2019 Golden State Medicare Health Plan Los Angeles, Orange, Riverside, and Stanislaus Counties This Formulary was updated on 7/01/19. For more recent information or other questions, please Drug Formulary contact Golden State Medicare Health Plan at (877) 541-4111 or, for TTY users, 711, 8am to 8pm Monday through Friday and daily during the enrollment periods, or visit www.gsmhp.com. Este formulario abreviado se actualizó el 7/01/19. Para obtener información más reciente o otras preguntas, por favor póngase en contacto con Golden State Medicare Health Plan al (877) 541- 4111. H2241_1085_C_2019 Accepted Golden State Medicare Health Plan 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Golden State Medicare Health Plan. When it refers to “plan” or “our plan,” it means Golden State (HMO). This document includes list of the drugs (formulary) for our plan which is current as of 7/01/19. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year. Golden State Medicare Health Plan is an HMO plan with a Medicare contract. Enrollment in Golden State Medicare Health Plan depends on contract renewal. H2241_1085_C_2019 Accepted Formulary ID: 00019167 Version Number: 11 Last Updated: July 2019 2 Golden State Medicare Health Plan 2019 Formulario (Lista de medicamentos cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS DROGAS QUE CONTEMPLAMOS EN ESTE PLAN Nota para los miembros existentes: Este formulario ha cambiado desde el año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma. Cuando esta lista de medicamentos (formulario) se refiere a "nosotros", "nosotros" o "nuestro", significa Golden State Medicare Health Plan. Cuando se refiere a "plan" o "nuestro plan", significa Golden State Medicare Health Plan. Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que está vigente el 7/01/19. Para obtener un formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos por última vez el formulario, aparece en las portadas de la portada y la parte de atrás. En general, debe utilizar las farmacias de la red para usar su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias y/o copagos/coseguro pueden cambiar el 1 de enero de 2020 y de vez en cuando durante el año. Golden State Medicare Health Plan es un plan HMO con un contrato de Medicare. La inscripción en Golden State Medicare Health Plan depende de la renovación del contrato. El Formulario puede cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario. ID del Formulario: 00019167 Número de version:11 Última actualización: Julio 2019 3 Golden State Medicare Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. (Spanish) Golden State Medicare Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. (Chinese) Golden State Medicare Health Plan 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血 統、年齡、殘障或性別而歧視任何人。 (Vietnamese) Golden State Medicare Health Plan tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính. (Tagalog) Sumusunod ang Golden State Medicare Health Plan sa mga naaangkop na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan o kasarian. (Korean) Golden State Medicare Health Plan 은(는) 관련 연방 공민권법을 준수하며 인종, 피부색, 출신 국가, 연령, 장애 또는 성별을 이유로 차별하지 않습니다. (Armenian) Golden State Medicare Health Plan -ը հ ե տև ո ւ մ է ք աղ աք աց ի ակ ան ի ր ավ ո ւ ն ք ն ե ր ի մ աս ի ն գ ո ր ծ ո ղ դ աշ ն այ ի ն օ ր ե ն ք ն ե ր ի ն և խտր ակ ան ո ւ թ յ ո ւ ն չ ի ց ո ւ ց աբ ե ր ո ւ մ ՝ ռ աս այ ի , մ աշ կ ի գ ո ւ յ ն ի , ազ գ այ ի ն պատկ ան ե լ ո ւ թ յ ան , տար ի ք ի , հ աշ մ ան դ ամ ո ւ թ յ ան կ ամ ս ե ռ ի հ ի մ ան վ ր ա. اﺳﺎس ﺑﺮ تبعیضی هیچگونه و کﻧﺪ می تبعیت ﻣﺮبوطه فدرال مدﻧﯽ حقوق قوانین از Plan Health Medicare State Golden (Farsi) .شود نﻣﯽ قایل اﻓﺮاد جنسیت یا ناتوانی ،ﺳﻦ ،ملیتی اصلیت ،پوست رنگ ،نژاد (Russian) Golden State Medicare Health Plan соблюдает применимое федеральное законодательство в области гражданских прав и не допускает дискриминации по признакам расы, цвета кожи, национальной принадлежности, возраста, инвалидности или пола. (Japanese) Golden State Medicare Health Plan は適用される連邦公民権法を遵守し、人種、肌の色、出身 国、年齢、障害または性別に基づく差別をいたしません。 األصل اﻟﻌﺮق أﺳﺎس ﻋﻞى یﻣﯿﺰ وال بھﺎ المعمول الفدرالیة اﻟﻤﺪنیة اﻟﺢقوق ﺑﻘﻮانین Plan Health Medicare State Goldenﯾﻠﺘﺰم اﻟﻮطﻨﻲ أو (Arabic) .اﻟﺞنس أو اإلعاقة أو اﻟﺲن (Punjabi) Golden State Medicare Health Plan ਲਾਗੂ ਸੰਘੀ ਨਾਗਿਰਕ ਹੱਕਾਾਂ ਦੇ ਕ ਾ ਨੰ ◌ੂਨਾਾਂ ਦੀ ਪਾਲਣਾ ਿਕਦੀ ਹੈ ਅਤੇ ਨਸਲ , ਿ◌◌ੰਗ ,ਿ◌◌ਾਸ਼ਿਟ◌ੀ ਮੂਲ ,ਉਿਮ ,ਅਸਮਿ◌ਥਤ◌ਾ ,ਜ◌ਾ◌ਾ◌ਂ ਰਲ◌ੰ ਗ' ਤ◌ੇ ਅਧਾਿ◌' ਤ◌ੇ ਰਿ◌ਤਕਿ◌◌ਾ ਨਹ◌ੀ ◌ਾ◌ਂ ਕਿ◌ਦ◌ੀ ਹੈ। . (Cambodian) Golden State Medicare Health Plan អន◌ុវត◌្ត�មច�ប់ស◌ិទ◌្ធ◌ិពលរដ◌្ឋននសហពនធ ដដ◌្លសមរមយនិងមិន �ន�រររសរេអើសរលម◌ូ លដ� ឋ ន ននព◌ូ ជ�សន◌៍ ពណ៌សមបរ ស�� ◌ា ត្◌ិរដ◌្េ◌ើម �យុ ព◌ិ�រភ◌ាព ឬរេ◌ទ◌្។ (Hmong) Golden State Medicare Health Plan ua raws cov kev cailij choj yuam siv ntawm Tsom Fwv Nrub Nrab Teb Chaw hais txog pej xeem cov cai (Federal civil rights laws) thiab tsis ciav-cais leejtwg vim nws hom neeg, nqaij tawv, lub tebchaws tuaj, hnub nyoog, kev tsis taus, los yog poj niam txiv. (Hindi) Golden State Medicare Health Plan लागू ह◌ोन◌े य◌ोग्य स◌ं घ ी य न◌ागरि◌क अधि◌क◌ाि◌ क़◌ानून का प◌ालन कि◌त◌ा ह◌ै औि◌ जाधत, ि◌◌ं ग, ि◌◌ा�� ीय म◌ू ल , आय◌ु , िधकल◌ा◌ं ग त ा , य◌ा ललग क◌े आि◌◌ाि◌ िप भेदभाि◌ नह◌ ी ◌ं कि◌त◌ा ह।◌ै (Thai) Golden State Medicare Health Plan ไดปฏ◌ิบต◌ั ญต◌ั ◌ิดา◌้ นส◌ิทธ◌์◌ิท◌ี◌่เหมาะสม และไม◌่ไดแ◌้ บ◌่งแยกทางชาต◌ิพนธ◌ุ◌์ ◌ิตามร◌ัฐบญ ทุพพลภาพ หรือเพศ ส◌ี ผ◌ิว เช◌้◌ือชาต◌ิ อาย◌ุ ความ What is the Golden State Medicare Health Plan Formulary? A formulary is a list of covered drugs selected by Golden State Medicare Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Golden State Medicare Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Golden State Medicare Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: • New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier andwith the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Golden State Medicare Health Plan Formulary?” • Drugs removed from the market.