PRESCRIPTION2020 DRUG FORMULARY Federal Exchange Plans This formulary was updated on 12/07/2020. For more recent information or other questions, please contact Florida Health Care Plans Member Services at 1-877-615-4022. TTY users, call 1-800-955-8770. Hours of operation are Monday through Friday, 8:00a.m. to 5:00p.m. or visit www.fhcp.com/QHP-2020 Note to existing members: Please review this document to make sure that it contains the drugs you take. When this drug list refers to “we,” “us”, or “our,” it means Florida Health Care Plans (FHCP). When it refers to “plan” or “our plan,” it means Florida Health Care Plans (FHCP). Note: This formulary applies only to Qualified Health Plans (QHP). Qualified Health Plans are plans that are subject to the provisions of the Federal Affordable Care Act (ACA) and are submitted to the Federal and/or applicable State agencies by an Insurer that has been approved for inclusion in the Federal and/or State Insurance Exchange Marketplace(s). For more information call Member Services at 1-877-615-4022, 7 days a week, 8 am – 8 pm. TTY users should call TRS Relay 711. This document includes a list of the drugs covered by FHCP which is effective 12/01/2020. The drug list begins on page 5. For an updated formulary, please contact us. Our contact information appears on the front cover page. Disclaimers: − You must use network pharmacies to receive your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change upon renewal of your plan. − This information is available for free in other languages. Please contact our Member Services number at 1-877-615-4022 for additional information. (TTY users should call TRS Relay 711). Hours are 8 am to 8 pm, 7 days a week. Member Services also has free language interpreter services available for non-English speakers. − Esta informacion esta disponible gratis en otros lenguajes. Por favor pongase en contacto con nuestro Servicios de Miembros a 1-877-615-4022 para informacion adicional. Usuarios de TTY deben de llamar TRS Relay 711. Horas son de 8 am hasta 8 pm, 7 dias de la semana. Servicios de Miembros tambien tiene servicios de interpretacion de lenguajes gratis disponible para personas que no hablan ingles. Formulary introduction The Florida Health Care Plans formulary is an extensive list of FDA approved brand and generic drugs used to treat the most common medical conditions. The FHCP Formulary is developed by FHCP's Pharmacy and Therapeutics Committee (P&T). The committee consists of physicians, pharmacists, and nurses who review drugs on the basis of safety, efficacy, tolerability, and cost. The P&T Committee reviews and updates the drug list quarterly. New drugs and newly available generics are added as needed, and drugs that are deemed unsafe by the Food and Drug Administration (FDA) are immediately removed. Your prescription drug benefit provides coverage for drugs listed in each of the therapeutic classes of the FHCP Formulary. The FHCP Formulary represents the major therapeutic classes and should serve as a quick reference to you, your physician, or pharmacist for those covered drugs within the classes listed. Information on drug coverage for a non- listed therapeutic drug class should be directed to an FHCP pharmacist or physician. If your physician prescribes a drug that is not covered, show your physician this list, and ask the physician to prescribe a drug from within the FHCP Formulary. i Any drug not listed in the FHCP Formulary is considered a non-covered drug and is subject to a higher out of pocket costs. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that FHCP does not cover your drug, you have two options: • You can ask Member Services for a list of similar drugs that are covered by FHCP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by FHCP. • You can ask FHCP to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Formulary? You can ask FHCP to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make: • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. • You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, FHCP limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, FHCP will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition, and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tier or utilization restriction exception. When you request a formulary, tier or utilization restriction exception you must submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 14 days of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 14 days for a decision. If your request to expedite is granted, we must give you a decision no later than 24 to 72 hours after we get a supporting statement from your doctor or other prescriber. ii What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing Member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a Member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to an FHCP pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a Member of the plan less than 90-days. Drug transition for new FHCP members FHCP pharmacies will dispense a one-time 31-day supply of the current transition drug, excluding specialty drugs, to allow you and our physician(s) to discuss possible formulary alternatives, request a prior authorization, or, in the event the physician(s) deems the non-formulary drug to be medically necessary, request a formulary exception. Specialty drugs will require review and authorization through the Referral Department prior to coverage. How much will my prescriptions cost? Your pharmacy benefit and the drugs listed in the formulary are assigned a “TIER.” There are seven (7) Tiers in the Formulary. Generally, the higher the “Tier,” the higher your cost will be. Carefully review your Summary of Benefits Coverage to ascertain if you have a pharmacy benefit and/or any pharmacy benefit limitations. For more information For more detailed information about your FHCP prescription drug coverage, please review your Certificate of Coverage, your Summary of Benefits Coverage and other plan materials for your cost sharing and any benefit limitations (such as “Generic Only" option). If you have questions, please contact us. Note: FHCP’s Formulary can also be found on our website at www.fhcp.com/QHP-2020. If you are unable to find a certain drug within this booklet, please check out our website. How to search for a drug in the Florida Health Care Plan preferred drug list (formulary) Go to www.fhcp.com/QHP-2020. When the PDF file comes up, press Control F. A pop- up search text box will appear at the top of the page. Type the drug name for which you are searching and click the right arrow in the pop-up search text box to begin the search. To close the pop-up search text box, click on the “x” in the pop-up search text box. iii Affordable Care Act - Preventive drugs available for $0 cost-sharing The Affordable Care Act (ACA) requires coverage of certain preventive drugs without any patient cost-sharing to ACA compliant and non-grandfathered plans.