2017 Prescription Drug Formulary High Performance Plus PLEASE READ: This document contains information about the drugs we cover in your plan. This formulary was updated 12/2017. C2383-RXX R12/17 7Multi-LanguageKLVGRFXPHQWQRWL¿HVLQ GInterpreterLYLGXDOVRIKRZ WRServicesVHHNDVVLVWD QFHLIWKH\VSHDNDODQJXDJHRWKHUWKDQ(QJOLVK & Nondiscrimination Notice $7(1&,Ï16LKDEODHVSDxROWLHQHDVXGLVSRVLFLyQ ;,<<(())$11$$$IDDQGXEEDWWX2URRPLIID SpanishVHUYLFLRVJUDWXLWRVGHDVLVWHQFLDOLQJtVWLFD/ODPHDO OromoWDMDDMLODJDUJDDUVDDIDDQLLNDQIDOWLLGKDDQDODQL 77< DUJDPD%LOELODD 77< 㽷㎞Ⱁ㨫㌷∎䞷僐浣₼㠖㌷♾ⅴ⏜彊䘁㈦崭岏㚃┸㦜 늱넍뼑霢꽩ꌱꩡ끞뼍겑鱉陲끥꽭꽩덵낅꫑ꟹ걙ꌱ ╨ᇭ嵚咃榊Chinese 77< ᇭ Koreanꓩꊁꈑ넩끞뼍겙ꯍ넽걪鱽鲙 77< ꘽냱ꈑ놹쀉뼩늱겢겑꿙 1-800-382-5729 $&+781*:HQQ6LH'HXWVFKVSUHFKHQVWHKHQ German,KQHQNRVWHQORVVSUDFKOLFKH+LOIVGLHQVWOHLVWXQJHQ]XU $77(1=,21(,QFDVRODOLQJXDSDUODWDVLDO¶LWDOLDQR 9HUIJXQJ5XIQXPPHU 77< ItalianVRQRGLVSRQLELOLVHUYL]LGLDVVLVWHQ]DOLQJXLVWLFDJUDWXLWL &KLDPDUHLOQXPHUR 77< ᦺᦿᦎᦳҫ᧎᥸᥷ᥴ᝔᧎ᦰᧀᦿҫҭᦊᦫ᥮ᦔᧄᦿҫҮ᥮ᧃᦊᦇӅᥨᦳҢᥴᦰᧀᦿҫᦎᦻҴҫүᦊᦄ᥸᥷᥶ᧈᦻҫҴҩᥴᦧ᧎ᦄᧀᧃ Arabic ᧂᦼᥲᦿҫӇᧂᦜᦿҫᦲ᥷᥮ᜣᧂᦷҵ ᧂᦷᦎᥱᦾᦜ᥷ҫӅ᥮ᦀᧄᦿ᥮ᥱ 㽷㎞ℚ檔㡴㦻崭ት崀ሸቯቮ⫃⚗ᇬ䎰㠨ቑ岏崭㞾㚃ት JapaneseሷⒸ䞷ሧቂቃሴቡሼᇭ 77< ቡ 711 1-800-382-5729 ቊᇬር榊崀቎቉ሷ抲俰ሲቃሸሧᇭ :DQQGX'HLWVFKVFKZHW]VFKWNDQQVFKWGXPLWDXV.RVFKWH HPennsylvaniaEEHUJULFNHDVV DutchGLKUKHOIWPLWGLHHQJOLVFK6FKSURRFK5XI VHOOL1XPPHUXII&DOO 77< $$1'$&+7$OVXQHGHUODQGVVSUHHNWNXQWXJUDWLV DutchJHEUXLNPDNHQYDQGHWDDONXQGLJHGLHQVWHQ%HO 77< ȼɇɂɆȺɇɂȿȿɫɥɢɜɵɝɨɜɨɪɢɬɟɧɚɪɭɫɫɤɨɦɹɡɵɤɟ ɬɨɜɚɦɞɨɫɬɭɩɧɵɛɟɫɩɥɚɬɧɵɟɭɫɥɭɝɢɩɟɪɟɜɨɞɚRussian Ɂɜɨɧɢɬɟ ɬɟɥɟɬɚɣɩ ɍȼȺȽȺəɤɳɨɜɢɪɨɡɦɨɜɥɹɽɬɟɭɤɪɚʀɧɫɶɤɨɸɦɨɜɨɸɜɢ Ukrainianɦɨɠɟɬɟɡɜɟɪɧɭɬɢɫɹɞɨɛɟɡɤɨɲɬɨɜɧɨʀɫɥɭɠɛɢɦɨɜɧɨʀ ɩɿɞɬɪɢɦɤɢɌɟɥɟɮɨɧɭɣɬɟɡɚɧɨɦɟɪɨɦ $77(17,216LYRXVSDUOH]IUDQoDLVGHVVHUYLFHV ɬɟɥɟɬɚɣɩ FrenchG¶DLGHOLQJXLVWLTXHYRXVVRQWSURSRVpVJUDWXLWHPHQW $SSHOH]OH $76 $7(17 ,('DFăYRUELWLOLPEDURPkQăYăVWDXOD RomanianGLVSR]LWLHVHUYLFLLGHDVLVWHQWăOLQJYLVWLFăJUDWXLW &+Òé1ӃXEҥQQyL7LӃQJ9LӋWFyFiFGӏFKYөKӛWUӧQJ{QQJӳ 6XQDWLOD 77< VietnamesePLӉQSKtGjQKFKREҥQ*ӑLVӕ 77< 1-800-382-5729 3$81$:$.XQJQDJVDVDOLWDNDQJ7DJDORJPDDDUL 'ttEDDDNyQtQt]LQ'ttVDDGEHH\iQtáWL¶JR'LQp TagalogNDQJJXPDPLWQJPJDVHUELV\RQJWXORQJVDZLNDQDQJ Navajo%L]DDGVDDGEHHiNi¶iQtGD¶iZR¶GