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Medperform High Formulary MedPerform High Formulary Scripps Health Plan Scripps Health Plan HMO Last updated: January 1, 2021 This Formulary is subject to change, and all previous versions of the Formulary are no longer in effect. This Formulary is available electronically at: www.ScrippsHealthPlan.com/Formulary A copy of the Evidence of Coverage is available at: www.ScrippsHealthPlan.com/EOC Table of Contents Informational Section................................................................................................................................2 Alternative Therapy - Vitamins and Minerals............................................................................................8 Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever...................................................8 Anesthetics - Drugs for Pain and Fever................................................................................................. 26 Anorectal Preparations - Rectal Preparations........................................................................................ 27 Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning............................................. 28 Anti-Infective Agents - Drugs for Infections............................................................................................ 30 Antineoplastics - Drugs for Cancer.........................................................................................................51 Antiseptics and Disinfectants - Antiseptics and Disinfectants................................................................ 63 Biologicals - Biological Agents............................................................................................................... 65 Cardiovascular Therapy Agents - Drugs for the Heart........................................................................... 67 Central Nervous System Agents - Drugs for the Nervous System.........................................................88 Chemical Dependency, Agents to Treat - Drugs for Addiction.............................................................143 Chemicals-Pharmaceutical Adjuvants..................................................................................................145 Cognitive Disorder Therapy - Drugs for the Nervous System.............................................................. 146 Contraceptives - Drugs for Women...................................................................................................... 147 Dermatological - Drugs for the Skin..................................................................................................... 161 Diagnostic Agents................................................................................................................................ 195 Drugs to treat Erectile Dysfunction - Drugs for the Urinary System..................................................... 196 Eating Disorder Therapy - Drugs for Eating Disorders.........................................................................197 Electrolyte Balance-Nutritional Products - Drugs for Nutrition..............................................................198 Endocrine - Hormones......................................................................................................................... 209 Enzymes - Vitamins and Minerals........................................................................................................ 234 FDB Class Obsolete-Not Used.............................................................................................................234 Gastrointestinal Therapy Agents - Drugs for the Stomach...................................................................235 Genitourinary Therapy - Drugs for the Urinary System........................................................................ 249 Gout and Hyperuricemia Therapy - Drugs for Pain and Fever.............................................................255 Hematological Agents - Drugs for the Blood........................................................................................ 256 Hepatobiliary System Treatment Agents - Drugs for the Liver............................................................. 265 Immunosuppressive Agents - Drugs for Organ Transplants................................................................ 265 Locomotor System - Drugs for Muscles, Ligaments, Tendons, and Bones..........................................267 Medical Supplies and Durable Medical Equipment (DME) - Medical Supplies and Durable Medical Equipment............................................................................................................................................ 269 Medical Supply, FDB Superset............................................................................................................ 314 Metabolic Disease Enzyme Replacement Agents - Drugs for Metabolic Disease............................... 343 Metabolic Modifiers - Drugs that Alter Metabolism...............................................................................343 Mouth-Throat-Dental - Preparations - Drugs for the Mouth and Throat............................................... 345 Multiple Sclerosis Agents - Drugs for the Nervous System..................................................................347 Ophthalmic Agents - Drugs for the Eye................................................................................................350 Organ Preservation Solutions.............................................................................................................. 364 Organ Preservation Solutions - Drugs for the Heart.............................................................................364 Otic (Ear) - Drugs for the Ear............................................................................................................... 366 Respiratory Therapy Agents - Drugs for the Lungs..............................................................................367 Vaginal Products - Drugs for Women...................................................................................................382 TOC-1 FORMULARY INFORMATION What is a Formulary? The Formulary provides a list of covered generic and brand name drugs selected by physician and pharmacist subject matter experts who collaboratively support MedImpact’s Pharmacy and Therapeutics (P&T) Committee. This Formulary does not apply to drugs or devices that are obtained through the medical benefit portion of your coverage. The health plan will cover drugs listed in the Formulary as long as the drug is indicated for the clinical condition, is prescribed in the appropriate manner, the prescription is filled at a participating network pharmacy, and other health plan rules are followed. The presence of a prescription drug on the Formulary does not guarantee an enrollee will be prescribed that prescription drug by his or her prescribing provider for a particular medical condition. For more information regarding the Formulary or your prescription drug benefit, please contact your health plan's Customer Service Department toll free at 1-844-337-3700, or for the hearing and speech impaired TTY: 1-888-515-4065, Monday through Friday, between 8:00a.m. and 5:00p.m. PST, or refer to the Evidence of Coverage, available at www.ScrippsHealthPlan.com/EOC. Can the Formulary (drug list) change? Drugs may be added or deleted from the Formulary during the policy year, and the Formulary will be updated with any changes on a monthly basis. Changes will be effective on the first day of the month. If there is a change in drug or dosage form, if a drug is removed from the Formulary, if prior authorization, quantity limits and/or step therapy restrictions are added to a drug, or if a drug moves to a higher cost sharing tier, the health plan will notify affected enrollees of the change before the change becomes effective. If the Food and Drug Administration (FDA) deems a drug on the Formulary to be unsafe or the drug’s manufacturer removes the drug from the market, the health plan will immediately remove the drug from the Formulary. The Formulary is subject to change and all previous versions of this Formulary are no longer in effect. How does an enrollee fill a prescription? To obtain drugs at a participating pharmacy, the enrollee must present his or her Scripps Health Plan identification card. Except for covered emergencies, claims for drugs obtained without using the identification card will be denied. To locate a participating pharmacy (including specialty pharmacies), check the cost-sharing for a particular drug, or enroll in mail-order, visit www.ScrippsHealthPlan.com/member-information and click on Prescription Drug Coverage. Benefits are provided for specialty drugs only when obtained from a Network Specialty Pharmacy, except in the case of an emergency. What are generic drugs? The health plan covers both brand name drugs and generic drugs provided they are prescribed per FDA approved indications and in accordance with the health plan pharmacy benefit coverage. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. How does an enrollee use the Formulary? The categorical list of drugs in this document groups drugs into categories and classes based on the First National Databank (FDB), a widely-accepted independent drug classification system. A prescription drug may be located by looking up the therapeutic category
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