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BlueAdvantage (PPO)SM2021 Formulary(List of Covered Drugs)BlueAdvantage Diamond (PPO)SMBlueAdvantage Ruby (PPO)SMBlueAdvantage Emerald (PPO)SMBlueAdvantage Sapphire (PPO)SMBlueAdvantage Garnet (PPO)SMPlease Read: This document contains information about the drugswe cover in this plan.We have made no changes to this formulary since 06/01/21.For more recent information or other questions, please contactMember Service at:bcbstmedicare.com1-800-831-2583, TTY 711Oct. 1 to March 31, seven days a week from 8 a.m. to 9 p.m. ET.From April 1 to Sept. 30, M-F from 8 a.m. to 9 p.m. ET.If you call outside of these hours or on a holiday – just leave amessage on our automated phone system and we will call youback the next business day.H7917 21FORM C (08/20) 21098, Version 10
2021 BlueAdvantage FormularyNote to existing members:This formulary has changed since last year.Please review this document to make surethat it still contains the drugs you take.When this drug list (formulary) refers to “we,”“us”, or “our,” it means BlueCross BlueShieldof Tennessee, Inc. When it refers to “plan”or “our plan,” it means BlueAdvantage.This document includes a list of the drugs(formulary) for our plan which is current asof 06/01/21. For an updated formulary, pleasecontact us. Our contact information, alongwith the date we last updated the formulary,appears on the front and back cover pages.You must generally use network pharmaciesto use your prescription drug benefit.Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change onJanuary 1, 2022, and from time to time duringthe year.i
What is theBlueAdvantage Formulary?If we remove drugs from our formulary, addprior authorization, quantity limits, and/orstep therapy restrictions on a drug or movea drug to a higher cost-sharing tier, we mustnotify affected members of the change atleast 30 days before the change becomeseffective, or at the time the memberrequests a refill of the drug, at which timethe member will receive a 30-day supplyof the drug.A formulary is a list of covered drugs selectedby BlueAdvantage in consultation with a teamof health care providers, which representsthe prescription therapies believed to be anecessary part of a quality treatment program.BlueAdvantage will generally cover the drugslisted in our formulary as long as the drug ismedically necessary, the prescription is filled ata BlueAdvantage network pharmacy, and otherplan rules are followed. For more informationon how to fill your prescriptions, please reviewyour Evidence of Coverage.–Can the Formulary(drug list) change?Most changes in drug coverage happen onJanuary 1, but we may add or remove drugson the drug list during the year, move themto different cost-sharing tiers, or add newrestrictions. We must follow the Medicarerules in making these changes.If we make these other changes,you or your prescriber can ask us tomake an exception and continue tocover the brand name drug for you.The notice we provide you will alsoinclude information on how to requestan exception, and you can also findinformation in the section below entitled“How do I request an exception to theBlueAdvantage formulary?”Changes that will not affect you if you arecurrently taking the drug. Generally, if youare taking a drug on our 2021 formulary thatwas covered at the beginning of the year,we will not discontinue or reduce coverageof the drug during the 2021 coverage yearexcept as described above. This means thesedrugs will remain available at the same costsharing and with no new restrictions for thosemembers taking them for the remainder of thecoverage year. You will not get direct noticethis year about changes that do not affect you.However, on January 1 of the next year, suchchanges would affect you, and it is important tocheck the drug list for the new benefit year forany changes to drugs.Changes that can affect you this year:In the below cases, you will be affected bycoverage changes during the year: Drugs removed from the market.If the Food and Drug Administration deemsa drug on our formulary to be unsafe or thedrug’s manufacturer removes the drug fromthe market, we will immediately remove thedrug from our formulary and provide noticeto members who take the drug. Other changes. We may make other changesthat affect members currently taking a drug.For instance, we may add a new genericdrug to replace a brand name drug currentlyon the formulary; or add new restrictions tothe brand name drug or move it to a differentcost-sharing tier or both. Or we may makechanges based on new clinical guidelines.The enclosed formulary is current as of 06/01/21.To get updated information about the drugscovered by BlueAdvantage, please contact us.Our contact information appears on the frontand back cover pages.ii
