Medi-Cal Formulary Is Subject to Change Throughout the Year
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Formulary Medi-Cal JUNE 2021 The IEHP Medi-Cal Formulary is subject to change throughout the year. All previous versions of the formulary are no longer in effect once a new formulary is available. The IEHP Medi-Cal Formulary can be found at: www.iehp.org/en/members/medical Last Updated: 05/14/2021 Inland Empire Health Plan (IEHP) Medi-Cal Formulary Table of Contents A. Foreword ..................................................................................................................... 2 B. IEHP Member Services .............................................................................................. 2 C. How to Use the Formulary .......................................................................................... 2 D. Prescription Coverage ................................................................................................. 3 D1. Quantity Limits .................................................................................................... 3 D2. Step Therapy ........................................................................................................ 3 E. Filling a Prescription and IEHP’s Pharmacy Network ............................................... 4 F. Definitions ................................................................................................................... 4 G. List of Covered Drugs .............................................................................................. 10 H. Index ....................................................................................................................... 115 Call IEHP Member Services toll free at 1-800-440-IEHP (4347), Monday – Friday, 8am – 5pm. TTY users should call 1-800-718-4347. Or visit us online at www.iehp.org. 1 A. Foreword The IEHP Medi-Cal Formulary (also known as a prescription drug list) is a preferred list of covered drugs that meet certain criteria and are approved for Members. This Formulary applies only to outpatient drugs and self-administered drugs. A Member’s covered services are free if they are medically necessary, and the approved services are from IEHP’s provider network. IEHP may make changes to the Formulary on a monthly basis. For example: Change a drug or the dosage form covered Decide to require or not require prior authorization for a drug Add or change the amount of a drug a member can get Add or change step therapy restrictions on a drug The Formulary is subject to change and all past versions of the Formulary are no longer in effect. The Formulary is reviewed on a regular basis and revised based on safety, clinical efficacy, and cost- effectiveness. You can access the most recent Formulary at www.iehp.org/en/members/medical. B. IEHP Member Services To learn more about prescription drug benefits, please call IEHP Member Services at 1-800-440-IEHP (4347), Monday – Friday, 8am – 5pm. TTY users should call 1-800-718-4347. C. How to Use the Formulary The IEHP Medi-Cal Formulary begins on page 11. Drugs are listed in order from A to Z by its brand and generic names by therapeutic category and class. You can also look up the brand or generic name of the drug in order from A to Z in the index on page 115. The generic name of a brand name drug is listed after the brand name in parentheses and in all bold and italicized lowercase letters. If a generic version of a brand name drug exists, and both versions are covered, the generic drug will be listed by itself in all bold and italicized lowercase letters. In the event a generic drug is a trademarked brand name, the brand name drug will be listed in all CAPITAL letters after the generic name in parentheses. The font will not be in bold, and the first letter of each word will be a capital letter. Brand name drugs: CAPITAL LETTERS Generic: bold and italicized lowercase letters F: Formulary PA: Prior authorization SPO: Specialty pharmacy required C1: Code 1 QL: Quantity limit 12MO: up to a 12-month supply allowed ST: Step therapy AR: age restriction Call IEHP Member Services toll free at 1-800-440-IEHP (4347), Monday – Friday, 8am – 5pm. TTY users should call 1-800-718-4347. Or visit us online at www.iehp.org. 2 D. Prescription Coverage First-line formulary drugs should be used instead of the nonformulary drugs, but coverage is not limited only to drugs on the IEHP Formulary. Many nonformulary drugs are still covered through the Prior Authorization (PA) process. The PA process at IEHP is based on current medical findings, FDA-approved data, and what the IEHP Pharmacy and Therapeutics Subcommittee recommends. The PA process helps to encourage the correct and rational use of drugs. It allows coverage only when certain conditions are met for nonformulary, PA, and step therapy drugs. If the drug prescribed is not on the IEHP Medi-Cal Formulary, the member’s doctor may submit a PA to IEHP. If the PA is approved, the member’s doctor will be informed, and the drug will be covered within 24 hours of getting the request. If the