Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2015 Lististahan ng Mga Sakop na Gamot (Formulary) Ini-update ang listahan ng gamot na ito noong 12/1/2015 . Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/calmediconnect. Formulary ID: 15417 Version: 37 Material ID #H3237_2015_0095_A_TAG CMS Approved 09112014 Listahan ito ng mga gamot na makukuha ng mga miyembro sa Health Net Cal MediConnect. • "OH )FBMUI /FU $Bl MFEJ$POOFDU • :PV DBO HFU UIJT JOGPSNBUJPO GPS GSFF JO BZ JTBOH QMBOPOH QBOHLBMVTVHBO OB PUIFS MBOHVBHFT $BMM GPS OBLBLPOUSBUB TB .FEJDBSF BU .FEJ$BM -PT "OHFMFT $PVOUZ PS VQBOH NBHCJHBZ OH NHB CFOFQJTZP OH GPS 4BO %JFHP $PVOUZ 55: ThF DBMM LBQXBOH QSPHSBNB TB NHB OBLBFOSPM JT GSFF • "OH NHB #FOFQJTZP -JTUBIBO OH .HB 4BLPQ OB (BNPU NHB OFUXPSL OH UBHBQBHMBBO BUP NHB DPQBZNFOU BZ NBBBSJOH NBHCBHP QBOBQBOBIPO TB CVPOH UBPO BU TB &OFSP OH CBXBU UBPO • "OVNBOH PSBT BZ NBUJUJOHOBO NP POMJOF BOH OBTBTBQBOBIPOH -JTUBIBO OH .HB 4BLPQ OB (BNPU OH )FBMUI /FU $Bl .FEJ$POOFDU TB XXXIFBMUIOFUDPN DBMNFEJDPOOFDU P TB QBNBNBHJUBO OH QBHUBXBH TB QBSB TB -PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55: • .BBBSJ NPOH IJOHJO BOH JNQPSNBTZPO OB JUP TB JCBOH NHB BZPT UVMBE OH #SBJMMF P NBMBLJOH MFUSB 5VNBXBH TB QBSB TB -PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55: -JCSF BOg tBXBH • .BBBSJOH QBJSBMJO BOH NHB MJNJUBTZPO DPQBZ BU SFTUSJLTZPO 1BSB TB LBSBHEBHBOH JNQPSNBTZPO UBXBHBO BOH )FBMUI /FU $Bl MFEJ$POOFDU .FNCFS 4FSWJDFT P CBTBIJO BOH )BOECPPL OH .JZFNCSP OH )FBMUI /FU $Bl MFEJ$POOFDU • "OH NHB DPQBZ QBSB TB NHB JOJSFTFUBOH HBNPU BZ NBBBSJOH NBHJCB CBUBZ TB BOUBT OH %BHEBH OB 5VMPOH OB JOZPOH OBUBUBOHHBQ .BOHZBSJOH NBLJQBH VHOBZBOBO TB QMBOP QBSB TB NHB EFUBMZF ? Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/ calmediconnect. i Mga Madalas *UBOPOH (FAQ) .BHIBOBQ OH NHB TBHPU EJUP QBSB TB NHB UBOPOH OB NBZSPPO LB UVOHLPL TB -JTUBIBO OH .HB 4BLPQ OB (BNPU OB JUP .BCBCBTB NP BOH MBIBU OH '"2 QBSB NBUVUP QB P NBHIBOBQ OH UBOPOH BU TBHPU 1. Ang mga de-resetang gamot ang nasa Listahan ng Mga Sakop na Gamot? (Tinatawag namin ang Listahan ng Mga Sakop na Gamot na maikling pangalang “Listahan