2018 Formulary Drug List For Small Groups and Large Groups GlobalHealth, Inc. 701 NE 10th Street, Suite 300 Oklahoma City, OK 73104-5403 MGDF18 Lists Updated 11/2017 www.GlobalHealth.com/commercial HELPFUL NUMBERS Plan Issuer: Medication Prior Authorizations: GlobalHealth, Inc. [email protected] PO Box 2393 918.878.7361 Oklahoma City, OK 73101-2393 Mail Claims to: GlobalHealth Customer Care, Language Magellan Rx Management, LLC Assistance, and Disease Management: PO Box 85042 [email protected] Richmond, VA 23261-5042 405.280.2964 (local) 1.877.280.2964 (toll-free) Mail Order Pharmacy: 711 (TTY) Magellan Rx Management, LLC Monday – Friday, 9 a.m. – 5 p.m. Central 1.800.424.1789 (toll-free) www.GlobalHealth.com/commercial 711 (TTY) P.O. Box 620968 Behavioral Health and Substance Use: Orlando, FL 32862 [email protected] 405.280.2964 (local) 24/7 Nurse Help Line: 1.877.280.2964 (toll-free) Information Line 711 (TTY) 1.877.280.2993 (toll-free) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/commercial GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) Pharmacy Benefits Manager: 405.280.5852 Magellan Rx Management, LLC [email protected] Customer Service 1.800.424.1789 (toll-free) GlobalHealth Privacy Officer: 711 (TTY) 405.280.5524 [email protected] i IMPORTANT INFORMATION This formulary applies to Members who enrolled through an employer in any of the following Plans: Platinum Plan 1 without Dental Gold Plan 1 with Dental Gold Plan 1 without Dental Standard Plan Member Materials Your comprehensive Member handbook has three booklets. Each one has a different purpose. These documents are important legal documents. Keep them in a safe place. Booklet Purpose Member Handbook Tells you about your benefits. – the name of your o What benefits are covered and how much you will pay. Member Handbook o How they are covered (including limitations and exclusions). will depend on o How to use them. which Plan you enrolled in Physicians and Lists our Network of doctors, Facilities, and pharmacies. Health Providers Tells you if a Facility is preferred or not. Directory (“Provider Directory”) Formulary Drug Lists drugs we cover. List for Small Tells you what Tier a drug is in. Groups and Large Tells you if there are any rules to getting a drug. Groups (“Drug Formulary” or “Formulary”) Member materials are available on our website. Contact Customer Care for printed copies at no charge. But, be aware that the most current Drug Formulary and Provider Directory lists are on the website. When this document says “we”, “us”, or “our”, it means GlobalHealth, Inc. Words or phrases that start with a capital letter are defined in the Member Handbook glossary. For specific questions about your coverage, please call the phone number printed on your Member ID card. ii Preferred Drugs Preferred drugs are listed in this Drug Formulary. Drugs on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the Formulary, which includes generics and brand name drugs that are approved by the U. S. Food and Drug Administration (“FDA”). For the Member: Generic drugs contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you. THIS DOCUMENT LIST IS EFFECTIVE AS OF THE DATE ON THE COVER. THIS LIST IS SUBJECT TO CHANGE. You may find the most current list, including any Utilization Management requirements, on our website. Contact Customer Care for printed copies. iii TIER DESCRIPTION 0 Health Care Reform Health Care Reform 1 Generics 2 Preferred Brands 3 Non-Preferred Brands 4 Specialty Drug TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame. Your provider is required to get prior authorization before you fill PA Prior Authorization your prescription, which ensures appropriate use of the selected drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before you move up a “step” to other drug options. GL Gender Limit This prescription drug is restricted for a single gender. This prescription drug may only be covered if you meet the AL Age Limit minimum or maximum age limit. C Custom This drug has unique restrictions. Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions. Some examples of the diseases include; multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. This medication is not on our drug list. Click on the THERAPEUTIC MED Medical Drug CLASS or sub class to find covered alternative medications. If you have questions, please contact member services. The Affordable Care Act (ACA) requires certain preventive generic HCR Health Care Reform Products products to be covered at zero dollar copay. This does not include plans that are grandfathered. PAGE 1 LAST UPDATED 10/2017 PS Preferred Specialty Preferred Specialty. Generic drugs available at the lowest cost. Please note the specific strengths and dosage forms; other strengths and/or dosage forms LCG Low Cost Generic of these products would be subject to the standard generic Cost- share. PAGE 2 LAST UPDATED 10/2017 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADRENERGIC AGENTS ALPHA AND BETA ADRENERGIC AGONIST(RESPR) QL 2 / fill ADRENACLICK 3 PA ADRENALIN 3 ADYPHREN 3 QL 2 / fill ADYPHREN AMP 3 QL 2 / fill ADYPHREN AMP II 3 QL 2 / fill ADYPHREN II 3 QL 2 / fill QL 2 / fill AUVI-Q 3 PA ephedrine hcl 3 ephedrine sulfate powder 3 epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject) 1 QL 2 / fill epinephrine (base powder, powder) 3 epinephrine (1 mg/ml ampul, 1 mg/ml vial) 1 epinephrine bitartrate 3 epinephrine hcl 3 EPINEPHRINESNAP-V 3 QL 2 / fill QL 2 / fill EPIPEN 3 PA QL 2 / fill EPIPEN 2-PAK 3 PA QL 4 / fill EPIPEN JR 2-PAK 3 PA PAGE 3 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EPISNAP 3 QL 2 / fill EPY 3 QL 2 / fill QL 40/ day HYCOFENIX 3 AL At least 18 yrs old pseudoephedrine hcl 3 racepinephrine hcl 3 QL 20 / day REZIRA 3 AL At least 18 yrs old NON-SELECT.BETA-ADRENERGIC AGONT(RESPIR) isoproterenol hcl powder 3 ISUPREL 3 SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR) ADVAIR DISKUS 2 QL 2 / day ADVAIR HFA 2 QL 0.4 / day QL 0.04 / day AIRDUO RESPICLICK 3 PA AL At least 12 yrs old albuterol sulfate powder 3 albuterol 5 mg/ml solution 1 LCG albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 ml sol, sulf 2 mg/5 ml syrup, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulfate 2 mg tab, sulfate 4 mg tab, sulfate er 4 mg tab, sulfate er 1 8 mg tab) ANORO ELLIPTA 2 QL 2 / day QL 1 / day ARCAPTA NEOHALER 3 ST QL 0.357 / day BEVESPI AEROSPHERE 3 ST PAGE 4 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BREO ELLIPTA 2 QL 2 / day BROVANA 3 QL 4 / day COMBIVENT RESPIMAT 2 QL 0.267 / day QL 0.434 / day DULERA 3 PA QL 0.04 / day fluticasone-salmeterol 1 AL At least 12 yrs old FORADIL 3 QL 3 / day formoterol fumarate (micro pwdr, powder) 3 ipratropium-albuterol 1 levalbuterol concentrate 1 levalbuterol hcl (100% powder, powder) 3 levalbuterol hcl (0.31 mg/3 ml sol, 0.63 mg/3 ml sol, 1.25 mg/3 ml sol) 1 QL 1.5 / day levalbuterol tartrate hfa 3 PA metaproterenol sulfate powder 3 metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syr, 20 mg tablet) 1 PERFOROMIST 3 QL 120 / 30 days PROAIR HFA 2 QL 0.8 / day QL 0.07 / day PROAIR RESPICLICK 2 AL At least 12 yrs old QL 0.6 / day PROVENTIL HFA 3 PA SEREVENT DISKUS 2 QL 2 / day PAGE 5 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL .144 / day STRIVERDI RESPIMAT 2 ST SYMBICORT 2 QL 0.4 / day terbutaline sulfate powder 3 terbutaline sulfate (2.5 mg tab, 5 mg tab) 1 LCG terbutaline sulf 1 mg/ml vial 1 QL 2 / day UTIBRON NEOHALER 3 ST AL At least 18 yrs old VENTOLIN HFA 2 QL 1.5 / day VOSPIRE ER 3 XOPENEX 3 XOPENEX CONCENTRATE 3 QL 1.5 / day XOPENEX HFA 3 PA ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS CARDURA 3 QL 1 / day CARDURA XL 3 ST doxazosin mesylate powder 3 doxazosin mesylate (1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab) 1 MINIPRESS 3 prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) 1 prazosin hcl powder 3 terazosin hcl 1 PAGE 6 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS CAFERGOT 3 D.H.E.45 3 DIBENZYLINE 3 dihydroergotamine mesylate (1 mg/ml am, 1 mg/ml vl) 1 dihydroergotamine powder 3 dihydroergotamine 4 mg/ml spry 1 QL 8 / 30 days ergoloid mesylates powder 3 ergoloid mesylates 1 mg tab 1 ERGOMAR 3 ergotamine tartrate 3 ergotamine-caffeine 1 methysergide maleate 3 MIGERGOT 3 MIGRANAL 3 QL 8 / 30 days phenoxybenzamine hcl 10 mg cap 1 phenoxybenzamine hcl powder 3 phentolamine mesylate powder 3 phentolamine 5 mg vial 1 phentolamine-alprostadil 1 SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT QL 1 / day alfuzosin hcl er 1 GL Male carvedilol 1 COREG 3 COREG CR (CR 10 MG CAPSULE, CR 20 MG CAPSULE, CR 40 MG QL 2 / day 3 CAPSULE) ST PAGE 7 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day COREG CR 80 MG CAPSULE 3 ST QL 1 / day dutasteride-tamsulosin 1 GL Male FLOMAX 3 QL 2 / day QL 1 / day JALYN 3 GL Male labetalol hcl powder 3 labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1 QL 1 / day RAPAFLO 2 GL Male tamsulosin hcl 1 QL 2 / day QL 1 / day UROXATRAL 3 GL Male ANALGESICS AND ANTIPYRETICS ANALGESICS AND ANTIPYRETICS, MISC.