prilotrandolaprilPzo enalapril oral solutionPzo Epaned zoQbrelisAngiotensin II Antagonistszoeprosartan anzovalsartanPzo AtacandPzo AvaproPzo BenicarPzo CozaarPzo DiovanPzo EdarbiPzo MicardisPzPrexxartanAnti-Adrenergic Blockers Centrally Actingoclonidine, oral, patch zdroxidopaoguanfacinemethyldopamidodrine zNortheraAnti-Adrenergic Blockers PeripheralodoxazosinoprazosinoterazosinoCardura noneopropafenone SRoquinidine gluconatequinidine sulfate SRosotalolLanoxinoMultaqLanoxin 62.5mcgoNorpace 311111311131111111111112233Antilipidemicszuo atorvastatin ibrate (generic)ofenofibric acid, tabogemfibrozilzuo lovastatinoniacin ERPoniacin IR 500mg tabletniacin (OTC)zoniacin/simvastatinzuo pravastatinzo rosuvastatinzuo simvastatinAdvicoroColestid zKynamro zoPraluent zoRepathazo Altoprevzuo CrestorocolesevelamzEpanovazo Ezallorzoezetimibe-simvastatinoFenofibrate (brand)zofenofibric acid, capsule DRzo fluvastatin zJuxtapidzuo Lescolzo Lescol XLzuo Lipitoro Livalo zoNexletol zoNexlizetzNikitazomega-3 acid ethyl esterszOmtrygzuo PravacholPzo RoszetVascepazuo Zocorzo ZypitamagBeta carvedilolocarvedilol ERolabetalolometoprololometoprolol anololotimololoInnopran XLoBystolicHemangeolCalcium Channel Blockersoamlodipineocartia XTodiltia XTodiltiazemodiltiazem CD/SR/ER/XRofelodipine ERoisradipineonicardipineonifediac CConifedical XLonifedipineonifedipine SRonimodipineonisoldipineoverapamil/SRPzo ConjupriDynacirc/CRPKaterziaoNymalizeCombination TZ Access restricted to specialty pharmacy.o Custom Home Delivery. ACA Preventive 1111111111111123311111111111111133331111111
Section I — Therapeutic drug categories (cont’d)Pzo rtan/HCTZzovalsartan/HCTZPzo Tekturna CTZPzAmturnidePzo Atacand HCTPzo AvalidezoAzorPzo Benicar HCTzoByvalsonPzo Diovan HCTPzo EdarbyclorzoExforge HCTPzo HyzaarPzo Micardis HCTzoolmesartan/amlodipine/HCTZzoPrestaliaPzo ide iamterene/HCTZzoCarospir oKerendiaMiscellaneous Cardiovascular Agentszoeplerenone zicatibantoranolazine ER ztolvaptan zBerinert zCinryzezoEntresto zRuconest zSamsca 15mgPzConsensi zoCorlanor zFirazyr zHaegarda zOrladeyooRanexa zSamsca 30mg zTakhzyroVecamyl zoVerquvo zVyndamax zVyndaqelPulmonary Arterial Hypertension zalyq zambrisentan zbosentan zsildenafil 20 mg tab ztadalafil (generic Adcirca) zTracleer tab for susp zTyvaso zUptravi zAdempas epoprostenol Pz Letairis 111111111111133111122222333333333333111112223333 Orenitram Pz Revatio Pz sildenafil suspension Pz Tracleer tab veletri Pz VentavisVasodilatorsdiazoxide oral suspensionohydralazineoisosorbide dinitrateoisosorbide mononitrateoisosorbide mononitrate SAoisoxsuprineominoxidil oralnitroglycerin pumpspraynitroglycerin SRnitroglycerin transdermal patchoDilatrate SRNitrostat SL tabsGonitroMinitranNitroDur patchesHIV - AntiviralsTIERTIERHuntington’s Disease333333 z z porineeverolimus (generic Zortress)gengrafmycophenolate mofetilmycophenolic acidsirolimustacrolimusAstagraf XLCellceptNeoralPrografSandimmuneEmpaveliEnvarsus suppressants111111111122333 z z zInfectionNon-Nucleoside Reverse Transcriptase Inhibitorefavirenz1efavirenz/emtricit/tenofovr df1etravirine1Edurant2Rescriptor2Viramune, XR2Atripla3Intelence3Nucleoside Analog Reverse Transcriptase 1efavirenz/lamivu/tenofovr