ng Gamot”.) "OH NHB HBNPU TB -JTUBIBO OH (BNPU BZ BOH NHB HBNPU OB TBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU .BCJCJMJ BOH NHB HBNPU TB NHB QBSNBTZB TB MPPC OH BNJOH OFUXPSL "OH QBSNBTZB BZ OBTB OFUXPSL OBNJO LVOH NBZSPPO LBNJOH LBTVOEVBO TB LBOJMB OB NBHUSBCBIP OBOH LBTBNB LBNJ BU NBHMBBO OH NHB TFSCJTZP TB JZP 5JOVUVLPZ OBNJO BOH NHB QBSNBTZBOH JUP CJMBOH iNHB QBSNBTZB OH OFUXPSLw 4BTBLVQJO OH )FBMUI /FU $Bl MFEJ$POOFDU MBIBU OH NFEJLBM OB LBJMBOHBOH HBNPU TB -JTUBIBO OH (BNPU LVOH • TJOBCJ OH JZPOH EPLUPS P OBHSFTFUB OB LBJMBOHBO NP JUP QBSB HVNBMJOH P NBOBUJMJOH NBMVTPH at • QJOVOBO NP BOH SFTFUB TB JTBOH QBSNBTZB OH OFUXPSL OH )FBMUI /FU $Bl MFEJ$POOFDU 4B JMBOH NHB LBTP NBZ LBJMBOHBO LBOH HBXJO CBHP LB NBLBLVIB OH HBNPU UJOHOBO BOH UBOPOH TB JCBCB .BUJUJOHOBO NP SJO TB BNJOH XFCTJUF BOH OBTBTBQBOBIPOH MJTUBIBO OH NHB HBNPU OB BNJOH TJOBTBLPQ TB XXXIFBMUIOFUDPN DBMNFEJDPOOFDU P UVNBXBH TB .FNCFS 4FSWJDFT TB QBSB TB -PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55: ii 2. Nagbabago ba ang Listahan ng Gamot? • "OVNBOH PSBT BZ NBBBSJ NPOH 0P .BBBSJOH NBHEBHEBH P NBH UJOHOBO BOH POMJOF OB OBTBTBQBOBIPOH BMJT OH NHB HBNPU BOH )FBMUI /FU -JTUBIBO OH (BNPU OH )FBMUI /FU $Bl MFEJ$POOFDU TB -JTUBIBO OH (BNPU TB $Bl .FEJ$POOFDU TB XXXIFBMUIOFUDPN UBPO 4B QBOHLBMBIBUBO NBHCBCBHP MBOH DBMNFEJDPOOFDU .BBBSJ LB SJOH UVNBXBH BOH -JTUBIBO OH (BNPU LVOH TB .FNCFS 4FSWJDFT QBSB UJOHOBO BOH LBTBMVLVZBOH -JTUBIBO OH (BNPU TB • NBZSPPOH NBT NVSBOH HBNPU OB QBSB TB -PT "OHFMFT EVNBUJOH OB LBTJOHCJTB OH HBNPU OB $PVOUZ P TB QBSB TB OBTB -JTUBIBO OH (BNPU OHBZPO o 4BO %JFHP $PVOUZ 55: • OBMBNBO OBNJO OB IJOEJ MJHUBT BOH JTBOH HBNPU 3. Ano ang mangyayari kapag may mas .BBBSJ SJO OBNJOH CBHVIJO BOH NHB murang gamot na dumating na kasing- QBUBLBSBO OBNJO UVOHLPM TB NHB HBNPU bisa ng gamot na nasa Listahan ng )BMJNCBXB NBBBSJ LBNJOH Gamot ngayon? ,VOH VNJJOPN LB OH HBNPU OB JOBMJT EBIJM • .BHQBTZBOH JBUBT P IJOEJ JBUBT BOH NBZ NBT NVSBOH HBNPU OB LBTJOH CJTB QBVOBOH QBIJOUVMPU QBSB TB JTBOH HBNPU BOH EVNBUJOH TBTBCJIJO OBNJO TB JZP Ang paunang pahintulot BZ QBIJOUVMPU 4BTBCJIJO OBNJO TB JZP OBOH IJOEJ CBCBCB