2018 LIST OF COVERED DRUGS (FORMULARY) Michigan Complete Health (Medicare-Medicaid Plan) Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. If you have questions, please call Michigan Complete Health (MMP) Member Services at 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. Updated 11/2018. HPMS Approved Formulary File Submission ID: 18491 Version Number: 15 H9487_18_LOD_Approved_09062017 Notice of Non-Discrimination. Michigan Complete Health Medicare-Medicaid Plan (MMP) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Michigan Complete Health (MMP) does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Michigan Complete Health (MMP): • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Michigan Complete Health (MMP)’s Member Services at 1-844-239-7387 (TTY: 711) from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. If you believe that Michigan Complete Health (MMP) has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Michigan Complete Health (MMP)’s Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368– 1019, (TDD: 1-800–537–7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Language Services ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-844-239-7387 (TTY: 711). ATENCIÓN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingística. Llame al 1-844-239-7387 (TTY: 711). ﻣﻠﺣوظﺔ: إذا ﻛﻧت ﺗﺗﺣدث اﻟﻠﻐﺔ اﻟﻌرﺑﯾﺔ، ﻓﺈن ﺧدﻣﺎت اﻟﻣﺳﺎﻋدة اﻟﻠﻐوﯾﺔ ﺗﺗواﻓر ﻟك ﺑﺎﻟﻣﺟﺎن. اﺗﺻل ﺑرﻗم 7387-239-844-1 (رﻗم ھﺎﺗف اﻟﺻم واﻟﺑﻛم: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請 電 1-844-239-7387（TTY：711)。 ܿ ܿ ܿ ܵ ܵ ܿ ܵ ܵ ܵ ܿ ܿ ܿ ܿ ܵ ܵ ܘܙ ܼ ܗܪܐ: ܸܐ ܢ ܼܐܚܬܘܢ ܹܟܐ ܼܗ ܸܡܙ ܝܡ ܼܬܘܢ ܸܠܫܢܐ ܐ ܬܘܪ ܵܝܐ، ܡ ܼܨܝܬܘܢ ܼܕܩ ܼܒܠܝܬܘܢ ܵ ܿ ܵ ܿ ܵ ܵ ܵ ܿ ܿ 1-844-239-7387 (TTY: 711) ܐܢ ܝܢܵ ܡܸ ܠܥܼܿ ܢ ܘܪܩ .ܬ ܼ ܐܝ ܢܓܵ ܡܼ ܐܢܫܠܒܸ ܐ ܪܬ ܝܼܿ ܗܕܼ ܐܬܹ ܡܠܼ ܚܸ CHÚ Ý: Nếu bạn ni Tiếng Việt, c các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-844-239- 7387 (TTY: 711). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-844-239-7387 (TTY: 711). 주의: 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844-239-7387 (TTY: 711) 번으로 전화해 주십시오. ল�뷍 ক쇁নঃ যিদ আপিন বাংলা, কথা বলেত পােরন, তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল� আেছ। েফান ক쇁ন ১-844-239-7387 (TTY: 711)। UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1- 844-239-7387 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfgung. Rufnummer: 1-844-239-7387 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-844-239-7387 (TTY: 711). 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-844-239-7387（TTY: 711）まで 、お電話にてご連絡ください。 ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-844-239-7387 (TTY: 711). OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-844-239-7387 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-844-239-7387 (TTY: 711). H9487_18_LOD_Approved_09062017 This is a list of drugs that members can get in Michigan Complete Health (MMP). Michigan Complete Health Medicare-Medicaid Plan (MMP) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check Michigan Complete Health (MMP)’s up-to-date List of Covered Drugs online at mmp.michigancompletehealth.com. Limitations, restrictions, and patient pay amounts may apply. This means that you may have to pay for some services and that you need to follow certain rules to have Michigan Complete Health (MMP) pay for your services. For more information, call Michigan Complete Health (MMP) Member Services or read the Michigan Complete Health (MMP) Member Handbook. Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingística. Llame al 1-844-239-7387 (TTY: 711) de 8 a. m. a 8 p. m., los siete días de la semana. Los usuarios de TTY deben llamar al 711. Los fines de semana y los días feriados estatales o nacionales, es posible que se le pida que deje un mensaje. Le devolveremos la llamada durante el prximo día hábil. La llamada es gratuita. You can also get this document for free in other formats, such as large print, braille, or audio. Call 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. If you would like us to send you member materials on an ongoing basis in other formats, such as Braille or large print, or in a language other than English, please call Member Services at the number at the bottom of the page. Tell Member Services that you would like to place a standing request to get your materials in another format or language. If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. i Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Michigan Complete Health (MMP). These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.” Michigan Complete Health (MMP) will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a Michigan Complete Health (MMP) network pharmacy. Michigan Complete Health (MMP) may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at mmp.michigancompletehealth.com or call Member Services toll-free at 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. 2. Does the Drug List ever change? Yes. Michigan Complete Health (MMP) may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe.