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Scripps Health Formulary July 2016 Foreword Pharmacy and Therapeutics Committee. MedImpact approves such multi- This document represents the efforts of the MedImpact Healthcare Systems source drugs for addition to the MAC list based on the following criteria: Pharmacy and Therapeutics (P & T) and Formulary Committees to provide physicians A multi-source drug product manufactured by at least one (1) nationally and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness marketed company. of commercially available drug products. A structured approach to the drug selection At least one (1) of the generic manufacturer’s products must have an “A” process is essential in ensuring continuing patient access to rational drug therapies. rating or the generic product has been determined to be unassociated with The ultimate goal of the Portfolio Formulary is to provide a process and framework to efficacy, safety or bioequivalency concerns by the MedImpact P & T support the dynamic evolution of this document to guide prescribing decisions that Committee. reflect the most current clinical consensus associated with drug therapy decisions. Drug product will be approved for generic substitution by the MedImpact P & T Committee. This is accomplished through the auspices of the MedImpact P & T and Formulary Committees. These committees meet quarterly and more often as warranted to ensure This list is reviewed and updated periodically based on the clinical literature and clinical relevancy of the Formulary. To accommodate changes to this document, pharmacokinetic characteristics of currently available versions of these drug updates are made accessible as necessary. products. As you use this Formulary, you are encouraged to review the information and provide If a member or physician requests a brand name product in lieu of an approved your input and comments to the MedImpact P & T and Formulary Committees. generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic. If a physician The MedImpact P & T and Formulary Committees use the following criteria in the determines that there is a documented medical need for the brand equivalent, a evaluation of drug selection for the Portfolio Formulary: request for coverage may be made using the medication request process. Drug safety profile Drug efficacy 2. Three Tier Benefit Comparison of relevant therapeutic benefits to current formulary agents of The Formulary may be applied to a three tier benefit design, where the member similar use, and to minimize therapeutic duplication where possible shares the cost of prescription drug therapy at three levels of copayment. In Cost-effectiveness relative to comparable therapies most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under How to Use the Formulary the second copay tier, and branded drugs not on the Formulary will be covered The Formulary is a list of medications available to MedImpact members under their under the third or highest copay tier. pharmacy benefit. All drugs are listed by their generic names and most common 3. Medication Request Process proprietary (branded) name. The Formulary may be accessed by using the index, Depending upon plan benefit design, a medication request process may apply either by generic or proprietary name (in capital letters) and by therapeutic drug as follows: category. In situations where an FDA approved generic equivalent is available, brand A. Formulary Agents names are listed for reference purposes only, and do not denote coverage for the Drugs that are listed in the Formulary with associated Prior Authorization brand, unless specifically noted. Any drug not found in this Formulary listing, or any (PA) require evaluation, per MedImpact P & T Committee Prior Formulary updates published by MedImpact shall be considered a Non-Formulary Authorization guidelines prior to dispensing at a network pharmacy. Each drug. request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P & T Committee, the All drugs are listed in each category in alphabetical order by generic name. Where an request will not be approved and alternative therapy may be FDA approved generic is available for the listed generic name, the generic name is recommended. bolded. B. Non-Formulary Agents For certain agents within the Formulary, a recommended prescribing guideline may Any drug not found in the Formulary listing, or any Formulary updates apply. These are denoted throughout the document using the following symbols: published by MedImpact, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for in advance. When AGE Age Edit Coverage may depend on patient age a member gives a prescription order for a non-formulary drug to a CU Concurrent Coverage or lack thereof may depend upon pharmacist, the pharmacist will evaluate the patient’s drug history and Use Edit concurrent use of another drug contact the physician to determine if there is a reasonable medical need G Gender Edit Coverage may depend on patient gender for a non-formulary drug. Each request will be reviewed on an individual MD Physician Coverage may depend on prescribing physician’s patient need basis. Approval will be given if a documented medical need Specialty specialty or board certification exists. The following basic guidelines are used: Edit The use of Formulary Drugs is contraindicated in the patient. PA Prior Requires specific physician request process The patient has failed an appropriate trial of Formulary or related Authorization agents. The choices available in the Formulary are not suited for the present QL Quantity Coverage may be limited to specific quantities patient care need, and the drug selected is required for patient Limit per prescription and/or time period safety. ST Step Coverage may depend on previous use of another The use of a Formulary drug may provoke an underlying condition, Therapy drug which would be detrimental to patient care. Please refer to the prescribing guideline appendix within this document for details If the request does not meet the guidelines established by the P & T regarding specific agents. Committee, the request will not be approved and alternative therapy may be recommended. Benefit Coverage and Limitations C. Obtaining Coverage This printed Formulary does not provide information regarding the specific coverage Coverage, questions or information regarding the medication request or and limitations an individual member may be subject to. Many members have specific formulary process may be obtained by: benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in 1. Faxing a completed Medication Request Form to MedImpact at the Formulary. (858) 790-7100. 2. Contacting MedImpact at (800) 788-2949 and providing all The Formulary applies only to outpatient drugs provided to members, and does not necessary information requested. apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or MedImpact will provide an authorization number, specific for the medical MedImpact at (800) 788-2949. need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal Depending upon a member’s specific benefit parameters, the following topics on the basis of medical necessity. Prior Authorization is generally not may apply: available for drugs that are specifically excluded by benefit design. 1. Generic Substitution When available, FDA approved generic drugs are to be used in all situations, 4. General Exclusions regardless of the brand name indicated. The generic names are bolded in the A. Over the Counter (OTC) medications or their equivalents, unless otherwise formulary listing wherever an FDA approved generic drug product is available. specified in the Formulary listing. Greater economy is realized through the use of generic equivalents. This policy B. Nicotine Smoking Cessation products (i.e., transdermal nicotine, nicotine is not meant to preclude or supplant any state statutes that may exist. All drugs gum, nicotine inhaler). that are or become available generically are subject to review by MedImpact’s C. Drugs specifically listed as not covered. 804 Portfolio High Formulary – July 2016 1 Portfolio High Formulary D. Any drug products used for cosmetic purposes. E. Experimental drug products or any drug product used in an experimental manner. F. Replacement of lost or stolen medication. G. Non self-administered injectable drug products unless otherwise specified in the Formulary listing. H. Foreign sourced drugs or drugs not approved by the United States Food & Drug Administration. The P & T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative therapies. 5. Pharmacist and Physician Communication The Formulary is a tool to promote cost-effective prescription drug use. The P & T and Formulary Committees have made every attempt to create a document that meets all therapeutic needs; however, the art of medicine makes this a formidable task. MedImpact welcomes the participation of physicians, pharmacists, and ancillary medical providers, in this dynamic process. Physicians and

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