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Western Sky Community Care Preferred Drug Locator Instructions: Preferred Drug List Includes a List of Drug Covered by Your Prescription 1

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Western Sky Community Care Preferred Drug Locator Instructions: Preferred Drug List Includes a List of Drug Covered by Your Prescription 1 Preferred Drug List The Western Sky Community care Preferred Drug Locator Instructions: Preferred Drug List includes a list of 1. Within the PDF, click on the drug covered by your prescription Edit menu, then click Find. benefit. This list is updated often and may change. 2. In the Find box, type the name of To get the most up-to-date the medication you want to information, you may view the latest locate. Preferred Drug List on our website: WesternSkyCommunityCare.com 3. Click the Next button or call 1-844-543-8996 (TTY/TDD until you find the drug(s). 711). What is the Western Sky made to the drug list that may impact you. Community Care Preferred Drug List (PDL)? How do I use the Preferred Drug The preferred drug list (which is also List? called a “formulary”) is a list showing The best way to find your drug is by the drugs that can be covered by your going to the back of this book to the Western Sky Community Health Plan. index and looking it up by name. If the The drug listed will be covered as long drug is in all CAPITAL LETTERS (EX: as you: CIPRO TABS) the drug is a BRAND Have a medical need for the drug name drug and if the drug is in all lower case letters (ex: ciprofloxacin) Fill your drugs at a pharmacy the drug is a generic name drug. Next that we cover to your drug, you will see the page Follow any other rules that number where you can find coverage may apply to you as a member information. For more information on how to fill your What are generic drugs? drugs, please review your Member A generic drug is approved by the Handbook or call Western Sky Food and Drug Administration Community Care (WSCC) Member (FDA) as having the same active Services at 1-844-543-8996 (TTY/TDD ingredient as the BRAND name 711). drug, but often costs less. How will I know what I will pay? Does the plan cover over–the – In most cases you will not have a counter (OTC) drugs? copay. However, depending on the Yes, Western Sky Community Care category you are eligible for or the covers certain OTC drugs. All drug(s) you are taking, you may have covered OTC drugs appear in the a copay PDL. All OTC drugs must be written on a valid prescription by a licensed Will the Preferred Drug List provider in order to be covered. change? Yes, it will change if there is a new Are there any limits on my drug drug or there is a less expensive coverage? generic that becomes available. You There may be some limits on covered will be notified if any changes are drugs such as: i PRIOR AUTHORIZATION (PA): HOW MUCH IS 90 MME/DAY FOR Your provider may need to get approval COMMONLY PRESCRIBED from us before you fill some of your OPIOIDS? 90 MME/day: drug orders. Drugs that require prior 90 mg of hydrocodone (9 tablets authorization are found in the PDL by a of hydrocodone/ PA in the Additional Information acetaminophen 10/325) column. To find out more about this process, please call Member Services 60 mg of oxycodone (2 tablets at 1-844-543-8996 (TTY/ TDD 711) and of oxycodone sustained- a representative will explain the release 30 mg) process to you. 20 mg of methadone (4 tablets of methadone 5 mg) QUANTITY LIMITS (QL): For certain drugs there are limits to the amount of a drug that will be covered SPECIALTY PHARMACY (SP) for a period of time. You can tell if your DRUGS: Specialty drugs are certain drug needs a QL in prescription drugs used to treat special Additional Information column. health conditions and often require special attention. These drugs need a You can also contact your provider prior authorization before a prescription to decide if you should first try a may be filled. Your prescription can be different drug on our list or different filled for up to a 30-day supply and dose of the drug before you request must be filled at Acaria Specialty an exception. Pharmacy. Your drugs will then be mailed to you. For more information Contact Member Services at 1- about specialty drugs, contact Member 844-543-8996 (TTY/TDD 711) Services at 1-844-543-8996 (TTY/TDD and ask how you or your provider 711). can submit a quantity limit exception request. What if my drug(s) is not on the Preferred Drug List? MORPHINE MILLIGRAM Talk to your provider to decide if you EQUIVALENT (MME) DOSING: should first try a different drug on the list MME dosing is a tool used to make sure before you request an exception. you are taking a safe dose of pain drugs. Member Services will tell you how you or This tool helps WSCC calculate the total your provider can ask for an exception if daily dose of pain drugs a member is your drug(s) are not covered. Contact taking no matter which pain drug is WSCC Member Services at 1-844- 543- prescribed. The current daily limit is 8996 (TTY/TDD 711) for further 90MME per day. If you are taking more assistance. than 90MME per day of pain drugs, you will need to get a prior authorization. ii Which drug categories are not calling Member Services at 1-844-543- covered by the Preferred Drug 8996 (TTY/TDD 711). List? Providers: In the event that a The following drug categories provider disagrees with the decision are not part of the benefit: regarding coverage of a drug, the provider may request an appeal by Fertility drugs submitting additional information to Weight loss or weight gain in writing to the Appeals Department at the following address: Drug Efficacy Study Implementation (DESI). These are Western Sky Community Care Health drugs that are not shown to be Plan safe and effective. Appeals Department 5300 Homestead Rd NE Albuquerque, NM, 87110 Drugs and other agents used for cosmetic purposes or for hair After a decision is made, the provider growth will receive a response by mail. An expedited appeal may be requested Erectile dysfunction drugs at any time the provider believes the prescribed to treat adverse determination might impotence seriously endanger the life or health of a member by calling Western Sky Bulk chemicals/powders Community Care Health Plan at 1- 844-543-8996 (TTY/TDD 711). Experimental and investigational drugs Abbreviations: Drugs and devices not approved AL: Age Limit by the FDA PA: Prior Authorization QL: Quantity Limit Contacts for Pharmacy SP: Specialty Medication Appeals/Grievances MP: Maintenance drug eligible for Members: In the event that a 90 day supply member disagrees with the decision regarding coverage of a drug, the member may request an appeal by iii Such services are funded in part with the State of New Mexico Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- DEXEDRINE CP24 5 MG QL(1 ea daily); OBESITY/ANOREXIANTS - Drugs to Treat (Use dextroamphetamine NP AL(At least 6 ADHD, Sleep and Eating Disorders sulfate) yrs old) QL(2 ea daily); Amphetamines dextroamphetamine sulfate P AL(At least 6 cp24 10 mg, 15 mg ADDERALL TABS (Use QL(2 ea daily); yrs old) amphetamine- NP AL(At least 3 dextroamphetamine) yrs old) QL(1 ea daily); dextroamphetamine sulfate P AL(At least 6 cp24 5 mg ADDERALL XR CP24 (Use QL(1 ea daily); yrs old) amphetamine- NP AL(At least 6 dextroamphetamine) yrs old) dextroamphetamine sulfate P AL(At least 3 soln 5 mg/5ml yrs old) ADZENYS ER SUER (Use P AL(At least 6 amphetamine) yrs old) QL(3 ea daily); dextroamphetamine sulfate P AL(At least 3 AL(At least 6 tabs 10 mg, 5 mg ADZENYS XR-ODT TBED P yrs old) yrs old) dextroamphetamine sulfate AL(At least 3 AL(At least 6 amphetamine suer P tabs 2.5 mg, 7.5 mg, 15 P yrs old) yrs old) mg, 20 mg, 30 mg AL(At least 3 amphetamine sulfate tabs P DYANAVEL XR SUER P AL(At least 6 yrs old) yrs old) amphetamine- QL(1 ea daily); EVEKEO TABS (Use NP AL(At least 3 dextroamphetamine cp24 AL(At least 6 amphetamine sulfate) yrs old) 1.25 mg-1.25 mg-1.25 mg- yrs old) 1.25 mg, 2.5 mg-2.5 mg- methamphetamine hcl tabs P 2.5 mg-2.5 mg, 3.75 mg- P AL(At least 13 3.75 mg-3.75 mg-3.75 mg, MYDAYIS CP24 P 5 mg-5 mg-5 mg-5 mg, yrs old) 6.25 mg-6.25 mg-6.25 mg- VYVANSE CAPS 10 MG, QL(1 ea daily); 6.25 mg, 7.5 mg-7.5 mg- 20 MG, 30 MG, 40 MG, 50 P AL(At least 6 7.5 mg-7.5 mg MG, 60 MG, 70 MG yrs old) amphetamine- QL(2 ea daily); VYVANSE CHEW 10 MG, AL(At least 6 dextroamphetamine tabs AL(At least 3 20 MG, 30 MG, 40 MG, 50 P yrs old) 1.25 mg-1.25 mg-1.25 mg- yrs old) MG, 60 MG 1.25 mg, 1.875 mg-1.875 Analeptics mg-1.875 mg-1.875 mg, CAFCIT SOLN (Use 2.5 mg-2.5 mg-2.5 mg-2.5 P NP mg, 3.125 mg-3.125 mg- caffeine citrate) 3.125 mg-3.125 mg, 3.75 caffeine & sodium P mg-3.75 mg-3.75 mg-3.75 benzoate soln mg, 5 mg-5 mg-5 mg-5 mg, caffeine citrate soln iv 60 P 7.5 mg-7.5 mg-7.5 mg-7.5 mg/3ml mg caffeine citrate soln or 20 P QL(45 ml per DESOXYN TABS (Use NP mg/ml, 60 mg/3ml fill retail) methamphetamine hcl) DEXEDRINE CP24 10 MG, QL(2 ea daily); caffeine tabs P 15 MG (Use NP AL(At least 6 dextroamphetamine yrs old) DOPRAM SOLN P sulfate) ENERGY CHEWS CHEW P New Mexico Western Sky Updated September 1, 2021 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply, NF = Non-formulary SmartPA-Automated Prior Authorization, Formulary Contraceptives covered up to 12 month 1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIVARIN TABS (Use NP DAYTRANA PTCH 10 QL(1 ea daily); caffeine) MG/9HR, 15 MG/9HR, 20 P AL(At least 3 MG/9HR yrs old) Attention-Deficit/Hyperactivity Disorder (ADHD) AL(At least 6 QL(1 ea daily); atomoxetine hcl caps P DAYTRANA PTCH 30 P AL(At least 6 yrs old) MG/9HR yrs old) AL(At least 6 clonidine hcl (adhd) tb12 P dexmethylphenidate
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