NVMB TB )FBMUI /FU $Bl MFEJ$POOFDU TB BSBX CBHP OBNJO JUP BMJTJO NVMB CBHP LB NBLBLVIB OH HBNPU TB -JTUBIBO OH (BNPU o LBQBH IVNJOHJ • .BHEBHEBH P NBHCBHP OH EBNJ OH LB OH SefiMM 1BHLBUBQPT BZ NBLBLBLVIB HBNPU OB NBLVLVIB NP UJOBUBXBH OB LB OH BSBX OB TVQQMZ OH HBNPU CBHP iNHB MJNJUBTZPO TB EBNJw BMJTJO BOH HBNPU NVMB TB MJTUBIBO OH HBNPU ,VOH HVNBXB LBNJ OH BOVNBOH • .BHEBHEBH P NBHCBHP OH NHB JCBOH OFHBUJCPOH QBHCBCBHP TB -JTUBIBO SFTUSJLTJZPO OH TUFQ UIFSBQZ TB JTBOH OH (BNPU QBEBEBMIBO LB OBNJO OH HBNPU "OH LBIVMVHBO OH step therapy MJIBN OB OBHTBTBCJ TB JZP UVOHLPM TB BZ LBJMBOHBOJO NPOH TVCVLBO BOH JTBOH NHB QBHCBCBHPOH JUP *MBMBHBZ EJO OBNJO HBNPU CBHP OBNJO TBTBLVQJO BOH JCBOH BOH NHB QBHCBCBHP TB BNJOH XFCTJUF TB HBNPU XXXIFBMUIOFUDPNDBMNFEJDPOOFDU 1BSB TB EBHEBH OB JNQPSNBTZPO TB NHB QBUBLBSBO TB HBNPU OB JUP UJOHOBO BOH 4. Ano ang mangyayari kapag nalaman QBIJOB JW naming hindi ligtas ang isang gamot? ,VOH TJOBCJ OH 'PPE BOE %SVH 4BTBCJIJO OBNJO TB JZP LBQBH BOH HBNPU OB "ENJOJTUSBUJPO '%" OB IJOEJ MJHUBT BOH JOJJOPN NP BZ JOBMJT NVMB TB -JTUBIBO OH HBNPU OB JOJJOPN NP BBMJTJO OBNJO JUP (BNPU 4BTBCJIJO EJO OBNJO TB JZP LBQBH BHBE TB -JTUBIBO OH (BNPU .BHQBQBEBMB CJOBHP OBNJO BOH NHB QBUBLBSBO OBNJO TB EJO LBNJ OH TVMBU TB JZP OB JZBO BOH QBHTBLPQ OH JTBOH HBNPU "OH NHB UBOPOH TJOBTBCJ ,VOH NBLBUBOHHBQ LB OH JTB TB BU TB JCBCB BZ NBZ NBT NBSBNJOH NHB MJIBN OB JUP NBOHZBSJOH UBXBHBO BOH JNQPSNBTZPO UVOHLPM TB LVOH BOP BOH EPLUPS NP QBSB QBHVTBQBO BOH NHB JCBOH NBOHZBZBSJ LBQBH OBHCBHP BOH -JTUBIBO PQTZPO TB HBNPU Og GaNPU ? Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/ calmediconnect. iii 5. Mayroon bang anumang restriksiyon • ,VOH JLBX BZ OBTB JTBOH OVSTJOH IPNF o limitasyon sa sakop sa gamot? O P JCBOH QBTJMJEBE TB QBOHNBUBHBMBOH may anubang inaatas na pagkilos na QBHBBMBHB BU LBJMBOHBO OH HBNPU OB XBMB gagawin upang makuha ang ilang mga TB -JTUBIBO OH (BNPU P LVOH IJOEJ NP gamot? NBEBMJOH NBLVIB BOH LBJMBOHBO NPOH 0P BOH JMBOH NHB HBNPU BZ NBZ NHB HBNPU NBLBLBUVMPOH LBNJ 4BTBLVQJO QBUBLBSBO TB TBLPQ P NBZ NHB MJNJUBTZPO OBNJO BOH BSBX OB FNFSIFOTJZBOH TB EBNJ OH NBLVLVIB NP 4B JMBOH NHB