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SUTTER HEALTH PLUS FORMULARY Drug List for HMO Members – Effective September 1, 2021

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SUTTER HEALTH PLUS FORMULARY Drug List for HMO Members – Effective September 1, 2021 SUTTER HEALTH PLUS FORMULARY Drug List for HMO Members – Effective September 1, 2021 This formulary is the list of prescription drugs available to Sutter Health Plus members for all plans and products Sutter Health Plus offers. This formulary is subject to change. All past versions of the formulary are no longer in use. Sutter Health Plus last updated the formulary on September 1, 2021. The current formulary is available to members on the Express Scripts custom website for Sutter Health Plus members at express-scripts.com/shp. It is also available on the Sutter Health Plus website at sutterhealthplus.org/pharmacy. Members can find complete information about their prescription drug benefits, including cost sharing amounts in their Evidence of Coverage and Disclosure Form (EOC). The EOC’s are available on the Sutter Health Plus member portal at https://shplus.org/memberportal (registration required). CRP2103_008427.1 DL2103_008427 1 Table of Contents Updates to the Formulary ................................................................................................................................. 3 How to Use the Formulary ............................................................................................................................... 3 Benefit Coverage and L imitat ions ...................................................................................................................... 5 Requesting a Prior Authorization ....................................................................................................................... 7 Locating a Retail Pharmacy ............................................................................................................................... 8 Mail Order with Express Scripts ........................................................................................................................ 8 Specialty Pharmacy Services ............................................................................................................................. 9 Definit ions ................................................................................................................................................... ….9 ANTI - INFECTIVES - DRUGS TO TREATBACTERIA INFECTION .................................................... 11 ANTI - INFECTIVES - DRUGS TO TREAT FUNGUS INFECTIONS ...................................................... 17 ANTI - INFECTIVES - DRUGS TO TREAT VIRUS INFECTIONS .......................................................... 18 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS - DRUGS TO TREAT CANCER AND SUPPRESS THE IMMUNE SYSTEM ......................................................................................................... 23 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH - DRUGS TO TREAT THE NERVOUS SYSTEM, SEIZURES, HEADACHE, OR FOR MENTAL HEALTH......................................................... 28 CARDIOVASCULAR, HYPERTENSION & LIPIDS - DRUGS TO TREAT HEART CONDITIONS OR HIGH BLOOD PRESSURE ......................................................................................................................... 53 DERMATOLOGICALS/TOPICAL THERAPY - DRUGS TO TREAT SKIN CONDITIONS .................. 64 DIAGNOSTICS & MISCELLANEOUS AGENTS - MISCELLANEOUS MEDICINES ........................... 78 EAR, NOSE & THROAT MEDICATIONS - DRUGS TO TREAT THE EAR, NOSE AND THROAT..... 81 ENDOCRINE/DIABETES - DRUGS TO TREAT HORMONE CONDITIONS OR DIABETES............... 83 GASTROENTEROLOGY - DRUGS TO TREAT STOMACH OR BOWEL CONDITIONS .................. 101 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY - DRUGS TO TREAT THE IMMUNE SYSTEM ..................................................................................................................................................................... 111 MUSCULOSKELETAL & RHEUMATOLOGY - DRUGS TO TREAT MUSCLE AND BONE CONDITIONS ............................................................................................................................................ 117 OBSTETRICS & GYNECOLOGY - GYNECOLOGY MEDICINES ....................................................... 120 OPHTHALMOLOGY - DRUGS TO TREAT EYE CONDITIONS .......................................................... 129 RESPIRATORY, ALLERGY, COUGH & COLD - DRUGS TO TREAT BREATHING CONDITIONS 137 UROLOGICALS - DRUGS TO TREAT BLADDER OR URINE CONDITIONS .................................... 144 VITAMINS, HEMATINICS & ELECTROLYTES - VITAMINS AND MINERALS ............................... 147 Index ........................................................................................................................................................... 