Hix Thp 2021
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2021 High Performance Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 8/1/2021. For more recent information or other questions, please contact The Health Plan Pharmacy Services at 1.800.624.6961 extension 7914, or visit www.heathplan.org. Pharmacy Benefit Programs How to Use Your Prescription Benefit Prescription drugs are an integral Please present The Health Plan ID card to component of a comprehensive health the pharmacist with your prescription. You maintenance plan. Pharmacy benefit will be required to pay a copayment programs at The Health Plan are developed (“copay”) at the time of service based on the through recommendations of participating prescription plan in which you are enrolled. physicians and pharmacists. This group of Your copayment levels are found under the professional health care providers, known as pharmacy benefit section Pharmacy Benefit the Pharmacy and Therapeutics Committee, of your Summary of Benefits. Your ID card evaluates therapeutic classes of drugs and also contains important information to allow recommends coverage guidelines for our the pharmacy to correctly submit your pharmacy benefit programs. The committee claim. Please take it with you to the uses current medical and pharmaceutical pharmacy. literature along with recommendations of Specialty Pharmacy Program experts in various clinical specialties in its Specialty drugs are high-cost medications evaluation of our pharmacy benefit including drugs manufactured by programs. The result is a list of drugs biotechnology. Specialty drugs may be (formulary) to allow for the availability of administered by injection, oral, transdermal, appropriate medications for our members’ or inhaled. Specialty drugs are used to treat needs. Also, the formulary and coverage very specific diseases and require extensive guidelines allow prescription costs and your management for safety and effectiveness. premium to be maintained at affordable Dosages need to be monitored for effect levels. and adjustments might be needed for Definitions adequate response to effectively treat the Prescription – Drugs which can only be disease. dispensed upon order (prescription) by a Specialty drug require prior authorization to qualified provider of care. Additionally, only assure appropriate candidate for the drug. drugs which are labeled “Caution: Federal Additionally, oversight is an integral part of law prohibits dispensing without the prior authorization process. Dispensing prescription” will be considered eligible. might be limited to pharmacies with specific Generic Drug – A drug available as a skills and distribution programs to assure chemically and therapeutically equivalent proper delivery of these medications. copy of a brand-name drug. It is usually Diseases targeted to receive therapy are, but available from several manufacturers. not limited to, rheumatoid arthritis, severe Brand Drug – A prescription item only chronic psoriasis, multiple sclerosis, available from a single-source supplier. hepatitis C, hemophilia, certain cancers, Multi-Source Brand Drugs – Brand-name growth deficiency, cystic fibrosis, Crohn’s drugs which are manufactured by more than disease and organ transplant. one producer. These agents are usually Coverage for these agents are provided available as generic equivalents. under your Specialty Pharmacy Benefit. The list of specialty drugs is available at www.healthplan.org/personal/products-and- services. Drugs Requiring Prior Authorization Non-Formulary Coverage Review Certain medications are eligible for coverage Certain non-formulary medications are only after a patient-specific approval has eligible for coverage only after a patient- been authorized. Patient-specific criteria specific approval has been authorized. may include age, gender, and clinical Patient-specific criteria may include age, conditions determined by the physician for gender, and clinical conditions determined authorization to be granted for a specific by the physician for authorization to be drug. A coverage determination request can granted for a specific drug. A non-formulary be made by the member, member’s exception request can be made by the representative or physician. To request a member, member’s representative or coverage determination please contact physician. To request an exception please pharmacy services at 1.800.624.6961, ext. contact pharmacy services at 7914. Standard requests for coverage 1.800.624.6961, ext. 7914. Standard determinations will be processed within 72 requests for exceptions will be processed hours. Requests for non-urgent coverage within 15 calendar days of receipt of the determinations received after 5pm will be request. Requests for non-urgent coverage processed the next business day. Urgent determinations received after 5pm will be requests for coverage determinations will be processed the next business day. Urgent processed within 24 hours. requests for coverage determinations will be processed within 24 hours or receipt. Quantity per Dispensing Event (QPC rules) Generic Difference Policy Generally, The Health Plan allows dispensing (copayment policy for multi-source drugs) of approved medications up to a 34-day If a prescription order specifies that a brand- supply per co-pay at the retail pharmacy name drug must be dispensed when the network. Quantity per dispensing event generic equivalent is available, or the rules (QPC) set thresholds that reduce prescription order allows for generic exposure to unnecessary cost, without substitution and the member elects to have creating obstacles to access for most the prescription filled with a brand-name members. Drugs that are subject to QPC drug instead, the member must pay the rules usually have specific limitations for brand copayment plus the difference use approved by the FDA. Examples include between The Health Plan cost of a brand- drugs to treat migraine headaches. These name and its generic equivalent (i.e., The drugs, known as “triptans,” are to be used in Health Plan only pays for the generic cost). specific doses up to a defined number of Please note: Non-formulary brand versions headaches per month. The QPC rules allow of generic drugs require coverage review as this specific number of triptan medications outlined above. to be dispensed per 34-day benefit period. Out-of-Area Emergencies To inquire about QPC limits to request an In situations of emergency need for a exemption, have your provider contact prescription outside The Health Plan service pharmacy services at 1.800.624.6961, ext. area, please contact The Health Plan for the 7914. location of a participating pharmacy in that area. Present The Health Plan ID card with the emergency prescription and pay your copayment. If no pharmacy in the area participates with The Health Plan, purchase the emergency prescription and send your washes, devices used in dental therapy. receipt to The Health Plan. You will be Certain oral fluoride products may be reimbursed in full, less your applicable covered as a preventative medication. copayment, for the prescription provided • The charge for prescription drugs or the prescription meets the guidelines devices used to promote weight loss. specified in this document. • Treatment of hyperhidrosis (excessive Exclusions and Limitations sweating). • Prescriptions used to treat sexual The following will not be covered or paid for dysfunction, either oral or topical, or by The Health Plan: devices used for impotence. • The charge for any prescription refill other • Appliances and therapeutic devices which than the number set by the prescriber. may require a prescription are not Additionally, no refills dispensed more covered. These include, but are not limited than one year from the date or the original to, garments, splints, bandages, braces or prescription. nebulizers regardless of intended use. • The charge for any prescription, oral or • Prescriptions dispenses by any other topical, that is prescribed for cosmetic delivery service other than Express Scripts. purposes. • Nutritional and/or dietary supplements, • Certain legend drugs when any version or except as covered in the Evidence of strength becomes available over the Coverage or required under Preventive counter. Care Services or other laws. This includes, • Drugs in quantity which exceed the limits but not limited to, nutritional formulas and established by The Health Plan, or which dietary supplements that can be purchased exceed any age limits established. over the count, which by law do not • Charges for administration of any drug. require either a written prescription or • Drugs consumed at the time and place dispensing by a licensed pharmacist. where they were dispenses or where the • The charge for any medications not FDA- prescription order was issued including but approved for use in the general not limited to samples provided from the population. physician. • Off label use of a drug which is not • Drugs or devices not requiring a medically accepted. The Health Plan uses prescription by Federal Law, except for the same guidelines as CMS for injectable insulin. determining whether a proposed use in • Charges for lost, stolen or damaged medically accepted. medication. • The charge for a drug not prescribed by a • Oral immunizations and biologicals. Health Plan qualified provider except in an • Drugs for the treatment of infertility. emergency situation. • Compounded drugs, unless there is at • The charge for any medication