diop1 emtricitabine/tenofovir disop1lamivudine/zidovudine1 tenofovir 300mg1Biktarvy2Cimduo2Complera2 Descovy2Dutrebis2Odefsey2Stribild2Triumeq2 Viread 150mg, 200mg, 250mg, 40mg/scoop powder2Symfi3Symfi Lo3 Truvada3Nucleoside Reverse Transcriptase bine1lamivudine tabs1stavudine1zidovudine1Emtriva solution2Epivir a2Isentress2Juluca2Selzentry 25mg, 7mg tab, 20mg/ml soln 2Tivicay2Tybost2Vitekta2Selzentry 150mg, 300mg3Protease Inhibitorsatazanavir1ritonavir vir capsule, solution2Prezcobix2Prezista2Viracept2Protease Inhibitors cterial ate ER1ampicillin1azithromycin suspension1azithromycin thromycin susp1clarithromycin tabs1clindamycin1dicloxacillin1doxycycline1ery-tab 250mg, 333mg1erythromycin base1erythromycin DR1erythromycin ethylsuccinate1erythromycin inocycline1nitrofurantoin1ofloxacin1penicillin k2Zmax2Baxdela3Biaxin XL3cefixime3Ceftin3Cleocin3zdoxycycline hyclate 50mg, 75mg, 150mg tab 3erythromycin estolate3erythromycin mazole inafine1zvoriconazole1zNoxafil2PzOxistat lotion2zPosaconazole2zSporanox suspension2 zBrexafemme3zCresemba3Ecoza3PzErtaczo3KEY: P A step edit applies to this drug.z Specific Quantity Limits Apply. Prior Authorization Required.u Included in Tablet-Splitting ProgramLamisil OralLuzuOravigPzOxistat cream PzTolsuraAntimalarialsatovaquone/proguanil HClchloroquine phosphatemefloquinepyrimethaminePrimaquinequinine oSirturoAntiviralszacyclovir oraloamantadinezfamciclovirganciclovir moderibaoseltamivir ribapak ribasphere ribavirinrimantadinezvalacyclovirvalganciclovir tablets zEpclusaEpivir-HBV solution zHarvonizHepsera zMavyret PegasysRelenza zSovaldi Victrelis Pz ViekiraBaraclude solutionentecavir tablets Pz Ledipasvir/Sofosbuvir zLivtencityzMolnupiravirzPaxlovid P Peg-Intron zPrevymis tablets Rebetol Ribatab PzSitavig Pz Sofosbuvir/VelpatasvirzTyzekavalganciclovir solutionzValtrexzVemlidy zVosevizXofluza Pz ZepatierOther Anti-Infectivesatovaquonedapsone tabletszlinezolidmethenamine momycinpentamidine inhal powdertrimethoprimtinidazole tobramycin ampule/nebvancomycin capsFirvanqzSivextro Tobi Podhaler Bethkis CaystonzDificidFlagyl/ERzImpavido zKitabis PakMacrodantin TobiVancocin zXifaxanz Access restricted to specialty pharmacy.o Custom Home Delivery. ACA Preventive 333333333333333311111111111112223333333333
Section I — Therapeutic drug categories (cont’d)TIERTIERMen’s HealthImpotencezosildenafil citrate 25mg, 50mg, 100mgzotadalafil (generic Cialis)zovardenafilzovardenafil ODTzCaverjectzMUSEPzo CialiszEdexPzLevitraPzo StaxynPzo StendraPzo ViagraMale Hormonestestosterone cypionatetestosterone enanthateztestosterone gelztestosterone pumpAndroderm enzoPzNatestoPStriantPzTestimPzTestosterone gel (brand)PzVogelxoPzXyostedProstate sinzofinasteride 5mgotamsulosin PzEntadfiosilodosinMental HealthAntidepressantsamitriptylineamitriptyline/ ebupropionbupropion 12HRbupropion ne succinate ERdoxepinduloxetineuescitalopramufluoxetine 10mg and 20mg tabletfluoxetine capsuleufluvoxamine xine ERViibrydzcitalopram 30mgDesvenlafaxine ERDesvenlafaxine Fumarate ERPDrizalma SprinkleFetzimafluoxetine 60mg tabletfluvoxamine ER capsuleForfivoKhedezlazuOleptro ERparoxetine suspensionPexevaSarafemSertraline capsulesTrintellixAntimanic