request is denied, the doctor who prescribed the drug and the member will be notified within 24 hours of getting the request. The member will also get detailed instructions about appeal rights and procedures to file a grievance or complaint about the denial. IEHP Medi-Cal will cover the prescribed drug and clinically appropriate number of refills. IEHP Medi-Cal will not limit or exclude coverage for a drug if the health plan approved it in the past for the member’s medical condition and the doctor who prescribed the drug continues to prescribe it for the medical condition, as long as it is appropriate, safe and effective for treating the member’s medical condition. D1. Quantity Limits Formulary drugs may have a limit on the amount of a drug the member can get called a quantity limit. The member’s prescribing provider may submit a request for an exception to the quantity limit through the PA process. IEHP shall make exceptions to quantity limits as long as it is appropriate, safe and effective for treating the member’s medical condition. D2. Step Therapy Formulary drugs may require the member to do step therapy. Step therapy requires the member to try one or more drugs to treat the medical condition before IEHP will cover another drug for the condition. The member’s prescribing provider may submit a request for step therapy exception through the PA process. IEHP shall make exceptions to step therapy as long as it is appropriate, safe and effective for treating the member’s medical condition. Drugs can be covered under the medical benefit or the outpatient prescription drug benefit of the health plan. This depends on many factors. The member’s prescribing provider may need to give IEHP more details about the use and setting of the drug. The following list of drugs gives you information about the drugs covered by IEHP Medi-Cal. For example, IEHP Medi-Cal formulary covers FDA approved contraceptive drugs, devices, and other products for women. However, the presence of a prescription drug on the formulary does not guarantee a member will be prescribed that drug by his or her prescribing provider for a particular medical condition. Call IEHP Member Services toll free at 1-800-440-IEHP (4347), Monday – Friday, 8am – 5pm. TTY users should call 1-800-718-4347. Or visit us online at www.iehp.org. 3 E. Filling a Prescription and IEHP’s Pharmacy Network If a prescribed drug is being filled by a member, it must come from an IEHP network pharmacy. A list of pharmacies can be found in the IEHP Provider and Pharmacy Directory at www.iehp.org. Members can also find a network pharmacy by calling IEHP Member Services at 1-800-440-IEHP (4347), Monday – Friday, 8am – 5pm. TTY users should call 1-800-718-4347. Once a member chooses a pharmacy, the prescription can be taken to the pharmacy and must be presented along with the IEHP Member card. Members should let the pharmacy know about all the drugs they take and any allergies they have. Members should also ask the pharmacist any questions they have about their medicine. IEHP restricts certain drugs to specialty pharmacies to provide certain Disease Therapy Management (DTM). The member’s prescribing provider may submit a request through the PA process to obtain certain drugs from specialty pharmacies. F. Definitions Brand name drug is a drug that has a trademark-protected name. The brand name drug is listed in all CAPITAL letters. Member is a person enrolled in a health plan who is entitled to get services from the plan. Exception request is a request for coverage of a prescribed drug. If a member, his or her designee, or health care provider who prescribes drugs submits an exception request, the health plan must cover the prescribed drug when the drug is determined to be medically necessary to treat the member’s illness. Formulary is the complete list of drugs preferred for use and eligible for coverage under a health plan product. This includes all drugs covered under the outpatient prescription drug benefit of the health plan product. The Formulary is also known as a prescription drug list. Generic drug is a version of a brand drug that is equal in dosage, safety, strength, how it is taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase letters. Nonformulary drug is a drug prescribed by a prescribing provider that is not listed on the health plan’s formulary. Prescribing provider is a health care provider who is allowed to write a prescription to treat a medical condition for a health plan member. Call IEHP Member Services toll free at 1-800-440-IEHP (4347), Monday – Friday, 8am – 5pm. TTY users should call 1-800-718-4347. Or visit us online at www.iehp.org. 4 Prescription is an oral, written, or electronic order by a prescribing provider for a specific member. It contains the name and the amount of the prescribed drug, the date of issue, the name, contact information and the signature of the prescribing provider (if the prescription is in writing). Prescription drug is a drug prescribed to a member by a prescribing provider who prescribes drugs and requires a prescription under the law.