2021 Formulary (List of Covered Drugs) Oscar 2021 Formulary What is the Oscar Formulary? A formulary is a list of covered drugs selected by Oscar in consultation with a team of health care providers, which r epresents the prescription therapies believed to be a necessary part of a quality treatment program. Oscar will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Oscar network pharmacy, and other plan rules are followed. This Formulary was updated as of 01/01/2021. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BYSTOLIC) and generic drugs are listed in lower-case italics (e.g., carvedilol). There are two ways to find your drug within the formulary: 01 Medical Condition 02 Alphabetical Listing The formulary begins on page 1. The If you are not sure what category to drugs in this formulary are grouped look under, you should look for your into categories depending on the type drug in the Index that begins on page of medical conditions that they are 89. The Index provides an alphabetical used to treat. For example, drugs used list of all of the drugs included in this to treat a heart condition are listed document. Both brand name drugs and under the category, Antiarrhythmics. generic drugs are listed in the Index. If you know what your drug is used for, Look in the Index and find your drug. look for the category name in the list Next to your drug, you will see the page that begins page 1. Then look under number where you can find coverage the category name for your drug. information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. Learn more at hioscar.com Oscar 2021 Formulary What are generic drugs? Oscar covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: Oscar requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Oscar before you fill your prescriptions. If you don’t get approval, Oscar may not cover the drug. • Quantity Limits: For certain drugs, Oscar limits the amount of the drug being filled. For example Oscar may limit a drug to only 48 pills in a 1-month timeframe. These amounts will be listed in the formulary below if they are applicable to your medication. • Step Therapy: In some cases, Oscar requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Oscar may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Oscar will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. What if my drug is not on the Formulary? If your drug is not included in this formulary , you should first contact Concierge and ask if your drug is covered. If you learn that Oscar does not cover your drug, you can ask Concierge for similar drugs that are covered by Oscar. Discuss these alternatives with your doctor and ask him or her to prescribe one of the alternatives that are covered by Oscar. Learn more at hioscar.com Oscar 2021 Formulary How do I request an exception to the Oscar Formulary? Your Doctor can ask Oscar to make an exception to our coverage rules. Generally, Oscar will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Can the Formulary change? Most changes in drug coverage happen on January 1, but during the year Oscar may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. You can contact Concierge to find out if your drug is still covered, visit hioscar. com and log in to your plan specific account, or use the Oscar app drug search feature. Changes that can affect you this year: • New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. You can find information in the section above entitled “How do I request an exception to the Oscar Formulary?” • Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Learn more at hioscar.com Oscar 2021 Formulary For more information For more detailed information about your Oscar prescription drug coverage, please visit www.hioscar.com or call Concierge at 1-855-OSCAR-88. You can also find your plan specific information on our Oscar app available through iTunes or Google Play. Formulary Terminology The formulary that begins on page 1 provides coverage information about the drugs covered by Oscar. If you have trouble finding your drug in the list, turn to the Index that begins on page 89. The information in the Requirements/Limits column tells you if Oscar has any special requirements for coverage of your drug. Abbreviation Term Description Your Physician must get approval from Oscar to PA Prior Authorization cover this medication Some drugs have a limit of how much you can fill at QL Quantity Limits a time For some drugs you must first try certain drugs to ST Step Therapy treat your medical condition before we will cover another drug for that condition Medications that can be purchased with1 or OTC Over-the-counter without a prescription from your Physician Prior Authorization if A Prior authorization will be needed if you do not PA** Step Therapy is not meet the step therapy met 1 to be covered at the pharmacy a prescription from your doctor is required Learn more at hioscar.com EXCH_CVSC CA 4T STND eff 01/01/2021 Drug Name Drug Tier Requirements/Limits ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION COX-2 INHIBITORS celecoxib CAPS 50mg, 100mg, 200mg 1 GOUT - DRUGS TO TREAT GOUT allopurinol TABS 100mg, 300mg 1 colchicine TABS .6mg 1 colchicine w/ probenecid tab 0.5-500 mg 1 febuxostat TABS 40mg, 80mg 1 ST; PA** probenecid TABS 500mg 1 NON-OPIOID ANALGESICS§ butalbital-acetaminophen-caffeine cap 50- 1 QL (48 caps / 25 days) 300-40 mg butalbital-acetaminophen-caffeine cap 50- 1 QL (48 caps / 25 days) 325-40 mg butalbital-acetaminophen-caffeine tab 50- 1 QL (48 tabs / 25 days) 325-40 mg butalbital-aspirin-caffeine cap 50-325-40 1 QL (48 caps / 25 days) mg tencon (Tencon) 1 QL (48 tabs / 25 days) NSAIDS, COMBINATIONS§ diclofenac w/ misoprostol tab delayed 1 release 50-0.2 mg diclofenac w/ misoprostol tab delayed 1 release 75-0.2 mg NSAIDS§ - DRUGS TO TREAT PAIN AND INFLAMMATION diclofenac potassium TABS 50mg 1 diclofenac sodium TB24 100mg; TBEC 1 25mg, 50mg, 75mg etodolac CAPS 200mg, 300mg; TABS 1 400mg, 500mg; TB24 400mg, 500mg, 600mg fenoprofen calcium TABS 600mg 3 flurbiprofen TABS 50mg, 100mg 1 ibuprofen SUSP 100mg/5ml; TABS 1 400mg, 600mg, 800mg ketoprofen CAPS 50mg, 75mg 1 ketorolac tromethamine SOLN 15mg/ml, 1 30mg/ml ketorolac tromethamine TABS 10mg 1 QL (20 tabs / 25 days) meclofenamate sodium CAPS 50mg, 1 100mg mefenamic acid CAPS 250mg 1 meloxicam TABS 7.5mg, 15mg 1 nabumetone TABS 500mg, 750mg 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 1 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits naproxen TABS 250mg, 375mg, 500mg 1 oxaprozin TABS 600mg 1 piroxicam CAPS 10mg, 20mg 1 sulindac TABS 150mg, 200mg 1 tolmetin sodium CAPS 400mg; TABS 1 600mg OPIOID AGONIST/ANTAGONIST§ buprenorphine hcl-naloxone hcl sl film 2- 1 QL (90 units / 25 days) 0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 4-1 1 QL (90 units / 25 days) mg (base equiv) buprenorphine hcl-naloxone hcl sl film 8-2 1 QL (90 units / 25 days) mg (base equiv) buprenorphine hcl-naloxone hcl sl film 12-3 1 QL (60 units / 25 days) mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 2- PV QL (90 tabs / 25 days); 0.5 mg (base equiv) $0 copay buprenorphine hcl-naloxone hcl sl tab 8-2 PV QL (90 tabs / 25 days); mg (base equiv) $0 copay ZUBSOLV SUB 0.7-0.18 (buprenorphine 2 QL (90 units / 25 days) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 1.4-0.36 (buprenorphine 2 QL (90 units / 25 days) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 2.9-0.71 (buprenorphine 2 QL (90 units / 25 days) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 5.7-1.4 (buprenorphine hcl- 2 QL (90 units