Agentslithium carbonateAntipsychotic ne fumarate ERzrisperidonezrisperidone idone capszLatudazSaphris zAbilify MycitezCaplytazFanaptFazaclozLybalvi tizSecuadoPVersaclozzVraylarzZyprexazZyprexa ZydisAnxiolytics, Sedatives, and Hypnoticsalprazolam/ERbuspironechloral mtemazepamtriazolamzzaleplonzzolpidemzzolpidem ER zHetlioz zXyremPzAmbienPzAmbien CRAtivanPzBelsomra zDayvigoPzEdluarPzIntermezzoLibriumPLoreev ata zXywavPzzolpidem ER sublingual tabletPzZolpimistCerebral edexmethylphenidate XRdextroamphetamine tabsgeneric Adderallgeneric Adderall XRgeneric Concertageneric Dexedrine spansulesguanfacine ERmetadate ERmethylphenidate ansezAdhansia XRzAdzenysPzAzstaryszCotempla XRPzDyanavel XRKEY: P A step edit applies to this drug.z Specific Quantity Limits Apply. Prior Authorization Required.u Included in Tablet-Splitting ProgramTIERFocalin XRzJornay PMMethylphenidate ER (brand)zQuillichew ERQuillivant XRMiscellaneousPzQelbree zSunosi tidiuretic Agentsdesmopressin solutiondesmopressin tabsStimateDDAVP nasal sprayDDAVP sol, tab zNocdurna zNoctivaOther CNSacamprosate calcium tablet ECbuprenorphine buprenorphine-naloxonebuprenorphine/naloxone filmdisulfiramnaltrexoneriluzolezNarcan nasal sprayZubsolvBunavailCampral dosepackzEvzio zExservan zGralise PzHorizantLucemyra zNuedextaSavella zTegsediPzTiglutikOther Endocrineocinacalcetdanazolfludrocortisone miglustat octreotide zCerdelga zEgrifta zHP Acthar Gel zMyalept Norditropin oSensipar zSynarel Zavesca Cortrophin Gel P Genotropin P Humatrope Increlex zMycapssa zNatpara P Nutropin/AQ P Omnitrope P Saizen Sandostatin P Serostim Skytrofa zSomavert P Tev-Tropin zVoxzogo P ZorbtiveOther Miscellaneous zoKeveyis zSignifor Strensiq betaine CarbagluCystadaneCystagon Dojolvi zEnspryng zEvrysdi zFirdapse zGalafold zIsturisa zKorlym Nityr Procysbi Ravicti zRecorlev IER zRuzurgisodium phenylbutyrate zTavneoszVeltassa zXuriden zZokinvyMiscellaneous Immunologicals Cutaquig Cuvitru Gammagard Liquid Gammaked Gamunex-C Hizentra HyQvia Xembify33333333 z z z z z z z z z P z P z z zdimethyl fumarateglatiramer mpridine zonecyclobenzaprinecyclobenzaprine 7.5mgdantrolene ecyclobenzaprine eineOzobax11111111111333333zozozozozo z onfortical NSibandronate ivaFosamaxFosamax Drisedronate 150mgrisedronate DR111112233333333Multiple Sclerosis AgentsMuscle RelaxantsPzPzPz Pz OsteoporosisPain/ArthritisAnalgesics, Opioid - Medications listed under thiscategory may require additional review for coveragebased on recommendations from the Centers forDisease Control and Prevention (CDC).zacetaminophen w/codeine1zbelladonna & opium supp1buprenorphine TD patch irin/codeine1zbutorphanol NS1zcodeine sulfate1zendocet1 zfentanyl lozenge1 fentanyl patch1zhydrocodone/APAP1zhydrocodone/ibuprofen1 Access restricted to specialty pharmacy.o Custom Home Delivery. ACA Preventive Drug4333333
Section I — Ther
Highmark Blue Shield of Northeastern New York is a trade name of Highmark Western and Northeastern New York Inc., an inde-pendent licensee of the Blue Cross Blue Shield Association. Highmark Blue Shield of Northeastern New York Formulary 2 Please bring this guide with you the next time you visit your doctor. CRP2206_0016282.1 MG016282E
