2020 Drug Formulary CHPW_RX_311_08_2020_Medicaid_Formulary_SEP COMMUNITY HEALTH PLAN of WASHINGTON 2020 DRUG FORMULARY The Community Health Plan of Washington (CHPW) drug formulary is developed by a Pharmacy and Therapeutics Committee. For medications included in the Apple Health Preferred Drug List, formulary status and coverage criteria are developed and approved by the Washington State Authority (HCA) Pharmacy and Therapeutics Committee before adoption by CHPW. All other medications’ formulary status and coverage criteria are developed and approved by the CHPW Pharmacy and Therapeutics Committee. The formulary is searchable on the website at http:// chpw.org/for-members/pharmacy. For more information on the Apple Health Preferred Drug List, please visit: https://www.hca.wa.gov/billers-providers-partners/programs-and-services/apple- health-preferred-drug-list-pdl. The Formulary may change at any time. For updates regarding periodic changes to the Formulary and other pharmaceutical management programs please check our website at www.chpw.org/for-members/pharmacy. This Drug Formulary is intended for use by our providers and pharmacies and applies only to medications prescribed to our members and dispensed by participating network pharmacies. The Formulary does not apply to inpatient medications. Generic Drug Policy Community Health Plan of Washington utilizes a mandatory generic policy. This means that unless specified, the brand product won’t be covered without adequate trial and documented failure of the formulary generic product. Only when generic substitution conflicts with state regulations or restrictions, the pharmacist must gain approval from the prescriber to use the generic equivalent. OTC Medication Policy Some Over-The-Counter (OTC) products are covered with a written prescription. If a prescription product is available in the identical strength, dosage form, and active ingredient(s) as an OTC product, the prescription product will not be covered. In these instances, providers and pharmacists should refer members to the OTC equivalent product. If the member or provider insists on the prescription equivalent product, the member must pay the entire cost of the prescription. Age Restrictions Age restrictions apply to selected drugs. These drugs are covered without prior authorization for specific age ranges but otherwise require prior authorization. Mental health medications outside of HCA mandated age/dose limits Tretinoin—covered for members under 30 years old Opioid prescriptions outside of HCA mandated age/dose limits 1 Second Opinion Network (SON) Community Health Plan of Washington has adopted Washington State Health Care Authority medication review thresholds for certain psychotropic medications for children under 18 years old. Clients currently receiving medications outside of these medication review thresholds will be allowed to continue, regardless of previous payer (whether HCA FFS, the plan themselves, or a previous payer prior to the client becoming a Medicaid enrollee). Clients being prescribed medications for the first time, or receiving prescriptions for dose escalations which exceed thresholds, will have those prescriptions denied by the managed care plans, and referred to HCA for initiation of the second opinion review process. After completion of the second opinion review, the managed care plan will receive a copy of the SON written recommendation, and approve or deny future prescriptions accordingly. Exception Request The health care professionals consulted in the development of this Formulary attempted to include medications for all therapeutic needs. Providers are expected to comply with the Drug Formulary when prescribing medications for plan members. If a patient requires a medication that is not covered, the provider may request an exception to allow payment for the non-covered medication. It is anticipated that such exceptions will be rare, and that most of the time, providers should be able to find a Formulary medication for the vast majority of therapeutic needs. However, if providers desire a non-covered product for members, they must call or submit a request explaining the necessity, past therapeutic failures and patient identification (name, address and Community Health Plan of Washington member number). Prior Authorization To promote the most appropriate utilization, selected high-risk or high-cost medications require prior authorization to be eligible for coverage. Prior authorization criteria have been developed using current, published, peer-reviewed, medical literature, as well as input from local providers. The prior authorization criteria are approved by the P&T Committee. The Formulary medications that require prior authorization are identified by a “PA” following their name. Most authorizations are good for one year; after that, the drugs listed here will need to be reauthorized. Drugs may be added or deleted from this list as deemed necessary. Prior Authorization Requests: Non Formulary and Prior Authorization requests must be directed to: Express Scripts Attn: Prior Authorization Mail Stop B401-03 8640 Evans Road St. Louis, MO 63134 Phone: 844-605-8168 Fax: 877-251-5896 Electronic Prior Authorization requests can be submitted through: www.express-scripts.com/PA 2 Step Therapy Step-­­therapy promotes appropriate utilization of first line drugs and/or therapeutic categories. Step-­­ therapy requires that participants receive one or more first-­­line drug(s), as defined by program criteria, before prescriptions are covered for second-­­line drugs. All step-­­therapy programs are supported by prior authorization criteria to determine coverage in the event that a participant does not meet the automated, on-­­line step-­­therapy criteria and coverage of a second line product is medically necessary. Benefit Exclusions Drugs in the following categories are not available as benefits of the plan: Non-­­FDA approved drug products Medications will be eligible for coverage only if they are FDA-­­ approved prescription medications used for non-­­experimental indications. Experimental and Investigational (E & I) drugs These are drugs that do not have FDA-­­ approved indication(s) for use, or other indications that are considered effective based on published scientific evidence. Compounded drugs with non-­­FDA approved ingredients (e.g. Estriol used in Bi-­­Est and Tri-­­Est) Samples Members started on samples of a non-­­formulary drug are not guaranteed coverage for that drug. Drugs for weight loss or appetite suppression (e.g. Xenical) Drugs for impotence or sexual dysfunction (e.g.Viagra) Drugs to treat cosmetic issues (e.g.Rogaine) Infertility drugs Prescription drugs that are equivalent to OTC medications or with an OTC add on (Some OTC medications are covered for Apple Health.) Benefit Information: Retail Pharmacy A 30 day supply is allowed at all network retail pharmacies and a 90-day supply of select generic maintenance medications at select pharmacies. Mail Order Pharmacy Contact Walmart pharmacy at 1-800-273-3455 to get your medications sent to you. Copay Determinations There is no copay or deductible for formulary products for Apple Health. OTC products: Only certain OTC products are covered for Community Health Plan of Washington members as determined by the Apple Health Preferred Drug List. 3 Formulary Legend: Generic drugs are listed in lower case BRAND drugs are listed in UPPER case Tier 1: Preferred. No limits. Tier 2: Preferred. With limits. Tier 3: Non Preferred. Tier 4: Medical Benefit. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, there are limits on the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 4 COMMUNITY HEALTH PLAN OF WASHINGTON FORMULARIO DE MEDICAMENTOS 2020 El Formulario de medicamentos de Community Health Plan of Washington (CHPW) es desarrollado por el Comité de Farmacia y Terapéutica (P&T). Para los medicamentos incluidos en la Lista de medicamentos preferidos de Apple Health, el Comité de Farmacia y Terapéutica de la Autoridad de Atención Médica de Washington (HCA) desarrolla y aprueba el estado del formulario y el criterio de cobertura antes de que CHPW los adopte. El resto de los criterios de cobertura y de los estados de los formularios de medicamentos son desarrollados y aprobados por el Comité de Farmacia y Terapéutica de CHPW. El formulario se puede consultar en el sitio web http://chpw.org/for-members/pharmacy. Para obtener más información sobre la Lista de medicamentos preferidos de Apple Health, visite https://www.hca.wa.gov/billers-providers-partners/programs-and-services/apple-health- preferred-drug-list-pdl. El Formulario puede cambiar en cualquier momento. Para acceder a los cambios periódicos en el Formulario y otros programas de administración de productos farmacéuticos, visite nuestro sitio web en www.chpw.org/for-members/pharmacy. Este Formulario de medicamentos está destinado a nuestros proveedores y farmacias, y se aplica solo a los medicamentos