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Prescription Drug Formulary This Formulary Is for the Community Care Health’S Commercial Large Group and Small Group HMO Business

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Prescription Drug Formulary This Formulary Is for the Community Care Health’S Commercial Large Group and Small Group HMO Business Prescription Drug Formulary This Formulary is for the Community Care Health’s Commercial Large Group and Small Group HMO business. Last updated on August 1, 2021. This Formulary is subject to change and all previous versions of the Formulary are no longer in effect. To locate an electronic version of the Formulary please go to: https://www.communitycarehealth.org/for-members/pharmacy-coverage/ To locate your plan specific documents please go to: https://secure.communitycarehealth.org/ After logging in to your account, click on Coverage Documents, scroll down to Benefits. You will be able to access plan documents including but not limited to; Evidence of Coverage, Schedule of Benefits, and Summary of Benefits and Coverage (SBC). Table of Contents Informational Section................................................................................................................................2 Alternative Therapy - Vitamins and Minerals............................................................................................8 Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever...................................................8 Anesthetics - Drugs for Pain and Fever................................................................................................. 25 Anorectal Preparations - Rectal Preparations........................................................................................ 26 Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning............................................. 27 Anti-Infective Agents - Drugs for Infections............................................................................................ 29 Antineoplastics....................................................................................................................................... 49 Antineoplastics - Drugs for Cancer.........................................................................................................49 Antiseptics and Disinfectants - Antiseptics and Disinfectants................................................................ 61 Biologicals - Biological Agents............................................................................................................... 61 Cardiovascular Therapy Agents - Drugs for the Heart........................................................................... 67 Central Nervous System Agents - Drugs for the Nervous System.........................................................86 Chemical Dependency, Agents to Treat - Drugs for Addiction.............................................................130 Chemicals-Pharmaceutical Adjuvants..................................................................................................132 Cognitive Disorder Therapy - Drugs for the Nervous System.............................................................. 133 Contraceptives - Drugs for Women...................................................................................................... 135 Dermatological - Drugs for the Skin..................................................................................................... 149 Diagnostic Agents................................................................................................................................ 183 Drugs to treat Erectile Dysfunction - Drugs for the Urinary System..................................................... 183 Eating Disorder Therapy - Drugs for Eating Disorders.........................................................................184 Electrolyte Balance-Nutritional Products - Drugs for Nutrition..............................................................186 Endocrine - Hormones......................................................................................................................... 190 Enzymes - Vitamins and Minerals........................................................................................................ 211 FDB Class Obsolete-Not Used.............................................................................................................212 Gastrointestinal Therapy Agents - Drugs for the Stomach...................................................................212 Genitourinary Therapy - Drugs for the Urinary System........................................................................ 225 Gout and Hyperuricemia Therapy - Drugs for Pain and Fever.............................................................231 Hematological Agents.......................................................................................................................... 232 Hematological Agents - Drugs for the Blood........................................................................................ 232 Hepatobiliary System Treatment Agents - Drugs for the Liver............................................................. 245 Immunosuppressive Agents - Drugs for Organ Transplants................................................................ 245 Locomotor System - Drugs for Muscles, Ligaments, Tendons, and Bones..........................................247 Medical Supplies and Durable Medical Equipment (DME) - Medical Supplies and Durable Medical Equipment............................................................................................................................................ 249 Medical Supply, FDB Superset............................................................................................................ 292 Metabolic Disease Enzyme Replacement Agents - Drugs for Metabolic Disease............................... 321 Metabolic Modifiers - Drugs that Alter Metabolism...............................................................................322 Mouth-Throat-Dental - Preparations - Drugs for the Mouth and Throat............................................... 324 Multiple Sclerosis Agents - Drugs for the Nervous System..................................................................327 Ophthalmic Agents - Drugs for the Eye................................................................................................329 Organ Preservation Solutions.............................................................................................................. 343 Organ Preservation Solutions - Drugs for the Heart.............................................................................344 Otic (Ear) - Drugs for the Ear............................................................................................................... 345 Respiratory Therapy Agents - Drugs for the Lungs..............................................................................346 Vaginal Products - Drugs for Women...................................................................................................361 TOC-1 INFORMATIONAL SECTION What is a Formulary? The Formulary provides a list of covered generic and brand name drugs selected by physician and pharmacist subject matter experts who collaboratively support MedImpact’s Pharmacy and Therapeutics (P&T) Committee. This Formulary does not apply to drugs or devices that are obtained through the medical benefit portion of enrollee coverage. The plan will cover drugs listed in the formulary as long as the drug is indicated for the clinical condition, is prescribed in the appropriate manner, the prescription is filled at a participating network pharmacy, and other plan rules are followed. The presence of a prescription drug on the formulary does not guarantee an enrollee will be prescribed that prescription drug by his or her prescribing provider for a particular medical condition. For more information regarding the Formulary or enrollee prescription drug benefit, please contact CCH Customer Service toll- free phone number 855-343-2247, or for the hearing and speech impaired TTY 866-735-2929 available Monday through Friday, between 8am and 5pm PST, or refer to the CCH Evidence of Coverage, available at www.communitycarehealth.org, click on Member Login. Can the Formulary (drug list) change? Drugs may be added or deleted from the Formulary during the policy year, and the Formulary will be updated with any changes on a monthly basis. Changes will be effective on the first day of the month. If there is a change in drug or dosage form, if a drug is removed from the Formulary, if prior authorization, quantity limits and/or step therapy restrictions are added to a drug, or if a drug moves to a higher cost sharing tier, the plan will notify affected enrollees of the change before the change becomes effective. If the FDA deems a drug on the formulary to be unsafe or the drug’s manufacturer removes the drug from the market, the plan will immediately remove the drug from the formulary. The Formulary is subject to change and all previous versions of this formulary are no longer in effect. How does a member fill a prescription? To obtain drugs at a participating pharmacy, the enrollee must present his or her pharmacy benefit plan identification card. Except for covered emergencies, claims for drugs obtained without using the identification card will be denied. To locate a participating pharmacy (including specialty pharmacies), check the cost-sharing for a particular drug, or enroll in mail-order, visit www.communitycarehealth.org click on Pharmacy or the enrollee may visit the MedImpact website, https://mp.medimpact.com/pharmacylocator. Enrollee plan benefits may restrict coverage of specialty drugs only when obtained from a Network Specialty Pharmacy, except in
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