In the event of a mid-year non-maintenanceformulary change, we may reprint ourformulary and distribute copies to ourmembers. Updated formularies are postedto our website at bcbstmedicare.com.How do I use the Formulary?There are two ways to find your drug withinthe formulary: Medical ConditionThe formulary begins on page 3. The drugsin this formulary are grouped into categoriesdepending on the type of medical conditionsthat they are used to treat. For example,drugs used to treat a heart condition arelisted under the category, “Cardiovascular,Hypertension/Lipids.” If you know what yourdrug is used for, look for the category namein the list that begins on page 1. Then lookunder the category name for your drug. Alphabetical ListingIf you are not sure what category to lookunder, you should look for your drug in theIndex that begins on page 103. The Indexprovides an alphabetical list of all of thedrugs included in this document. Both brandname drugs and generic drugs are listed inthe Index. Look in the index and find yourdrug. Next to your drug, you will see thepage number where you can find coverageinformation. Turn to the page listed in theindex and find the name of your drug in thefirst column of the list.What are generic drugs?BlueAdvantage covers both brand namedrugs and generic drugs. A generic drug isapproved by the FDA as having the same activeingredient as the brand name drug. Generally,generic drugs cost less than brand name drugs.Are there any restrictionson my coverage?Some covered drugs may have additionalrequirements or limits on coverage.These requirements and limits may include: Prior Authorization: BlueAdvantagerequires you or your physician to get priorauthorization for certain drugs. This meansthat you will need to get approval fromBlueAdvantage before you fill yourprescriptions. If you don’t get approval,BlueAdvantage may not cover the drug. Quantity Limits: For certain drugs,BlueAdvantage limits the amount of thedrug that our plan will cover. For example,BlueAdvantage provides 90 capsulesper 90 days per prescription for Dexilant.This may be in addition to a standard onemonth or three-month supply. Step Therapy: In some cases, BlueAdvantagerequires you to first try certain drugs to treatyour medical condition before we will coveranother drug for that condition. For example,if Drug A and Drug B both treat your medicalcondition, our plan may not cover Drug Bunless you try Drug A first. If Drug A does notwork for you, our plan will then cover Drug B.You can find out if your drug has any additionalrequirements or limits by looking in theformulary that begins on page 3. You can alsoget more information about the restrictionsapplied to specific covered drugs by visiting ourwebsite. We have posted online documents thatexplain our prior authorization and step therapyrestrictions. You may also ask us to send you acopy. Our contact information, along with thedate we last updated the formulary, appears onthe front and back cover pages.iii
Y ou can ask us to cover a formulary drugat a lower cost-sharing level if this drugis not on the specialty tier. If approved thiswould lower the amount you must pay foryour drug.You can ask BlueAdvantage to make anexception to these restrictions or limits or fora list of other, similar drugs that may treat yourhealth condition. See the section, “How do Irequest an exception to the BlueAdvantageformulary?” on this page for information abouthow to request an exception. Y ou can ask us to waive coverage restrictionsor limits on your drug. For example, for certaindrugs, our plan limits the amount of the drugthat we will cover. If your drug has a quantitylimit, you can ask us to waive the limit andcover a greater amount.What if my drug is not onthe Formulary?If your drug is not included in this formulary(list of covered drugs), you should first contactMember Service and ask if your drug is covered.If you learn that BlueAdvantage does not coveryour drug, you have two options:Generally, BlueAdvantage will only approveyour request for an exception if the alternativedrugs included on the plan’s formulary, thelower cost-sharing drug or additional utilizationrestrictions would not be as effective in treatingyour condition and/or would cause you to haveadverse medical effects. Y ou can ask Member Service for a listof similar drugs that are covered byBlueAdvantage. When you receive the list,show it to your doctor and ask him or herto prescribe