MedPerform Medium Formulary Administered by MedImpact July 2018 Foreword For certain agents within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout This document represents the efforts of the MedImpact the document using the following symbols: Healthcare Systems Pharmacy and Therapeutics (P&T) and Formulary Committees to provide physicians and pharmacists with a method to evaluate the safety, efficacy, and cost- Symbol Guideline Description effectiveness of commercially available drug products. A AGE Age Edit Coverage may depend on patient structured and dynamic approach to the drug selection process age is essential to ensure continuing patient access to rational drug PA Prior Requires specific physician request therapies. Authorization process This is accomplished through the auspices of the MedImpact QL Quantity Coverage may be limited to specific P&T and Formulary Committees. These committees meet Limit quantities per prescription and/or quarterly and more often as warranted to ensure clinical time period relevancy of the Formulary. To accommodate changes to this document, updates are made accessible as necessary. ST Step Therapy Coverage may depend on previous use of another drug Access to the most current version of the MedPerform Medium Formulary can be obtained by visiting Please refer to the prescribing guideline appendix within this www.MedImpact.com. document for details regarding specific agents. The MedImpact P&T and Formulary Committees use the Benefit Coverage and Limitations following criteria in the evaluation of drug selection for the This printed Formulary does not provide information regarding Marketplace Exchange Standard Formulary: the specific coverage and limitations an individual member may • Drug safety be subject to. Many members have specific benefit inclusions, • Drug efficacy exclusions, copayments, or a lack of coverage, which are not • Comparison of relevant therapeutic benefits to current reflected in the Formulary. formulary agents of similar use, and reduction of therapeutic duplication wherever possible The Formulary applies only to outpatient drugs provided to • Cost-effectiveness relative to comparable therapies members and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their How to Use the Formulary coverage, they should contact their Plan Sponsor or MedImpact The Formulary is a list of medications available to MedImpact at (800) 788-2949. members under their pharmacy benefit. All drugs are listed by their generic names and the most common proprietary Depending upon a member’s specific (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name and by therapeutic benefit parameters, the following topics drug category. In situations where an FDA-approved generic may apply: equivalent is available, brand names are listed for reference 1. Generic Substitution purposes only, and do not denote coverage for the brand, unless When available, FDA-approved generic drugs are to be specifically noted. used in all situations, regardless of the brand name indicated. The generic names are bolded in the formulary All drugs are listed in each category in alphabetical order by listing wherever an FDA-approved generic drug product is generic name. Where an FDA-approved generic is available for available. Greater economy is realized through the use of the listed generic name, the generic name is bolded. generic equivalents. This policy is not meant to preclude or supplant any state statutes that may exist. All drugs that are 3. Medication Request Process or become available generically are subject to review by Depending upon plan benefit design, a medication request the MedImpact P&T Committee. MedImpact approves process may apply as follows: such multi-source drugs for addition to the Maximum A. Coverage Exceptions Allowable Cost (MAC) list based on the following criteria: Drugs that are listed in the Formulary with associated • A multi-source drug product manufactured by at least Prior Authorization (PA) require evaluation, per one (1) nationally marketed company. MedImpact P&T Committee Prior Authorization • At least one (1) of the generic manufacturer’s products guidelines, prior to dispensing at a pharmacy. Each must have an “A” rating or the generic product has been request will be reviewed on an individual patient need determined to be unassociated with efficacy, safety or basis. If the request does not meet the guidelines bioequivalency concerns by the MedImpact P&T established by the P&T Committee, the request will Committee. not be approved and alternative therapy may be • Drug product will be approved for generic substitution recommended. by the MedImpact P&T Committee. B. Obtaining Coverage This list is reviewed and updated periodically based on the Coverage, questions or information regarding the clinical literature and pharmacokinetic characteristics of medication request or formulary process may be currently available versions of these drug products. obtained by: 1. Faxing a completed Medication Request Form to If a member or physician requests a brand name product in MedImpact at (858) 790-7100. lieu of an approved generic, the member, based upon their 2. Contacting MedImpact at (800) 788-2949 and coverage, will typically be required to pay the difference in providing all necessary information requested. cost between the brand and the generic. If a physician MedImpact will provide an authorization number, determines that there is a documented medical need for the specific for the medical need, for all approved brand equivalent, a request for coverage may be made using requests. Non-approved requests may be appealed. the medication request process. The prescriber must provide information to support the appeal on the basis of medical necessity. Prior 2. Tier Benefit Design Authorization is generally not available for drugs that The Formulary may be applied to a tier benefit design, are specifically excluded by benefit design. where the member shares the cost of prescription drug therapy based on the drug’s tier and copayment or 4. General Exclusions coinsurance. In most instances, generically available drugs A. Over the Counter (OTC) medications or their will be covered in a separate lower tier (low copay), equivalents, unless the individual's pharmacy benefit preferred branded drugs listed on the Formulary will be offers coverage of OTC medications. covered under a higher tier, and branded drugs not on the B. Drugs specifically listed as not covered. Formulary will be covered under a separate non-preferred C. Any drug products used for cosmetic purposes. branded drug copay tier. Specialty drugs may be covered D. Experimental drug products or any drug product used at a higher copay or coinsurance. Essential health in an experimental manner. benefit/preventative medications, if available on your plans E. Replacement of lost or stolen medication. formulary (applies to new and non-grandfathered plans), F. Non self-administered injectable drug products unless will be covered without cost sharing (zero copay). otherwise specified in the Formulary listing. G. Foreign sourced drugs or drugs not approved by the Tier Definitions United States Food & Drug Administration, except in Tier 0: EHB Zero Copay/Preventative certain cases of drug shortage, when allowed under the Tier 1: Preferred generic medications (formulary individual's pharmacy benefit. agents) Tier 2: Preferred brand medications (formulary agents) Tier 3: Non-preferred medications (non-formulary agents) Excluded Agents As new drugs become available, they will be considered for coverage under the MedPerform Formulary. The plan administrator has the right to decide what drugs are covered and to what extent, as well as the right to modify coverage including the exclusion of any prescription drugs. Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives. The P&T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative therapies. 5. Pharmacist and Physician Communication The Formulary is a tool to promote cost-effective prescription drug use. The P&T and Formulary Committees have made every attempt to create a document that meets all therapeutic needs; however, the art of medicine makes this a formidable task. MedImpact welcomes the participation of physicians, pharmacists, and ancillary medical providers, in this dynamic process. Physicians and pharmacists are highly encouraged to direct any suggestions, comments or formulary additions to MedImpact at the following address: Chairperson, Pharmacy & Therapeutics Committee MedImpact Healthcare Systems, Inc. 10181 Scripps Gateway Court San Diego, CA 92131 Formulary Drug Exclusions (July 1, 2018) DRUG CATEGORY EXCLUDED DRUGS (SELECTED) PREFERRED ALTERNATIVES ALLERGY NASAL CORTICOSTEROIDS Beconase AQ, Omnaris, Ticanase, Zetonna nasal budesonide, flunisolide, fluticasone, mometasone, triamcinolone, Qnasl OPHTHALMIC ANTIHISTAMINES Bepreve, Emadine, Lastacaft, Pazeo azelastine, olopatadine, Pataday NASAL CORTICOSTEROID AND Ticalast azelastine, fluticasone ANTIHISTAMINE COMBINATIONS BEHAVIORAL HEALTH ADHD AGENTS Adzenys ER, Adzenys XR-ODT, Mydayis Adderall XR, dextroamphetamine/amphetamine Aptensio XR, Cotempla XR-ODT methylphenidate ANTIDEPRESSANTS Forfivo XL bupropion extended