Portfolio Medium – Preferred Drug List (PDL) MemorialCare Select Health Plan Applies to: MemorialCare Select Members Last Updated: February 2021 Please note the formulary is subject to change and all previous versions of the formulary will no longer be in effect. To Access MemorialCare Select Pharmacy information: https://www.memorialcareselecthealthplan.org/access-information To Access MemorialCare Select EOC: https://www.memorialcareselecthealthplan.org/seaside-select-member-services Table of Contents Informational Section................................................................................................................................2 Alternative Therapy - Vitamins and Minerals............................................................................................8 Analgesic, Anti-inflammatory or Antipyretic - Drugs for Pain and Fever...................................................8 Anesthetics - Drugs for Pain and Fever................................................................................................. 33 Anorectal Preparations - Rectal Preparations........................................................................................ 34 Antidotes and other Reversal Agents - Drugs for Overdose or Poisoning............................................. 35 Anti-Infective Agents - Drugs for Infections............................................................................................ 37 Antineoplastics - Drugs for Cancer.........................................................................................................60 Antiseptics and Disinfectants - Antiseptics and Disinfectants................................................................ 72 Biologicals - Biological Agents............................................................................................................... 72 Cardiovascular Therapy Agents............................................................................................................. 80 Cardiovascular Therapy Agents - Drugs for the Heart........................................................................... 81 Central Nervous System Agents - Drugs for the Nervous System.......................................................102 Chemical Dependency, Agents to Treat - Drugs for Addiction.............................................................146 Chemicals-Pharmaceutical Adjuvants..................................................................................................148 Cognitive Disorder Therapy - Drugs for the Nervous System.............................................................. 149 Contraceptives - Drugs for Women...................................................................................................... 151 Dermatological..................................................................................................................................... 165 Dermatological - Drugs for the Skin..................................................................................................... 165 Diagnostic Agents................................................................................................................................ 217 Drugs to treat Erectile Dysfunction - Drugs for the Urinary System..................................................... 217 Eating Disorder Therapy...................................................................................................................... 218 Eating Disorder Therapy - Drugs for Eating Disorders.........................................................................218 Electrolyte Balance-Nutritional Products - Drugs for Nutrition..............................................................220 Endocrine - Hormones......................................................................................................................... 224 Enzymes - Vitamins and Minerals........................................................................................................ 258 FDB Class Obsolete-Not Used.............................................................................................................258 Gastrointestinal Therapy Agents - Drugs for the Stomach...................................................................259 Genitourinary Therapy - Drugs for the Urinary System........................................................................ 276 Gout and Hyperuricemia Therapy - Drugs for Pain and Fever.............................................................282 Hematological Agents - Drugs for the Blood........................................................................................ 283 Hepatobiliary System Treatment Agents - Drugs for the Liver............................................................. 297 Immunosuppressive Agents - Drugs for Organ Transplants................................................................ 297 Locomotor System - Drugs for Muscles, Ligaments, Tendons, and Bones..........................................299 Medical Supplies and Durable Medical Equipment (DME) - Medical Supplies and Durable Medical Equipment............................................................................................................................................ 301 Medical Supply, FDB Superset............................................................................................................ 378 Metabolic Disease Enzyme Replacement Agents - Drugs for Metabolic Disease............................... 423 Metabolic Modifiers.............................................................................................................................. 423 Metabolic Modifiers - Drugs that Alter Metabolism...............................................................................423 Mouth-Throat-Dental - Preparations - Drugs for the Mouth and Throat............................................... 426 Multiple Sclerosis Agents - Drugs for the Nervous System..................................................................430 Ophthalmic Agents - Drugs for the Eye................................................................................................432 Organ Preservation Solutions.............................................................................................................. 446 Organ Preservation Solutions - Drugs for the Heart.............................................................................446 Otic (Ear) - Drugs for the Ear............................................................................................................... 448 Respiratory Therapy Agents - Drugs for the Lungs..............................................................................449 Vaginal Products - Drugs for Women...................................................................................................466 TOC-1 FORMULARY INFORMATION What is a Formulary? The Formulary provides a list of covered generic and brand name drugs selected by physician and pharmacist subject matter experts who collaboratively support MedImpact’s Pharmacy and Therapeutics (P&T) Committee. This Formulary does not apply to drugs or devices that are obtained through the medical benefit portion of your coverage. The plan will cover drugs listed in the formulary as long as the drug is indicated for the clinical condition, is prescribed in the appropriate manner, the prescription is filled at a participating network pharmacy, and other plan rules are followed. The presence of a prescription drug on the formulary does not guarantee an enrollee will be prescribed that prescription drug by his or her prescribing provider for a particular medical condition. For more information regarding the Formulary or your prescription drug benefit, please contact your plan’s Member Services department at (855) 367- 7747, or for the hearing and speech impaired TTY: 711, Monday through Friday, between 8:00 am – 5:00 pm PST, or refer to your Plan Benefit Documents, available at https://www.memorialcareselecthealthplan.org. Can the Formulary (drug list) change? Drugs may be added or deleted from the Formulary during the policy year, and the Formulary will be updated with any changes on a monthly basis. Changes will be effective on the first day of the month. If there is a change in drug or dosage form, if a drug is removed from the Formulary, if prior authorization, quantity limits and/or step therapy restrictions are added to a drug, or if a drug moves to a higher cost sharing tier, the plan will notify affected enrollees of the change before the change becomes effective. If the FDA deems a drug on the formulary to be unsafe or the drug’s manufacturer removes the drug from the market, the plan will immediately remove the drug from the formulary. The Formulary is subject to change and all previous versions of this formulary are no longer in effect. How does a member fill a prescription? To obtain drugs at a participating pharmacy, the enrollee must present his or her pharmacy benefit plan identification card. Except for covered emergencies, claims for drugs obtained without using the identification card will be denied. To locate a participating pharmacy (including specialty pharmacies), check the cost-sharing for a particular drug, or enroll in mail-order, visit https://www.memorialcareselecthealthplan.org . Your plan benefits may restrict coverage of specialty drugs only when obtained from a Network Specialty Pharmacy, except in case of an emergency. What are generic drugs? The plan covers both brand name