MDwise Formulary Introduction – Healthy Indiana Plan Basic (HIP Basic) HIP members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular Disease”. Then look under the category name for your drug. Alphabetical Listing The Index provides an alphabetical list of all of the drugs included in this formulary. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. The formulary provides coverage information about drugs covered by the plan. If you have trouble finding your drug in the list, turn to the Index. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the Index, either by generic or proprietary name or by therapeutic drug category. In situations where an FDA-approved generic equivalent is available, brand names are listed for reference purposes only, and do not denote coverage for the brand name, unless specifically noted. All drugs are listed in each category in alphabetical order by generic name. Where an FDA-approved generic is available for the listed generic name, the generic name is bolded. A generic drug has the same active-ingredient as the brand name drug. Generic drugs usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA), which assures that the following conditions are met. • The generic drug must contain the same active ingredients, be the same strength, and the same dosage form as the brand name drug. • The FDA has given an “A” rating compared to the brand name drug and thus the generic drug is determined to be therapeutically bioequivalent. • When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Additional Requirements Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: MDwise requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from the pharmacy benefits manager (MedImpact) before you fill your prescription. If you don’t get approval, the drug may not be covered. Drugs that are subject to a prior authorization will have a “PA” symbol next to the drug. Physicians and Pharmacies call (844) 336-2677 or FAX: (858) 790-7100. • Quantity Limits: For certain drugs, the plan limits the amount of the drug that is covered. Drugs that are subject to a quantity limit will have a “QL” symbol next to the drug. • Refill Limitations: Prescriptions may be refilled when 75% or more of the days’ supply has been used. • Step Therapy: In some cases, the plan requires you to first try certain drugs to treat your medical condition before it 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. Drugs that are subject to Step Therapy will have a “ST” symbol next to the drug. • Age Limit: In some cases, drugs are only available to a member in a select age category. Drugs that are subject to an Age Limit will have an “AGE” symbol next to the drug. • Gender Limit: Some drugs are only available to members of a certain gender. Drugs that are available to only a certain gender will have a “G” symbol next to the drug. You can find out if your drug has any additional requirements or limits by looking in the formulary starting on the next page. If you have any additional questions, please visit our website at mdwise.org or contact the customer service center at (844) 336-2677. Table of Contents Allergy....................................................................................................................................................................................... 3 Antiemesis/Antivertigo...............................................................................................................................................................6 Asthma And Copd..................................................................................................................................................................... 6 Autonomic Nervous System Disorders................................................................................................................................... 11 Behavioral Health - Antidepressants.......................................................................................................................................12 Behavioral Health - Other........................................................................................................................................................14 Cardiovascular Disease - Arrhythmia......................................................................................................................................23 Cardiovascular Disease - Cardiac Stimulant...........................................................................................................................23 Cardiovascular Disease - Hypertension..................................................................................................................................23 Cardiovascular Disease - Lipid Irregularity............................................................................................................................. 27 Cardiovascular Disease - Miscellaneous Agents.................................................................................................................... 35 Cardiovascular Disease - Vasodilation................................................................................................................................... 35 Contraception/Oxytocics......................................................................................................................................................... 36 Cough And Cold......................................................................................................................................................................41 Dermatology - Acne................................................................................................................................................................ 51 Dermatology - Antiinfective..................................................................................................................................................... 53 Dermatology - Antiinflammatory..............................................................................................................................................57 Dermatology - Antipruritic Drugs............................................................................................................................................. 60 Dermatology - Miscellaneous..................................................................................................................................................60 Dermatology - Pigmentation Disorders................................................................................................................................... 72 Dermatology - Psoriasis/Eczema............................................................................................................................................ 72 Diabetes.................................................................................................................................................................................. 74 Ear - General Disorders.......................................................................................................................................................... 80 Electrolyte Regulation............................................................................................................................................................. 81 Endocrine Disorder - Fertility...................................................................................................................................................83 Endocrine Disorder - Other..................................................................................................................................................... 83 Endocrine Disorder - Thyroid.................................................................................................................................................. 86 Eye - General Disorders..........................................................................................................................................................87 Eye - Glaucoma...................................................................................................................................................................... 89 Eye - Miscellaneous...............................................................................................................................................................