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2023 Medicare Advantage Drug Formulary and Pharmacy Prior Authorization Changes

November 29, 2022

To: All Providers

Contracts Affected: Medicare Advantage

Beginning January 1, 2023, some of your Highmark Blue Cross Blue Shield of Western New York (Highmark BCBSWNY) Medicare Advantage patients may be affected by changes to Highmark’s pharmacy drug formulary. Additionally, prior authorization requests will be submitted to and reviewed by our Utilization Management (UM) team.

Formulary Updates You Can Expect

In 2023, pharmacy drug formulary changes may impact some medications currently prescribed to your Highmark BCBSWNY Medicare Advantage patients. These changes include removing some medications from the drug formulary, requiring a prior authorization, quantity limits, and moving medications to a higher coverage tier.

Medications moving to a higher tier can result in a higher copay for your patients. Some of the medications changing tiers in 2023 include:

  • Oxybutynin chloride
  • Euthyrox/levoxyl and unithroid
  • Travoprost
  • Trospium

In early December, you will receive a letter detailing select medication changes that will impact your patients. Please save this letter and speak with your affected patients about changing medications to a covered alternative, if you feel this discussion is appropriate. Some covered alternatives will be provided; additional alternatives are included in the patient’s Medicare formulary.

To review the full 2023 Medicare formularies, visit the Provider Resource Center (PRC) > Pharmacy Programs/Formularies > Medicare Formularies.

Prior Authorization Review Process Changes

Medication  prior authorization requests for 2023 coverage and beyond for your Medicare Advantage patients will now be submitted through NaviNet and reviewed directly by our Highmark Utilization Management team. Prior authorization requests may also be faxed to Highmark at 1-866-240-8123. You can also request an authorization by calling 1-800-600-2227 Monday – Friday, 8:30 a.m. – 4:30 p.m.

You may begin submitting medication prior authorization requests for 2023 coverage on December 12.

Please note: any prior authorization requests needed for 2022 coverage should still be sent to Express Scripts. While the process for medication prior authorization requests is changing for 2023, Express Scripts will remain our pharmacy benefits manager.

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