DOCSLIB.ORG

Preferred Drug List (PDL) Memorialcare Select Health Plan Applies To: Memorialcare Select Members Last Updated: February 2021

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Preferred Drug List (PDL) Memorialcare Select Health Plan Applies To: Memorialcare Select Members Last Updated: February 2021 Portfolio Medium – Preferred Drug List (PDL) MemorialCare Select Health Plan Applies to: MemorialCare Select Members Last Updated: February 2021 Please note the formulary is subject to change and all previous versions of the formulary will no longer be in effect. To Access MemorialCare Select Pharmacy information: https://www.memorialcareselecthealthplan.org/access-information To Access MemorialCare Select EOC: https://www.memorialcareselecthealthplan.org/seaside-select-member-services 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................................................................................................. 33 Anorectal Preparations - Rectal Preparations........................................................................................ 34 Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning............................................. 35 Anti-Infective Agents - Drugs for Infections............................................................................................ 37 Antineoplastics - Drugs for Cancer.........................................................................................................60 Antiseptics and Disinfectants - Antiseptics and Disinfectants................................................................ 72 Biologicals - Biological Agents............................................................................................................... 72 Cardiovascular Therapy Agents............................................................................................................. 80 Cardiovascular Therapy Agents - Drugs for the Heart........................................................................... 81 Central Nervous System Agents - Drugs for the Nervous System.......................................................102 Chemical Dependency, Agents to Treat - Drugs for Addiction.............................................................146 Chemicals-Pharmaceutical Adjuvants..................................................................................................148 Cognitive Disorder Therapy - Drugs for the Nervous System.............................................................. 149 Contraceptives - Drugs for Women...................................................................................................... 151 Dermatological..................................................................................................................................... 165 Dermatological - Drugs for the Skin..................................................................................................... 165 Diagnostic Agents................................................................................................................................ 217 Drugs to treat Erectile Dysfunction - Drugs for the Urinary System..................................................... 217 Eating Disorder Therapy...................................................................................................................... 218 Eating Disorder Therapy - Drugs for Eating Disorders.........................................................................218 Electrolyte Balance-Nutritional Products - Drugs for Nutrition..............................................................220 Endocrine - Hormones......................................................................................................................... 224 Enzymes - Vitamins and Minerals........................................................................................................ 258 FDB Class Obsolete-Not Used.............................................................................................................258 Gastrointestinal Therapy Agents - Drugs for the Stomach...................................................................259 Genitourinary Therapy - Drugs for the Urinary System........................................................................ 276 Gout and Hyperuricemia Therapy - Drugs for Pain and Fever.............................................................282 Hematological Agents - Drugs for the Blood........................................................................................ 283 Hepatobiliary System Treatment Agents - Drugs for the Liver............................................................. 297 Immunosuppressive Agents - Drugs for Organ Transplants................................................................ 297 Locomotor System - Drugs for Muscles, Ligaments, Tendons, and Bones..........................................299 Medical Supplies and Durable Medical Equipment (DME) - Medical Supplies and Durable Medical Equipment............................................................................................................................................ 301 Medical Supply, FDB Superset............................................................................................................ 378 Metabolic Disease Enzyme Replacement Agents - Drugs for Metabolic Disease............................... 423 Metabolic Modifiers.............................................................................................................................. 