a similar drug that is coveredby BlueAdvantage.You should contact us to ask us for an initialcoverage decision for a formulary, tiering orutilization restriction exception. When yourequest a formulary, tiering or utilizationrestriction exception you should submit astatement from your prescriber or physiciansupporting your request. Generally, we mustmake our decision within 72 hours of gettingyour prescriber’s supporting statement. Youcan request an expedited (fast) exception ifyou or your doctor believe that your healthcould be seriously harmed by waiting up to 72hours for a decision. If your request to expediteis granted, we must give you a decision nolater than 24 hours after we get a supportingstatement from your doctor or other prescriber. Y ou can ask BlueAdvantage to makean exception and cover your drug.See the next section for informationabout how to request an exception.How do I requestan exception to theBlueAdvantage Formulary?Y ou can ask BlueAdvantage to make anexception to our coverage rules. There areseveral types of exceptions that you can askus to make. Y ou can ask us to cover a drug even if it isnot on our formulary. If approved, this drugwill be covered at a pre-determined costsharing level, and you would not be able toask us to provide the drug at a lower costsharing level.iv
What do I do before I can talkto my doctor about changingmy drugs or requestingan exception?For more informationFor more detailed information about yourBlueAdvantage prescription drug coverage,please review your Evidence of Coverage andother plan materials.As a new or continuing member in our planyou may be taking drugs that are not on ourformulary. Or, you may be taking a drug thatis on our formulary but your ability to get itis limited. For example, you may need a priorauthorization from us before you can fill yourprescription. You should talk to your doctor todecide if you should switch to an appropriatedrug that we cover or request a formularyexception so that we will cover the drug youtake. While you talk to your doctor to determinethe right course of action for you, we may coveryour drug in certain cases during the first 90days you are a member of our plan.If you have questions about our plan, pleasecontact us. Our contact information, along withthe date we last updated the formulary, appearson the front and back cover pages.If you have general questions aboutMedicare prescription drug coverage,please call Medicare at 1-800-MEDICARE(1-800-633-4227) 24 hours a day/7 days aweek. TTY users should call 1-877-486-2048.Or, visit http://www.medicare.gov.BlueAdvantage’s FormularyThe formulary that begins on page 3 providescoverage information about the drugs coveredby BlueAdvantage. If you have trouble findingyour drug in the list, turn to the Index thatbegins on page 103.For each of your drugs that is not on ourformulary or if your ability to get your drugsis limited, we will cover a temporary 30 days(or 31 days for long-term care (LTC)) supply.If your prescription is written for fewer days,we’ll allow refills to provide up to a maximum30 days (or 31 days for long-term care (LTC))supply of medication. After your first 30 days(or 31 days for long-term care (LTC)) supply,we will not pay for these drugs, even if you havebeen a member of the plan less than 90 days.The first column of the chart lists the drugname. Brand name drugs are capitalized(e.g., JANUMET) and generic drugs are listedin lower-case italics (e.g., metformin).The information in the Requirements/Limitscolumn tells you if BlueAdvantage has anyspecial requirements for coverage of your drug.If you are a resident of a long-term carefacility and you need a drug that is not on ourformulary or if your ability to get your drugsis limited, but you are past the first 90 days ofmembership in our plan, we will cover a 31-dayemergency supply of that drug while you pursuea formulary exception.For a member with a level of care change(e.g., member is discharged from a long-termcare facility to a home setting) outside of thetransition window, a pharmacy may obtain aone-time supply of a transition-eligible drug bycontacting the help desk.Every drug on the plan’s drug list is in one offive tiers. In general, the higher the tier, thehigher your cost-sharing for the drug.v
Sapphire & GarnetPreferred Retail andMail Order Pharmacy30/90 Day SupplyStandardRetail Pharmacy30/90 Day SupplyTier 1: Preferred GenericTier 2: GenericTier 3: Select Insulin DrugsTier 3: Preferred Brand DrugsTier 4: Non-Preferred Drugs 1/ 1 copay 10/ 10 copay 30/ 90 copay 42/ 105 copay 92/ 225 copay 6/ 15 copay 15/ 35 copay 35/ 105 copay 47/ 135 copay 97/ 285 copayTier 5: Specialty Tier33% of the cost/Specialty medications 33% of the cost/Specialty medicationsare limited to a 30-day supplyare limited to a 30-day supplyEmeraldTier 1: Preferred GenericTier 2: GenericTier 3: Select Insulin DrugsTier 3: Preferred Brand DrugsTier 4: Non-Preferred Drugs 1/ 1 copay 5/ 5 copay 30/ 90 copay 35/ 90 copay 80/ 200 copay 6/ 15 copay 10/ 25 copay 35/ 100 copay 40/ 100 copay 85/ 215 copayTier 5: Specialty Tier33% of the cost/Specialty medications 33% of the cost/Specialty medicationsare limited to a 30-day supplyare limited to a 30-day supplyRubyTier 1: Preferred GenericTier 2: GenericTier 3: Select Insulin DrugsTier 3: Preferred Brand DrugsTier 4: Non-Preferred Drugs 1/ 1 copay 5/ 5 copay 28/ 70 copay 28/ 70 copay 65/ 165 copay 6/ 15 copay 10/ 25 copay 33/ 95 copay 33/ 95 copay 70/ 185 copayTier 5: Specialty Tier33% of the cost/Specialty medications 33% of the cost/Specialty medicationsare limited to a 30-day supplyare limited to a 30-day supplyDiamondTier 1: Preferred GenericTier 2: GenericTier 3: Select Insulin DrugsTier 3: Preferred Brand DrugsTier 4: Non-Preferred Drugs 1/ 1 copay 5/ 5 copay 28/ 70 copay 28/ 70 copay 50/ 125 copay 6/ 15 copay 10/ 25 copay 33/ 95 copay 33/ 95 copay 55/ 145 copayTier 5: Specialty Tier33% of the cost/Specialty medications 33% of the cost/Specialty medicationsare limited to a 30-day supplyare limited to a 30-day supplyYou can get a 90-day supply of drugs in Tiers 1 and 2 for the 30-day copay amountat preferred pharmacies. To find a preferred pharmacy in your neighborhood, give usa call at the number on the back of this formulary or visit www.bcbstmedicare.com.vi
Table of ContentsANTI - INFECTIVES . 3ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS . 15AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH . 28CARDIOVASCULAR, HYPERTENSION / LIPIDS . 46DERMATOLOGICALS/TOPICAL THERAPY . 54DIAGNOSTICS / MISCELLANEOUS AGENTS . 61EAR, NOSE / THROAT MEDICATIONS . 64ENDOCRINE/DIABETES . 64GASTROENTEROLOGY . 73IMMUNOLOGY, VACCINES / BIOTECHNOLOGY. 77MUSCULOSKELETAL / RHEUMATOLOGY . 83OBSTETRICS / GYNECOLOGY . 86OPHTHALMOLOGY . 90RESPIRATORY AND ALLERGY . 93UROLOGICALS . 98VITAMINS, HEMATINICS / ELECTROLYTES . 99
Updated 06/2021Abbreviations: Requirements & LimitsDrug Tiers30D Specialty Drug. May only obtain a 30 day supply.Tier 1 Preferred GenericsTier 2 GenericsTier 3 Preferred BrandsTier 4 Non Preferred DrugsTier 5 Brands and Generics: Costover 670 per monthB/D This prescription drug may be covered under MedicarePart B or D depending upon the circumstances. Information mayneed to be submitted describing the use and setting of the drugto make the determination.GC Gap Coverage. We provide coverage of this prescriptiondrug in the Coverage Gap. Please refer to our Evidence ofCoverage for more information about this coverage.HRM High Risk Medication for people over age 65, ensurebenefits outweigh risk.LA Limited Availability. This prescription may be availableonly at certain pharmacies. For more information, please callCustomer Service.PA Prior Authorization. The Plan requires you or yourphysician to get prior authorization for certain drugs. Thismeans that you will need to get approval before you fill yourprescriptions. If you don’t get approval, we may not cover thedrug.QL Quantity Limit. For certain drugs, the plan limits theamount of the drug that we will cover.SSM Senior Savings Model. For this select insulin drug, yourcopay will be the same in all stages until you reach theCatastrophic Coverage Stage. Please refer to Chapter 6 of ourEvidence of Coverage for more information. If you receiveExtra Help, you do not qualify for this program and your LowIncome Subsidy (LIS) copay level will apply.lowercase italics Generic drugsUPPERCASE BOLD Brand name drugsFormulary ID 21098, Version 10Approved by CMS on 05/17/20212
Updated 06/2021Drug NameDrug TierRequirements/LimitsANTI - INFECTIVESANTIFUNGAL AGENTSABELCET INTRAVENOUS SUSPENSION4B/D PAAMBISOME INTRAVENOUS SUSPENSIONFOR RECONSTITUTION5B/D PA; 30Damphotericin b injection recon soln4B/D PAcaspofungin intravenous recon soln5B/D PA; 30Dclotrimazole mucous membrane troche2ERAXIS(WATER DILUENT)INTRAVENOUS RECON SOLN 100 MG5ERAXIS(WATER DILUENT)INTRAVENOUS RECON SOLN 50 MG4fluconazole in nacl (iso-osm) intravenouspiggyback 200 mg/100 ml, 400 mg/200 ml2fluconazole oral suspension for reconstitution2fluconazole oral tablet2flucytosine oral capsule5griseofulvin
restrictions. We must follow the Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year: Drugs removed from the market. If the Food and Drug Adminis
