2020 Prescription Drug Formulary Basic/Basic Plus PLEASE READ: This document contains information about the drugs we cover in your plan. This formulary was updated December 1, 2020 and is subject to change. Coverage is subject to the definitions, limitations, exclusions and parameters set forth in your official plan benefit documents. Please refer to your Certificate or Benefit Book for more information. C2382-RXX R12/20 Multi-Language Interpreter Services & Nondiscrimination Notice This document notifies individuals of how to seek assistance if they speak a language other than English. Spanish Oromo ATENCIÓN: Si habla español, tiene a su disposición XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, servicios gratuitos de asistencia lingüística. Llame al tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni 1-800-382-5729 (TTY: 711). argama. Bilbilaa 1-800-382-5729 (TTY: 711). 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Bel Russian 1-800-382-5729 (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Ukrainian Звоните 1-800-382-5729 (телетайп: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної French підтримки. Телефонуйте за номером 1-800-382-5729 ATTENTION: Si vous parlez français, des services (телетайп: 711). d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-382-5729 (ATS: 711). Romanian ATENT, IE: Dacă vorbit,i limba română, vă stau la Vietnamese dispozit,ie servicii de asistent,ă lingvistică, gratuit. CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ Sunat,i la 1-800-382-5729 (TTY: 711). miễn phí dành cho bạn. Gọi số 1-800-382-5729 (TTY: 711). Tagalog Navajo PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari Díí baa akó nínízin: Díí saad bee yáníłti’ go Diné kang gumamit ng mga serbisyo ng tulong sa wika nang Bizaad, saad bee áká’ánída’áwo’dę΄ę΄’, t’áá jiik’eh, éí walang bayad. Tumawag sa 1-800-382-5729 (TTY: 711). ná hólǫ´, kojį’ hódíílnih 1-800-382-5729 (TTY: 711). Please Note: Products marketed by Medical Mutual may be underwritten by one of its subsidiaries, such Order Number: Z8188-MCA R4/19 as Medical Health Insuring Corporation of Ohio or Dept of Ins. Filing Number: Z8188-MCA R9/16 MedMutual Life Insurance Company. QUESTIONS ABOUT YOUR BENEFITS OR OTHER INQUIRIES ABOUT YOUR HEALTH INSURANCE SHOULD BE DIRECTED TO MEDICAL MUTUAL’S CUSTOMER CARE DEPARTMENT AT 1-800-382-5729. Nondiscrimination Notice Medical Mutual of Ohio complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex in its operation of health programs and activities. Medical Mutual does not exclude people or treat them differently because of race, color, national origin, age, disability or sex in its operation of health programs and activities. n Medical Mutual 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, audio, accessible electronic formats, etc.). n Medical Mutual 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 or if you believe Medical Mutual failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, with respect to your health care benefits or services, you can submit a written complaint to the person listed below. Please include as much detail as possible in your written complaint to allow us to effectively research and respond. Civil Rights Coordinator Medical Mutual of Ohio 2060 East Ninth Street Cleveland, OH 44115-1355 MZ: 01-10-1900 Email: [email protected] You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. n Electronically through the Office for Civil Rights Complaint Portal available at: ocrportal.hhs.gov/ocr/portal/lobby.jsf n By mail at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington, DC 20201-0004 n By phone at: 1-800-368-1019 (TDD: 1-800-537-7697) n Complaint forms are available at: hhs.gov/ocr/office/file/index.html Products marketed by Medical Mutual may be underwritten by one of its subsidiaries, such as Medical Health Insuring Corporation of Ohio or MedMutual Life Insurance Company. Basic/Basic Plus Formulary What is the Basic/Basic Plus formulary? What do I do if my medication requires prior The Basic/Basic Plus formulary is a list of authorization or step therapy, or has a medications covered by your plan. The quantity limit? formulary includes five tiers: You, your doctor or your pharmacist can call 1. Generic (lowest out-of-pocket cost) Express Scripts at 1-800-753-2851 to begin the 2. Preferred brand review process for medications that require 3. Non-preferred brand prior authorization or step therapy, or that have 4. Specialty (highest out-of-pocket cost) a quantity limit. After contacting Express 5. Preventive ($0 out-of-pocket cost) Scripts, your doctor will receive a form to fill out and fax back to Express Scripts. Express Refer to your Certificate or Benefit Book for Scripts will send you and your doctor a letter information about your cost share, including confirming if coverage has been approved copays, coinsurance and/or deductibles. Not all (usually within three business days of receiving tiers apply to all plans. the necessary information). • If you ordered your prescription through mail If you are a member of a plan that includes a order, Express Scripts will automatically preferred pharmacy network (e.g., CLE-Care), send it to you once coverage is approved. those preferred pharmacies may offer lower • If you tried to fill your prescription at a retail cost sharing to help you save money. Check pharmacy, you will need to return to the your benefit materials for more details. pharmacy to pick up your medication. Your plan may exclude certain medications. Does the Basic/Basic Plus formulary include Please refer to your Certificate or Benefit Book generic and brand medications? for more information. Yes. The Basic/Basic Plus formulary includes a variety of generic and brand medications to How do I use the Basic/Basic Plus help you pay less out of pocket. formulary? Covered medications are organized two ways in Generic medications are shown in this the Basic/Basic Plus formulary: document in lower-case italic letters. Generics 1. By condition are approved by the U.S. Food and Drug 2. By name Administration (FDA) as having the same active ingredient as their brand-name counterparts. In If you know what your medication is used to addition, the FDA requires generics to be just treat, you can look it up by condition in the front as safe and strong as their brand-name of the document. If you don’t know what counterparts so you get the same medical condition it is used to treat, you can look for it in benefit. the alphabetical Index at the back of the document. Brand medications are shown in this document in ALL CAPITAL LETTERS. Does the Basic/Basic Plus formulary include brand medications are covered by your plan, specialty medications? and which may help you save money. Yes. Specialty medications are used to treat certain complex medical conditions and may If you are a member of a plan that includes a require special handling, instruction, or preferred pharmacy network (e.g., CLE-Care), monitoring. Many plans limit you to a 30-day those preferred pharmacies may offer lower supply for most specialty medications and/or cost sharing to help you save money. Check require you to fill prescriptions for these your benefit materials for more details. medications through one of Medical Mutual’s contracted specialty pharmacies, Accredo or Do I have to use mail order for my Gentry. maintenance medications? Depending on your plan, you may be required If you are a member of a plan that includes a to use mail order for your maintenance preferred pharmacy network (e.g., CLE-Care), medications (those you take for three months or you may be required to use specific preferred more). Check your Certificate or Benefit Book pharmacies for specialty drugs. for details. (Note: If you are a member of a CLE-Care plan, you must fill mail-order Please check your Certificate or Benefit Book medications through the MetroHealth Central for more details about ordering specialty drugs. Fill Pharmacy. Visit metrohealth.org/pharmacy for more information and to download a form.) Are there other limitations or coverage rules in addition to what are listed in this guide? Even if you are not required to do so, you may Yes.