423 Metabolic Modifiers - Drugs that Alter Metabolism...............................................................................423 Mouth-Throat-Dental - Preparations - Drugs for the Mouth and Throat............................................... 426 Multiple Sclerosis Agents - Drugs for the Nervous System..................................................................430 Ophthalmic Agents - Drugs for the Eye................................................................................................432 Organ Preservation Solutions.............................................................................................................. 446 Organ Preservation Solutions - Drugs for the Heart.............................................................................446 Otic (Ear) - Drugs for the Ear............................................................................................................... 448 Respiratory Therapy Agents - Drugs for the Lungs..............................................................................449 Vaginal Products - Drugs for Women...................................................................................................466 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 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 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 plan’s Member Services department at (855) 367- 7747, or for the hearing and speech impaired TTY: 711, Monday through Friday, between 8:00 am – 5:00 pm PST, or refer to your Plan Benefit Documents, available at https://www.memorialcareselecthealthplan.org. 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 plan will notify affected enrollees of the change before the change becomes effective. If the FDA deems a drug on the formulary to be unsafe or the drug’s manufacturer removes the drug from the market, the 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 a member fill a prescription? To obtain drugs at a participating pharmacy, the enrollee must present his or her pharmacy benefit 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 https://www.memorialcareselecthealthplan.org . Your plan benefits may restrict coverage of specialty drugs only when obtained from a Network Specialty Pharmacy, except in case of an emergency. What are generic drugs? The plan covers both brand name
Load more

Recommended publications
  • WSAVA List of Essential Medicines for Cats and Dogs
    The World Small Animal Veterinary Association (WSAVA) List of Essential Medicines for Cats and Dogs Version 1; January 20th, 2020 Members of the WSAVA Therapeutic Guidelines Group (TGG) Steagall PV, Pelligand L, Page SW, Bourgeois M, Weese S, Manigot G, Dublin D, Ferreira JP, Guardabassi L © 2020 WSAVA All Rights Reserved Contents Background ................................................................................................................................... 2 Definition ...................................................................................................................................... 2 Using the List of Essential Medicines ............................................................................................ 2 Criteria for selection of essential medicines ................................................................................. 3 Anaesthetic, analgesic, sedative and emergency drugs ............................................................... 4 Antimicrobial drugs ....................................................................................................................... 7 Antibacterial and antiprotozoal drugs ....................................................................................... 7 Systemic administration ........................................................................................................ 7 Topical administration ........................................................................................................... 9 Antifungal drugs .....................................................................................................................
    [Show full text]
  • Premium Formulary 1 Quantity Limits — Premium Premium Non-Specialty Quantity Limit
    Your 2021 Premium Standard Formulary Effective July 1, 2021 For the most current list of covered medications or if you have questions: Call the number on your member ID card Visit your plan’s website on your member ID card or log on to the OptumRx app to: • Find a participating retail pharmacy by ZIP code • Look up possible lower-cost medication alternatives • Compare medication pricing and options Understanding your formulary What is a formulary? About this formulary A formulary is a list of prescribed medications or other When differences between this formulary and your pharmacy care products, services or supplies chosen for benefit plan exist, the benefit plan documents rule. This their safety, cost, and effectiveness. Medications are formulary may not be a complete list of medications that listed by categories or classes and are placed into cost are covered by your plan. Please review your benefit plan levels known as tiers. It includes both brand and generic for full details. prescription medications. ® To create the list, OptumRx is guided by the Pharmacy and When does the formulary change? Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how • Medications may move to a lower tier at any time. well the drugs work, and overall value. They also make sure • Medications may move to a higher tier when a generic there are safe and covered options. equal becomes available. • Medications may move to a higher tier or be excluded from How do I use my formulary? coverage on January 1 or July 1 of each year.
