Drug Formulary

DRUG FORMULARY EFFECTIVE JANUARY 1, 2018 LAST UPDATED OCTOBER 26, 2018 TABLE OF CONTENTS INTRODUCTION................................................................................................................................................. 2 HOW TO USE THIS LIST .................................................................................................................................. 2 COVERAGE AND LIMITATIONS ................................................................................................................... 3 PHARMACY SAVINGS PROGRAMS .............................................................................................................. 4 CONTACT US ...................................................................................................................................................... 4 DRUG FORMULARY LIST ............................................................................................................................... 5 ANTI-INFECTIVE DRUGS ................................................................................................................................ 5 AUTOIMMUNE INFLAMMATORY DISORDERS ........................................................................................ 7 BLOOD MODIFYING DRUGS .......................................................................................................................... 8 CANCER DRUGS ................................................................................................................................................ 8 CENTRAL NERVOUS SYSTEM ....................................................................................................................... 9 GASTROINTESTINAL DRUGS ...................................................................................................................... 12 GENITOURINARY DRUGS ............................................................................................................................. 13 HEART AND CIRCULATORY DRUGS ........................................................................................................ 14 HORMONES, DIABETES, TEST SUPPLIES, AND RELATED DRUGS .................................................. 18 MISCELLANEOUS CATEGORIES (INCLUDES SUPPLIES AND DEVICES) ....................................... 21 MULTIPLE SCLEROSIS .................................................................................................................................. 21 NEUROMUSCULAR DRUGS .......................................................................................................................... 22 PAIN-RELIEF DRUGS ..................................................................................................................................... 23 RESPIRATORY, ALLERGY, ETC ................................................................................................................. 25 SUPPLEMENTS ................................................................................................................................................. 26 TOPICAL DRUGS ............................................................................................................................................. 26 MANAGED DOSE LIMITATIONS (MDL) .................................................................................................... 31 PREAUTHORIZATION (PA) ........................................................................................................................... 34 STEP-THERAPY (ST) ....................................................................................................................................... 38 WELLNESS MEDICATIONS .......................................................................................................................... 41 INDEX .................................................................................................................................................................. 43 1 ph-commercialformprivate-1018-2 INTRODUCTION Example: VESICARE - solefenacin This is the 2018 Health Alliance Drug Covered generic drugs appear in lowercase bold Formulary. In order to assist members and providers type, followed by their reference brand drug in in choosing covered prescription drugs for parentheses. (Exceptions are noted.) treatment, we encourage members to show this list Example: atenolol (Tenormin) to their physicians and pharmacists. In addition, we encourage prescribers to use this list when Generics considering treatment options. Final decisions Like brand drugs, generic drugs go through an regarding treatment options are made between the approval process by the Food and Drug physician and patient. Administration (FDA) and must meet similar The formulary is subject to change at any time. standards of effectiveness and chemical make-up as Members can access the most up-to-date version of branded drugs. this list by visiting the Pharmacy section of The main difference between the reference brand HealthAlliance.org. In addition, members can login drug and its generic equivalent is that the generic to OptumRx.com to access specific drug coverage often costs much less. and pricing information. As a general rule, generic drugs have the lowest The formulary does not provide information member copayment. Typically, when a generic about an individual’s specific coverage. Please refer enters the market the brand drug moves to Tier 3. to your plan documents for complete coverage Members who choose the brand name after the details. release of a generic version may pay the copayment plus the difference in cost between the brand and HOW TO USE THIS LIST generic drug. Generic drugs can help members save on out-of-pocket medication costs. This drug list is organized in sections by drug class or medical condition. Within each section are Generic Equivalent vs. Generic Alternative subsections to help locate medications. Most drugs Generic equivalents are medications that contain listed, whether generic or brand, are formulary the same active ingredient, with the same strength drugs. There are a few nonformulary drugs listed and dosage form as the brand medication. Generic and designated as Tier 3. equivalents are as safe and effective and produce To search within the PDF, choose the search the same results as the brand counterpart. function, enter a drug name and click “search” or Generic alternatives can produce the same “find.” You can also search using the index, which intended effect on the body as the comparable lists drugs alphabetically. brand. Generic alternatives are medications that work like a particular brand drug and are used to The list is organized first by therapeutic class. treat the same condition. However, the active ingredient in a generic alternative is different from THERAPEUTIC CLASS the brand medication. Talk to Your Doctor Then by sub-type (if applicable). If your doctor writes a prescription for a brand drug that does not have a generic equivalent, SUB-TYPE consider asking if an appropriate generic alternative is available. And last by additional sub-type (if applicable). As a patient, you can tell your pharmacist you are interested in generics. In most situations, your pharmacist can substitute a generic equivalent for ADDITIONAL SUB-TYPE its brand counterpart without a new prescription from your doctor. Covered brand-name drugs are listed in all For more information on generics, visit CAPITAL letters, followed by the generic name. AskForGenerics.org. (Exceptions are noted.) 2 Drugs to Treat Multiple Conditions may qualify for a medical exception if they meet Doctors use some drugs to treat more than one one of these: medical condition. Within this document, each drug A. Documented failure of all formulary drugs is listed according to its first FDA-approved use. within the same therapeutic class Please check the index if you do not find your B. Documented allergy to a formulary drug, medication in the therapeutic class that corresponds with no other formulary choices to your condition. C. Successfully maintained condition on a specific drug where switching to an COVERAGE AND LIMITATIONS alternative drug may cause a health risk: o Antiarrhythmics Tier Information o Theophylline products A drug’s copayment tier indicates what you will o Seizure medications pay for the medication with each fill. o Antipsychotics o Antidepressants • The majority of generics are Tier 1. These are your least expensive prescription drugs. Physicians—Requesting a Medical • Formulary brands listed in this document are Exception available at the lowest brand tier, unless To request a Medical Exception for a otherwise noted. medication on behalf of a member, or to request • Specialty drugs may have a different further information, please call the Health Alliance copayment. For a complete listing of Pharmacy department at 1-800-851-3379, option 4, specialty drugs, please click on one of the or fax the Preauthorization/Medical Exception form links below: to 217-902-9798. Please provide the following information when requesting a Medical Exception: Standard Specialty Drug List • Patient name and Health Alliance State of Illinois Employee Specialty Drug identification number • List Physician name, address and phone number • Drug name and strength Depending on your plan, you may have a three- • Patient diagnosis tier or a six-tier copayment structure. Refer to your • Chart documentation/documentation of description of coverage documents for details. Your

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