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Formulary (List of Covered Drugs)

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Formulary (List of Covered Drugs) 3ODQ<HDU 202 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THE FOLLOWING PLAN: $0 Cost Share AI/AN HMO Minimum Coverage HMO Silver 70 HMO Active Choice PPO Silver Opal 25 Gold HMO Silver 70 OFF Exchange HMO Amber 50 HMO Silver Opal 50 Silver HMO Silver 73 HMO Bronze 60 HDHP HMO Platinum 90 HMO Silver 87 HMO Bronze 60 HMO Ruby 10 Platinum HMO Silver 94 HMO Gold 80 HMO Ruby 20 Platinum HMO Jade 15 HMO Ruby 40 Platinum HMO This formulary was last updated on8//20. This formulary is VXEMHFWto change and all previous versions of the formulary no longer apply. For more recent information or other questions, please contact Chinese Community Health Plan Member Services at 1-888-775-7888 or, for TTY users, 1-877-681-8898, seven days a week from 8:00 a.m. to 8:00 p.m., or visit www.cchphealthplan.com/family-member -,-ϭ -,-ϭ"&* !#" + 5 5 ),-$+" %(%'.')/"+#" %&/"+ -%/"$)% "%&/"+ *& )&! %&/"+ 0 $(#" '"+ %&/"+ *& %&/"+ %&/"+ +)(2" &-%(.' %&/"+ +)(2" .1&-%(.' %&/"+ )&! .1&-%(.' !" .1&-%(.' dŚŝƐĨŽƌŵƵůĂƌLJǁĂƐůĂƐƚƵƉĚĂƚĞĚ8ͬϭͬϮϬϮϭ͘dŚŝƐĨŽƌŵƵůĂƌLJŝƐƐƵďũĞĐƚƚŽ ĐŚĂŶŐĞĂŶĚĂůůƉƌĞǀŝŽƵƐǀĞƌƐŝŽŶƐŽĨƚŚĞĨŽƌŵƵůĂƌLJŶŽůŽŶŐĞƌĂƉƉůLJ͘&ŽƌŵŽƌĞ ƌĞĐĞŶƚŝŶĨŽƌŵĂƚŝŽŶŽƌŽƚŚĞƌƋƵĞƐƚŝŽŶƐ͕ƉůĞĂƐĞĐŽŶƚĂĐƚŚŝŶĞƐĞŽŵŵƵŶŝƚLJ ,ĞĂůƚŚWůĂŶDĞŵďĞƌ^ĞƌǀŝĐĞƐĂƚϭͲϴϴϴͲϳϳϱͲϳϴϴϴŽƌ͕ĨŽƌddzƵƐĞƌƐ͕ ϭͲϴϳϳͲϲϴϭͲϴϴϵϴ͕ƐĞǀĞŶĚĂLJƐĂǁĞĞŬĨƌŽŵϴ͗ϬϬĂ͘ŵ͘ƚŽϴ͗ϬϬƉ͘ŵ͕͘ŽƌǀŝƐŝƚ ǁǁǁ͘ĐĐŚƉŚĞĂůƚŚƉůĂŶ͘ĐŽŵͬĨĂŵŝůLJͲŵĞŵďĞƌ !! %+)&,+ &%+&+&)$,#)0),# *+666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666I % + &%*6666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666I &.& %),&%+ *# *+26666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666J &.& "%&. +),# *+ *)%&)%) ),26666666666666666666666666666666666666666666666666666666666666666J +)),+ )*26666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666K &.+&)+&)$,#)0666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666K &.&+%. ##+&)$,#)0%26666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666L + *$ #% +),-)*,*),&-),%)+,+'+ %+)*) '+ &%),% +2 666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666L +)')-%+ -#+),*2666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666L + *&%+)'+ -),&)- 26666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666M + +*)),*%')&,+*)&-),%)+,+'+ %+)*) '+ &%),% +2M + 0&,)), *&-),%)+$ #% +2666666666666666666666666666666666666666666666666666666666666666666666M + **+'+)'0266666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666M + *+') &),+&) 1+ &%:/'+ &%)(,*+')&**26666666666666666666666666666666666666666666666666666666666666666M )+ '+ %)+ #')$ *666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666N +)*' #+0),*26666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666N #&))')$0666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666N + 0&,)), *%&+&%+&)$,#)02666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666N H !"!!!"&" ! ),&)$,#)0 *# *+&$ + &%*++)'')&-0+&&%),$ % *+)+ &% =>%)*#+*&%*+03+ -%**3%&*+6 *# *+&%) %)%),* * &-)00&,)#+ %*,)%'&# 0,%)+')*) '+ &%),% +&+'&# 06 ! &##&. %.&)*% % + &%*. ##,*+)&,&,++&)$,#)0),# *+6 )%%$), ),++ *$)"+,%)')&') +)03+)$)"')&++%$6 )%%$),*### *+ %## #++)*6 & %*,)% ')%+&+&*+&&-)#+)% +++%%)&## '0*+)+%)&##*' +,+ #3 ,+ #''# *+&+ #+)% +3*,*+')*) '+ &%),% +6 &'0$%+ /&##)$&,%+++%%)&##'0*&)&-)#+)% + +)+%)&##*' +,+ #3 ,+ #''# *+&+ #+)% +3*,*+')*) '+ &%),% +6 ,+ # $&,%+%%)&##'0*&)&-)#+)% +*&)+ %)&##@*#+'#% %*'0$%+&)##&)')+&+&*+&+#+ )% +,%)++)$*&+'&# 06 ),+ ) )&,'&')*) '+ &%),*++&))*'&%*+&*' &*+*) % + ) %+#+'#%@*')*) '+ &%),&-)6+ ) %. 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