    [Show full text]
  • Beta-Sitosterol [BSS] and Betasitosterol Glucoside [BSSG] As an Adjuvant in the Treatment of Pulmonary Tuberculosis Patients.” TB Weekly (4 Mar 1996)
    Saw Palmetto (Serenoa repens) and One of Its Constituent Sterols -Sitosterol [83-46-5] Review of Toxicological Literature Prepared for Errol Zeiger, Ph.D. National Institute of Environmental Health Sciences P.O. Box 12233 Research Triangle Park, North Carolina 27709 Contract No. N01-ES-65402 Submitted by Raymond Tice, Ph.D. Integrated Laboratory Systems P.O. Box 13501 Research Triangle Park, North Carolina 27709 November 1997 EXECUTIVE SUMMARY The nomination of saw palmetto and -sitosterol for testing is based on the potential for human exposure and the limited amount of toxicity and carcinogenicity data. Saw palmetto (Serenoa repens), a member of the palm family Arecaceae, is native to the West Indies and the Atlantic Coast of North America, from South Carolina to Florida. The plant may grow to a height of 20 feet (6.10 m), with leaves up to 3 feet (0.914 m) across. The berries are fleshy, about 0.75 inch (1.9 cm) in diameter, and blue-black in color. Saw palmetto berries contain sterols and lipids, including relatively high concentrations of free and bound sitosterols. The following chemicals have been identified in the berries: anthranilic acid, capric acid, caproic acid, caprylic acid, - carotene, ferulic acid, mannitol, -sitosterol, -sitosterol-D-glucoside, linoleic acid, myristic acid, oleic acid, palmitic acid, 1-monolaurin and 1-monomyristin. A number of other common plants (e.g., basil, corn, soybean) also contain -sitosterol. Saw palmetto extract has become the sixth best-selling herbal dietary supplement in the United States. In Europe, several pharmaceutical companies sell saw palmetto-based over-the-counter (OTC) drugs for treating benign prostatic hyperplasia (BPH).
    [Show full text]
  • Preferred Drug List
    October 2021 Preferred Drug List The Preferred Drug List, administered by CVS Caremark® on behalf of Siemens, is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred medicine from authorize generic substitution whenever possible. If you believe a this list. Take this list along when you or a covered family member brand-name product is necessary, consider prescribing a brand name sees a doctor. on this list. Please note: Please note: • Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in • This drug list represents a summary of prescription coverage. It is this document. Products recently approved by the U.S. Food and not all-inclusive and does not guarantee coverage.
    [Show full text]
  • National Drug List
    National Drug List Drug list — Five Tier Drug Plan Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). The following is a list of plan names to which this formulary may apply. Additional plans may be applicable. If you are a current Anthem member with questions about your pharmacy benefits, we're here to help. Just call us at the Pharmacy Member Services number on your ID card. Solution PPO 1500/15/20 $5/$15/$50/$65/30% to $250 after deductible Solution PPO 2000/20/20 $5/$20/$30/$50/30% to $250 Solution PPO 2500/25/20 $5/$20/$40/$60/30% to $250 Solution PPO 3500/30/30 $5/$20/$40/$60/30% to $250 Rx ded $150 Solution PPO 4500/30/30 $5/$20/$40/$75/30% to $250 Solution PPO 5500/30/30 $5/$20/$40/$75/30% to $250 Rx ded $250 $5/$15/$25/$45/30% to $250 $5/$20/$50/$65/30% to $250 Rx ded $500 $5/$15/$30/$50/30% to $250 $5/$20/$50/$70/30% to $250 $5/$15/$40/$60/30% to $250 $5/$20/$50/$70/30% to $250 after deductible Here are a few things to remember: o You can view and search our current drug lists when you visit anthem.com/ca and choose Prescription Benefits. Please note: The formulary is subject to change and all previous versions of the formulary are no longer in effect.
    [Show full text]
  • 2021 Hormone Therapy Prescription Coverage Guide
    HORMONE THERAPY PRESCRIPTION COVERAGE GUIDE COLORADO 2021 This document can be used to review the coverage and forms of hormone therapy by each insurance company. Not all health plans cover all prescriptions. Each insurance company has a list of prescriptions they cover, called a formulary or drug list, on their website. These lists often split drugs into ‘tiers’ or categories, which determine your share of the costs. While some plans have a copay for prescriptions—a fixed amount that starts right away—other plans require you to pay the full cost until you hit a prescription deductible (if there is one) or your overall plan deductible, which is more common. This document does not review each plan offered through each carrier. Lower tiers generally mean generic and lower-cost drugs. Middle tiers often include brand name drugs. Higher tiers generally include specialty drugs or drugs administered in a medical facility (although this is not the case for Denver Health Medical Plan, whose fifth tier covers zero cost-share drugs). Each company tiers drugs differently, so it is important that you look at each plan specifically to see what the medications may cost you. This is a summary of hormone therapy drugs available, but may not be an exhaustive list. Want to know if your prescription medication is covered? You can use the Quick Cost and Plan Finder tool offered by Connect for Health Colorado, found at https://planfinder.connectforhealthco.com. You can click on the hyperlinked name of each insurance company below for more information about how each company tiers their drugs.