155 2 This document is the Sutter Health Plus Formulary, a list of Food and Drug Administration (FDA)-approved generic and brand name drugs covered by Sutter Health Plus under your outpatient prescription drug benefit. The availability of a drug on the formulary does not mean your doctor will prescribe it for your condition. The formulary helps you and your doctor determine the right drug to prescribe to treat your needs. Sutter Health Plus covers drugs not listed on the formulary or (non-formulary drugs) if medically necessary. All non-formulary drugs require prior authorization. The Express Scripts Pharmacy and Therapeutics (P&T) Committee assesses all drugs included in the formulary for tier placement, process requirements and coverage limitations. When necessary, the Sutter Health Plus P&T Committee reviews, approves, and modifies Express Scripts selections. Doctors and pharmacists make up both P&T Committees. They meet regularly to decide what drugs should be included in the formulary. The P&T Committees choose drugs based on their safety, effectiveness and value. Updates to the Formulary Express Scripts updates the drugs on a monthly basis and content may change. Changes to the drugs listed in this formulary may include: • Removing a drug or dosage form of a drug • Changing tier placement of a drug that results in a different cost share • Adding or changing prior authorization and step therapy requirements for a drug During your plan year, any changes to the formulary that benefit you, such as moving a drug to a lower tier for lower cost share, happen right away. Sutter Health Plus notifies you at least 60 days in advance of any changes that increase your cost share or impose new limits or processes on a drug you take. You can get the most current formulary on the Sutter Health Plus website at sutterhealthplus.org/pharmacy, or the Express Scripts member portal at express-scripts.com/shp. If you have questions about your pharmacy coverage or the list of drugs covered by Sutter Health Plus, call Sutter Health Plus Member Services at 1-855-315-5800. Member Services is available Monday through Friday, 8 a.m. to 7 p.m. Member Services can answer questions about your pharmacy benefits, including: • The process for submitting a prior authorization (PA) request (exception request) for drugs that require PA or a step therapy exception • Information about drugs covered under your medical benefit versus your pharmacy benefit • Actual dollar amounts of your cost sharing (copays, coinsurance and deductibles) How to Use the Formulary Sutter Health Plus organizes the drugs by drug category and class based on the American Hospital Formulary Service (AHFS) drug classification system. The drugs in each category are in alphabetical order by their generic name or most common brand name. The formulary lists generic drugs in lowercase bold italic letters and brand names in all uppercase letters followed by the generic name in parentheses in lowercase bold italics. 3 Example: Drug Type How drug will appear in the categorical list generic drug pravastatin brand drug PRAVACHOL (pravastatin) When a generic equivalent for a brand name drug is available and covered, Sutter Health Plus lists the generic drug separately from the brand name drug in all lowercase italicized letters. When a generic equivalent for a brand name drug is not available or not covered, Sutter Health Plus does not list the generic drug separately. When a manufacturer markets a generic drug under a proprietary, trademark-protected brand name, we list the brand name after the generic drug in parentheses with the first letter of each word capitalized. For example, digoxin (Digitek). Members can search the formulary by using the index, either by generic or brand name and by therapeutic drug category. Brand names usually cost more and are not preferred over generic alternatives. Any drug not found in this list or any updates published by Express Scripts or Sutter Health Plus requires prior authorization. Some drugs have certain process requirements or limitations for coverage. We identify these drugs on the formulary by the letters listed and explained below. Your Sutter Health Plus EOC explains the details of the process requirements and limitations and how you or your provider can ask for exceptions. AG Age Edit Drug may not be recommended for some patients based on age PA Prior Authorization Requires your doctor to request prior authorization to support use of this drug QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period ST Step Therapy Coverage may depend on previous use of another drug OAC Oral Anticancer Orally administered anti-cancer drugs have a maximum limit on the copayment amount 4 Benefit Coverage and Limitations This printed formulary does not provide information regarding the specific benefit coverage and
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