2020 Pharmacy Benefits 1 Table of Contents Prescription Drug Program ...................................................................................................................................................ii Generic Medications ..............................................................................................................................................................ii Step Therapy ............................................................................................................................................................................ii Prior Authorization Drugs ....................................................................................................................................................iii Once-Daily Medications ......................................................................................................................................................iii Quantity Limits .......................................................................................................................................................................iii Affordable Care Act...............................................................................................................................................................iii Medications Not Covered ....................................................................................................................................................iii Participating Pharmacies ......................................................................................................................................................iv Copayments.............................................................................................................................................................................iv Specialty and Injectable Drugs ...........................................................................................................................................iv 90-Day Supply for Maintenance Medications ...............................................................................................................iv Pharmacy Benefit Questions ...............................................................................................................................................iv Drug Formulary List ................................................................................................................................................................ 1 Anti-Infectives .................................................................................................................................................................3 Antineoplastic & Immunosuppressant Drugs ........................................................................................................11 Autonomic & CNS Drugs, Neurology & Psychiatric Drugs ................................................................................16 Cardiovascular, Hypertension & Lipids .................................................................................................................. 32 Dermatologicals/Topical Therapy ..........................................................................................................................39 Diagnostics & Miscellaneous Agents .....................................................................................................................46 Ear, Nose & Throat Medications .............................................................................................................................48 Endocrine/Diabetes ....................................................................................................................................................49 Gastroenterology .........................................................................................................................................................56 Immunology, Vaccines & Biotechnology ...............................................................................................................62 Musculoskeletal & Rheumatology ..........................................................................................................................65 Obstetrics & Gynecology...........................................................................................................................................67 Ophthalmology ............................................................................................................................................................ 75 Respiratory, Allergy, Cough & Cold ........................................................................................................................79 Urologicals .....................................................................................................................................................................90 Vitamins, Hematinics & Electrolytes .......................................................................................................................91 Drug Formulary Index .......................................................................................................................................................106 i Prescription Drug Program For maximum coverage, your child’s provider The UPMC for Kids formulary is developed by the should prescribe medications from the formulary UPMC Health Plan Pharmacy and Therapeutics (preferred medications). A nonformulary (P&T) Committee. The formulary is composed (nonpreferred) medication is one that is not on of medications approved by the Food and Drug the list of medications covered by UPMC for Administration (FDA). Kids. To have a prescription for a nonformulary (nonpreferred) medicine covered, your child’s The P&T Committee makes decisions about provider must contact our Health Care Concierge which medications to include in the UPMC for team toll-free at 1-800-650-8762 (TTY: 711) to Kids Pharmacy Benefit program. The committee, ask for a medical exception. The provider should made up of physicians and pharmacists from call our Health Care Concierge team before you communities throughout the UPMC Health Plan go to the pharmacy. service area, decides which medications to cover based on a drug’s safety, effectiveness, and cost. Your child can get covered over-the-counter medications when the provider writes a prescription The P&T Committee’s job is to make sure that for them. Over-the-counter medications appear on the UPMC for Kids Pharmacy Benefit program the formulary with OTC following their name. provides children with high-quality, cost-effective prescription medications. The P&T Committee If you have questions about the formulary, its reviews and updates the UPMC for Kids Pharmacy use, or specific medications, call our Health Care Benefit program regularly during the year. You Concierge team toll-free at 1-800-650-8762. TTY can find information about these updates in the users should call 711. UPMC for Kids member newsletters and pharmacy mailings. Generic Medications UPMC for Kids requires that generic medications Medications on the formulary (drug list) are be used when available. Generic drugs have the covered (paid for) by UPMC for Kids. This booklet same active ingredients as their brand-name provides lists of covered prescription and over- versions and are just as safe and effective. Health the-counter medications. Please note that there care providers are encouraged to prescribe generic are other drugs that UPMC for Kids covers in medications whenever clinically appropriate. If your addition to the ones listed in this booklet. The child’s provider prescribes a drug by brand name, drugs on the formulary were selected because Pennsylvania law permits the pharmacist to give they are safe, work well, and cost less than other you a generic version of that drug. If the provider drugs with the same level of effectiveness. For a thinks your child needs the brand-name version of complete list of covered medications, visit the drug, the provider must call our Health Care www.upmchealthplan.com/forkids. Concierge team to request a medical exception. UPMC for Kids allows the brand-name drug at the The amount of medication your child may receive generic cost-sharing rate if the provider establishes through the UPMC for Kids pharmacy program is that the brand-name drug is medically necessary based on the type of medication ordered. Specialty and the medical exception request is approved. medications and controlled substances are limited to a 30-day supply. You may receive a 30-day Step Therapy or 90-day supply of medications filled at a retail Step therapy is a process that encourages the use of pharmacy. See the 90-day Supply for Maintenance medications preferred by UPMC for Kids as the first Medications section on page iv of this booklet course of treatment. If the preferred medication is for more information on getting a 90-day supply. not clinically effective or if the member suffers side Prescription refills will be allowed for a maximum effects, another medication may be approved as the period of one year from the date of the original second course of treatment. prescription. Medications that require step therapy appear on the formulary with ST following their name. ii Prior Authorization Drugs Affordable Care Act Certain drugs require prior authorization, which You will see the abbreviation ACA next to some means that the provider must consult with UPMC drugs on the formulary tables in this booklet.