    [Show full text]
  • 2019 Prohibited List
    THE WORLD ANTI-DOPING CODE INTERNATIONAL STANDARD PROHIBITED LIST JANUARY 2019 The official text of the Prohibited List shall be maintained by WADA and shall be published in English and French. In the event of any conflict between the English and French versions, the English version shall prevail. This List shall come into effect on 1 January 2019 SUBSTANCES & METHODS PROHIBITED AT ALL TIMES (IN- AND OUT-OF-COMPETITION) IN ACCORDANCE WITH ARTICLE 4.2.2 OF THE WORLD ANTI-DOPING CODE, ALL PROHIBITED SUBSTANCES SHALL BE CONSIDERED AS “SPECIFIED SUBSTANCES” EXCEPT SUBSTANCES IN CLASSES S1, S2, S4.4, S4.5, S6.A, AND PROHIBITED METHODS M1, M2 AND M3. PROHIBITED SUBSTANCES NON-APPROVED SUBSTANCES Mestanolone; S0 Mesterolone; Any pharmacological substance which is not Metandienone (17β-hydroxy-17α-methylandrosta-1,4-dien- addressed by any of the subsequent sections of the 3-one); List and with no current approval by any governmental Metenolone; regulatory health authority for human therapeutic use Methandriol; (e.g. drugs under pre-clinical or clinical development Methasterone (17β-hydroxy-2α,17α-dimethyl-5α- or discontinued, designer drugs, substances approved androstan-3-one); only for veterinary use) is prohibited at all times. Methyldienolone (17β-hydroxy-17α-methylestra-4,9-dien- 3-one); ANABOLIC AGENTS Methyl-1-testosterone (17β-hydroxy-17α-methyl-5α- S1 androst-1-en-3-one); Anabolic agents are prohibited. Methylnortestosterone (17β-hydroxy-17α-methylestr-4-en- 3-one); 1. ANABOLIC ANDROGENIC STEROIDS (AAS) Methyltestosterone; a. Exogenous*
    [Show full text]
  • Stembook 2018.Pdf
    The use of stems in the selection of International Nonproprietary Names (INN) for pharmaceutical substances FORMER DOCUMENT NUMBER: WHO/PHARM S/NOM 15 WHO/EMP/RHT/TSN/2018.1 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. The use of stems in the selection of International Nonproprietary Names (INN) for pharmaceutical substances. Geneva: World Health Organization; 2018 (WHO/EMP/RHT/TSN/2018.1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data.
