2018 Formulary Drug List For State, Education, and Local Government Employees GlobalHealth, Inc. 701 NE 10th Street, Suite 300 MSTDF18 Lists Updated 11/2017 Oklahoma City, OK 73104-5403 www.GlobalHealth.com/state HELPFUL NUMBERS Plan Issuer: Medication Prior Authorizations: GlobalHealth, Inc. [email protected] PO Box 2393 918.878.7361 Oklahoma City, OK 73101-2393 Mail Claims to: GlobalHealth Customer Care, Language Magellan Rx Management, LLC Assistance, and Disease Management: PO Box 85042 [email protected] Richmond, VA 23261-5042 405.280.5600 (local) 1.877.280.5600 (toll-free) Mail Order Pharmacy: 711 (TTY) Magellan Rx Management, LLC Monday – Friday, 9 a.m. – 5 p.m. Central 1.800.424.1789 (toll-free) www.GlobalHealth.com/state 711 (TTY) P.O. Box 620968 Behavioral Health and Substance Use: Orlando, FL 32862 [email protected] 405.280.5600 (local) 24/7 Nurse Help Line: 1.877.280.5600 (toll-free) Information Line 711 (TTY) 1.877.280.2993 (toll-free) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/state GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) Pharmacy Benefits Manager: 405.280.5852 Magellan Rx Management, LLC [email protected] Customer Service 1.800.424.1789 (toll-free) GlobalHealth Privacy Officer: 711 (TTY) 405.280.5524 [email protected] i IMPORTANT INFORMATION This formulary applies to Members who enrolled through the State, Education, and Local Government employees Plan. Member Materials Your comprehensive Member handbook has three booklets. Each one has a different purpose. These documents are important legal documents. Keep them in a safe place. Booklet Purpose Member Handbook Tells you about your benefits. for State, Education, o What benefits are covered and how much you will pay. and Local o How they are covered (including limitations and exclusions). Government o How to use them. Employees (“Member Handbook”) Physicians and Lists our Network of doctors, Facilities, and pharmacies. Health Providers Tells you if a Facility is preferred or not. Directory (“Provider Directory”) Formulary Drug List Lists drugs we cover. for State, Education, Tells you what Tier a drug is in. and Local Tells you if there are any rules to getting a drug. Government Employees (“Drug Formulary” or “Formulary”) Member materials are available on our website. Contact Customer Care for printed copies at no charge. But, be aware that the most current Drug Formulary and Provider Directory lists are on the website. This is an important legal document. Please keep it in a safe place. When this document says “we”, “us”, or “our”, it means GlobalHealth, Inc. Words or phrases that start with a capital letter are defined in the Member Handbook glossary. For specific questions about your coverage, please call the phone number printed on your Member ID card. Preferred Drugs Preferred drugs are listed in this Drug Formulary. Drugs on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the Formulary, which includes generics and brand name drugs that are approved by the U. S. Food and Drug Administration (“FDA”). ii For the Member: Generic drugs contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you. THIS DOCUMENT LIST IS EFFECTIVE AS OF THE DATE ON THE COVER. THIS LIST IS SUBJECT TO CHANGE. You may find the most current list, including any Utilization Management requirements, on our website. Contact Customer Care for printed copies. iii NOTICE ABOUT NON-DISCRIMINATION GlobalHealth, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. GlobalHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. GlobalHealth: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact the Director of Compliance and Legal Services. If you believe that GlobalHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: ATTN: Director of Compliance and Legal Services, 701 NE 10th St, Ste. 300, Oklahoma City, OK 73104-5403, Fax: (405) 280-5894, or E-mail: [email protected]. You can file a grievance in person or by mail, fax, or e-mail. If you need help filing a grievance, the Compliance Attorney is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Language Translation Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-280-5600 (TTY: 711). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-280-5600 (TTY: 711). Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-280- 5600 (TTY: 711). Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-280-5600 OR (TTY: 711)번으로 전화해 주십시오. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Language Translation Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-280-5600 (TTY: 711). 117) .اتصل .إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان :ملحوظة Arabic 4692-082-778-1 (ھاتف الصم والبكم برقم Burmese သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-877-280-5600 (TTY: 711) သုိ႔ ေခၚဆိုပါ။ Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-280-5600 (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-280-5600 (TTY: 711). French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-280-5600 (ATS: 711). Laotian ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ ທ່ານ. ໂທຣ 1-877-280-5600 (TTY: 711). Thai เรียน: ถ ้าคุณพูดภาษาไทยคุณสามารถใชบริการช้ วยเหลือทางภาษาได่ ้ฟรี โทร 1-877-280-5600 (TTY: 711). -280-877-1 کریں کال ۔ ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں، بولتے اردو آپ اگر :خبردار Urdu 5600 (TTY: 711). Cherokee Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1-877-280-5600 (TTY: 711). اگر بھ زبان فارسی گفتگو می کنید، تسھیﻻت زبانی بصورت رایگان برای شما :توجھ Persian .با تماس بگیرید .فراھم می باشد (TTY: 711) 1-877-280-5600 TIER DESCRIPTION 0 Health Care Reform 1 Generics 2 Preferred Brands 3 Non-Preferred Brands 4 Specialty Drug TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame. Your provider is required to get prior authorization before you fill PA Prior Authorization your prescription, which ensures appropriate use of the selected drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before you move up a “step” to other drug options. GL Gender Limit This prescription drug is restricted for a single gender. This prescription drug may only be covered if you meet the AL Age Limit minimum or maximum age limit. C Custom This drug has unique restrictions. Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions. Some examples of the diseases include; multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. This medication is not on our drug list. Click on the THERAPEUTIC MED Medical Drug CLASS or sub class to find covered alternative medications. If you have questions, please contact member services. The Affordable Care Act (ACA) requires certain preventive generic HCR Health Care Reform Products products to be covered at zero dollar copay. This does not include plans that are grandfathered. PAGE 1 LAST UPDATED 10/2017 PS Preferred Specialty Preferred Specialty. HCG High Cost Generic High Cost Generic. Generic drugs available at the lowest cost. Please note the specific strengths and dosage forms; other strengths and/or dosage forms LCG Low Cost Generic of these products would be subject to the standard generic Cost- share. PAGE 2 LAST UPDATED 10/2017 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADRENERGIC AGENTS ALPHA AND BETA ADRENERGIC AGONIST(RESPR) QL 2 / fill ADRENACLICK 3 PA ADRENALIN 3 ADYPHREN