Skip to main content

2023 Medicare Advantage Drug Formulary and Pharmacy Prior Authorization Changes

Date:
November 29, 2022

To: All Providers

Contracts Affected: Medicare Advantage

Beginning January 1, 2023, some of your Highmark Blue Shield of Northeastern New York (Highmark BSNENY) 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 BSNENY 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 Resources Center (PRC)» [NENY] > 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. 

Recent Articles

  • Introducing Highmark’s Provider News
    As part of our affiliation with Highmark, we want to create a more seamless and enhanced provider experience. To support this, we will transition our monthly provider communication from “Blue Bulletin” to “Provider News.” Beginning in January, you’ll receive Highmark’s monthly Provider News emails at the end of each month replacing Blue Bulletin. Provider News will deliver local information to help you work with us, including reimbursement, coding, preauthorization, and policy updates. In this article, you can find more information and view the Provider News webpage on the Highmark Provider Resource Center (PRC).
  • Reminder: Highmark Commercial and Medicare Advantage Reimbursement Policies
    As a reminder, on January 1 after all your Highmark Blue Shield of Northeastern New York patients are on Highmark’s systems, we will be following Highmark’s reimbursement policies for commercial and Medicare Advantage lines of business. Here, you can find out how to access Reimbursement Policies on the Highmark Provider Resource Center (PRC).
  • Population Health University - Clinical Pharmacy Resources Available Online
    Before discussing, prescribing, and deprescribing certain medications with your Highmark Blue Shield of Northeastern New York patients, Highmark’s Population Health University offers clinical pharmacy resources to assist you. In this article, you can learn how to access the toolkits that provide useful pharmacy guidance.
  • Provider Tools and Resources Remaining on the Legacy Website
    Our legacy provider website will be decommissioned on February 1, 2023, at which point you will be redirected to the Highmark Provider Resource Center (PRC). Despite this change, you will still be able to access several tools and pages on the legacy website. Here, you can find out which content will be remaining and where to find it.
  • Credentialing and Enumeration for Nurse Practitioners and Certified Registered Nurse Anesthetists
    Beginning January 1, nurse practitioners will have the option to be fully credentialed as a primary care provider (PCP), specialist, or enumerated in either role. Certified registered nurse anesthetists will have to option to credential as a specialist or be enumerated in the reimbursement system only. In this article, you can find information on how to credential and enumerate.