    [Show full text]
  • Rxoutlook® 3Rd Quarter 2020
    ® RxOutlook 3rd Quarter 2020 optum.com/optumrx a RxOutlook 3rd Quarter 2020 In this edition of RxOutlook, we highlight 13 key pipeline drugs with potential to launch by the end of the fourth quarter of 2020. In this list of drugs, we continue to see an emphasis on rare diseases. Indeed, almost half of the drugs we review here have FDA Orphan Drug Designation for a rare, or ultra-rare condition. However, this emphasis on rare diseases is also balanced by several drugs for more “mainstream” conditions such as attention deficit hyperactivity disorder, hypercholesterolemia, and osteoarthritis. Seven are delivered via the oral route of administration and three of these are particularly notable because they are the first oral option in their respective categories. Berotralstat is the first oral treatment for hereditary angioedema, relugolix is the first oral gonadotropin releasing hormone receptor antagonist for prostate cancer, and roxadustat is the first oral treatment for anemia of chronic kidney disease. Two drugs this list use RNA-based mechanisms to dampen or “silence” genetic signaling in order to correct an underlying genetic condition: Lumasiran for primary hyperoxaluria type 1, and inclisiran for atherosclerosis and familial hypercholesterolemia. These agents can be given every 3 or 6 months and fill a space between more traditional chronic maintenance drugs the require daily administration and gene therapies that require one time dosing for long term (and possible life-long) benefits. Key pipeline drugs with FDA approval decisions
    [Show full text]
  • Drug Interactions with Dietary Supplements by Chenita W
    CONTINUING EDUCATION Drug Interactions With Dietary Supplements by Chenita W. Carter, PharmD; Maegan Boyd, PharmD; and Megan Nelson, PharmD pon successful completion of this ar- this CE presentation, there Useful Websites ticle, pharmacists should be able to: will be a review of the most 1. Describe the common uses and commonly used dietary ■ www.mskcc.org/mskcc/html/44.cfm proposed mechanisms of action supplements including an Memorial Sloan-Kettering Cancer Center of 19 dietary supplements. explanation of the therapeutic Contains an entire database of dietary 2. Describe adverse effects associated with the uses as well as the potential supplement medicines. Of note on U this site is that chemotherapy drug use of dietary supplements. adverse effects of each. Also, 3. Describe the mechanisms of drug interactions each section will address interactions are included with all other involving a given dietary supplement. possible drug interactions re- drug interactions. 4. Evaluate resources for pharmacists, physi- lated to the supplement. After ■ www.altnature.com/gallery/index.html cians, and consumers for dietary supplements. completing this presentation, Alternative Nature Enterprises the reader will be adept at re- Contains information about the most Pharmacy Technician CE Objectives viewing a patient’s complete commonly used herbs. It includes pictures 1. Describe the common uses of 19 herbal supplement and medication of the natural source, as well as information therapies. list and identifying potential about its use and adverse effects. 2. Describe adverse effects associated with the drug-supplement interactions. use of dietary supplements. 3. List prescription drugs that interact with di- ANTACIDS etary supplements. Antacids are one of the most common drugs that are purchased over the counter.
    [Show full text]
  • National Drug List Drug List — Four Tier Drug Plan
    National Drug List Drug list — Four Tier Drug Plan Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). The following is a list of plan names to which this formulary may apply. Additional plans may be applicable. If you are a current Anthem member with questions about your pharmacy benefits, we're here to help. Just call us at the Pharmacy Member Services number on your ID card. Solution PPO 1500/15/20 $5/$15/$50/$65/30% to $250 after deductible Solution PPO 2000/20/20 $5/$20/$30/$50/30% to $250 Solution PPO 2500/25/20 $5/$20/$40/$60/30% to $250 Solution PPO 3500/30/30 $5/$20/$40/$60/30% to $250 Rx ded $150 Solution PPO 4500/30/30 $5/$20/$40/$75/30% to $250 Solution PPO 5500/30/30 $5/$20/$40/$75/30% to $250 Rx ded $250 $5/$15/$25/$45/30% to $250 $5/$20/$50/$65/30% to $250 Rx ded $500 $5/$15/$30/$50/30% to $250 $5/$20/$50/$70/30% to $250 $5/$15/$40/$60/30% to $250 $5/$20/$50/$70/30% to $250 after deductible Here are a few things to remember: o You can view and search our current drug lists when you visit anthem.com/ca and choose Prescription Benefits. Please note: The formulary is subject to change and all previous versions of the formulary are no longer in effect.
    [Show full text]
  • FEP 5 Tier Rx Drug Formulary (607) Standard Option
    FEP 5 Tier Rx Drug Formulary (607) Standard Option Effective July 1, 2021 The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty drugs. Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to prescribe a preferred brand-name drug. The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective. Click on the category name in the Table of Contents below to go directly to that page INTRODUCTION ........................................................................................................................................................................................................................ 5 PREFACE ................................................................................................................................................................................................................................... 5 EXCLUDED DRUGS .................................................................................................................................................................................................................. 6 PRIOR APPROVAL ..................................................................................................................................................................................................................
    [Show full text]