TVQQMZ OH LBJMBOHBO OJOZPOH HBNPU LBTP NBZ EBQBU LBOH HBXJO CBHP NP NBMJCBO LVOH NBZSPPO LBOH HBNPU NBLVIB BOH HBNPU )BMJNCBXB QBSB TB JMBOH BSBX JLBX NBO BZ CBHPOH NJZFNCSP P IJOEJ OH )FBMUI /FU • Paunang pag-apruba (o paunang $Bl MFEJ$POOFDU #JCJHZBO LB OJUP OH pahintulot): 1BSB TB JMBOH NHB HBNPU PSBT QBSB NBLJQBHVTBQ TB JZPOH EPLUPS JLBX P BOH JZPOH EPLUPS P JCBOH P JCBOH OBHSFSFTFUB .BUVUVMVOHBO LB OBHSFTFUB BZ EBQBU LVNVIB OH QBIJOUVMPU OJZBOH NBHEFTJTZPO LVOH NBZSPPOH NVMB TB )FBMUI /FU $Bl MFEJ$POOFDU LBUVMBE OB HBNPU TB -JTUBIBO OH (BNPU CBHP NP QVOBO BOH JZPOH SFTFUB ,BQBH OB NBBBSJ NPOH JOVNJO TB IBMJQ P IJOEJ LB OBLBLVIB BOH QBIJOUVMPU LVOH IJIJMJOH OH IJOEJ QBHTBTBNB NBBBSJOH IJOEJ TBLVQJO OH )FBMUI /FU .BOHZBSJOH UJOHOBO BOH 5BOPOH QBSB $Bl MFEJ$POOFDU BOH HBNPU TB LBSBHEBHBOH JNQPSNBTZPO UVOHLPM TB • Mga limitasyon sa dami: .JOTBO NHB IJOEJ LBTBNB OJMJMJNJUB OH )FBMUI /FU $Bl MFEJ$POOFDU BOH EBNJ OH HBNPU OB NBLVLVIB NP 6. Paano mo malalaman kung ang • Step therapy: .JOTBO BBUBTBO LB OH ninanais mong gamot ay mayroong )FBMUI /FU $Bl MFEJ$POOFDU OB HVNBXB mga limitasyon o kung mayroong mga OH TUFQ UIFSBQZ /BOHBOHBIVMVHBO JUP OB kailangang gawin na pagkilos para LBLBJMBOHBOJO NPOH TVCVLBO BOH NHB makuha ang gamot? HBNPU TB QBSUJLVMBS OB QBHLBLBTVOPE "OH -JTUBIBO OH NHB 4BLPQ OB (BNPU TB TVOPE QBSB TB JZPOH NFEJLBM OB QBIJOB BZ NBZ IBOBZ OB NBZ NBSLBOH LBMBHBZBO .BBBSJOH LBJMBOHBOJO NPOH i.HB LJOBLBJMBOHBOH QBHLJMPT QBHIJIJHQJU TVCVLBO BOH JTBOH HBNPU CBHP OBNJO P MJNJUBTZPO TB QBHHBNJUw TBTBLVQJO BOH JCBOH HBNPU ,VOH TB QBMBHBZ OH EPLUPS NP BZ IJOEJ HVNBHBOB 7. Ano ang mangyayari kung babaguhin BOH VOBOH HBNPU QBSB TB JZP TBTBLVQJO namin ang aming mga tuntunin sa OBNJO BOH QBOHBMBXB kung paano namin sinasakop ang .BMBMBNBO NP LVOH BOH HBNPU NP BZ ilan sa mga gamot? Halimbawa, NBZ BOVNBOH NHB LBSBHEBHBOH JOBBUBT kung magdadagdag kami ng P NHB MJNJUBTZPO TB QBNBNBHJUBO OH paunang pahintulot (pag-apruba), QBHUJOHJO TB NHB UBMBIBOBZBO TB QBIJOB o mga limitasyon sa dami at/o mga *OEJTF .BLBLBLVIB LB SJO OH IJHJU QBOH paghihigpit ng step therapy sa isang JNQPSNBTZPO TB QBNBNBHJUBO OH QBHCJTJUB gamot.