2021 Formulary of Covered Prescription Drugs Prescription Covered Formulary of 2021 Formulary of Covered Prescription Drugs Formulario De Medicamentos Con Receta Cubiertos Effective 7/1/2021 - 9/30/2021 SelectHealth from VNSNY CHOICE July 2021 Foreword MedImpact is a Pharmacy Benefit Manager for SelectHealth. This document represents the efforts of the MedImpact 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- effectiveness of commercially available drug products. A structured approach to the drug selection process is essential in ensuring continuing patient access to rational drug therapies. This is accomplished through the auspices of the MedImpact P&T and Formulary Committees. These committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary. To accommodate changes to this document, updates are made accessible as necessary. Access to the most current version of the SelectHealth Formulary can be obtained by visiting SelectHealthNY.org/member. The MedImpact P&T and Formulary Committees use the following criteria in the evaluation of drug selection for SelectHealth Formulary: ● Drug safety profile ● Drug efficacy ● Comparison of relevant therapeutic benefits to current formulary agents of similar use, and to minimize therapeutic duplication where possible ● Cost-effectiveness relative to comparable therapies How to Use the Formulary The Formulary is a list of medications available to SelectHealth members under their pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name and by therapeutic drug category. In situations where an FDA approved generic equivalent is available, brand names are listed for reference purposes only, and do not denote coverage for the brand, unless specifically noted. All drugs are listed in each category in alphabetical order by generic name. Where an FDA approved generic is available for the listed generic name, the generic name is bolded. For certain agents within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols: AGE Age Edit Coverage may depend on patient age G Gender Edit Coverage may depend on patient gender PA Prior Authorization Requires specific physician request process QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period ST Step Therapy Coverage may depend on previous use of another drug Please refer to the prescribing guideline appendix within this document for details regarding specific agents. SelectHealth Benefit Coverage and Limitations This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members have specific benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in the Formulary. The Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact SelectHealth Member Services at 1-866-469-7774 Monday through Friday, 8:00 am to 6:00 pm. TTY users call 711. Depending upon a member’s specific benefit parameters, the following topics may apply: 1. Generic Substitution When available, FDA approved generic drugs are to be used in all situations, regardless of the brand name indicated. The generic names are bolded in the formulary listing wherever an FDA approved generic drug product is available. Greater economy is realized through the use of generic equivalents. This policy is not meant to preclude or supplant any state statutes that may exist. All drugs that are or become available generically are subject to review by MedImpact’s Pharmacy and Therapeutics Committee. MedImpact approves such multi-source drugs for addition to the MAC list based on the following criteria: ● A multi-source drug product manufactured by at least one (1) nationally marketed company. ● At least one (1) of the generic manufacturer’s products must have an “A” rating or the generic product has been determined to be unassociated with efficacy, safety or bioequivalence concerns by the MedImpact P&T Committee. ● Drug product will be approved for generic substitution by the MedImpact P&T Committee. This list is reviewed and updated periodically based on the clinical literature and pharmacokinetic characteristics of currently available versions of these drug products. If a member or physician requests a brand name product in lieu of an approved generic, and physician determines that there is a documented medical need for the brand equivalent, a request for coverage may be made using the medication request process at 1-888-678-7741, 24 hours a day, and 7 days a week. 2. Tier Benefit Design The Formulary may be applied to a tier benefit design, where the member shares the cost of prescription drug therapy based on the drug’s tier and copayment or coinsurance. In most instances, generically available drugs will be covered in a separate lower tier (low copay), preferred branded drugs listed onthe Formulary will be covered under a higher tier, and branded drugst no on the Formulary will be covered under a separate non-preferred branded drug copay tir.e Essential health benefit/preventative medications, if available on your plans formulary (applies to new and non-grandfathered plans), will be covered without cost sharing (zero copay). TIER DEFINITIONS: TIER 1: Preferred generic medications (formulary agents) TIER 2: Preferred brand medications (formulary agents) TIER 3: Non-preferred medications (non-formulary agents) TIER 4: Zero Copay/Preventative medications TIER 5: Over the Counter (OTC) SelectHealth 3. Medication Request Process Depending upon plan benefit design, a medication request process may apply as follows: A. Coverage Exceptions: Drugs that are listed in the Formulary with associated Prior Authorization (PA) require evaluation, per MedImpact P&T Committee Prior Authorization guidelines prior to dispensing at a network pharmacy. Each request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P&T Committee, the request will not be approved and alternative therapy may be recommended. B. Obtaining Coverage: Coverage, questions or information regarding the medication request or formulary process may be obtained by: 1. Faxing a completed Medication Request Form to MedImpact at 1-858-790-7100. 2. Contacting MedImpact at 1-888-678-7741 and providing all necessary information requested. MedImpact will provide an authorization number, specific for the medical need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity. Prior Authorization is generally not available for drugs that are specifically excluded by benefit design. 4. General Exclusions A. Drugs specifically listed as not covered. B. Any drug products used for cosmetic purposes. C. Experimental drug products or any drug product used in an experimental manner. D. Replacement of lost or stolen medication. E. Non-self-administered injectable drug products unless otherwise specified in the Formulary listing. F. Foreign sourced drugs or drugs not approved by the United States Food & Drug Administration, except in certain cases of drug shortage, when allowed under the individual’s pharmacy benefit. 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 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 SelectHealth Plan Name: SelectHealth Plan Phone No. 1-888-678-7741 Website: SelectHealthNY.org Plan Fax No. 1-858-790-7100 NYS Medicaid Prior Authorization Request Form For Prescriptions Rationale for Exception Request or Prior Authorization - All information must be complete and legible Patient Information First Name: Last Name: MI: Male Female Date of Birth: Member ID: Is patient transitioning from a facility? Yes No / / If yes, provide name of facility: Provider Information First Name: Last Name: Address: NPI No:1 Phone No: Fax No: Office Contact: Specialty: Medication/Medical and Dispensing Information Medication: Strength: Frequency: Qty: Refill(s): Case Specific Diagnosis/ICD10:2 Route of Administration: Oral IM SC Transdermal IV Other For physician administered, will this provider be ordering & administering? Yes No If no, supply administering provider: Please check one of the following: This is a new medication and/or new health plan This is continued therapy previously covered by the patient’s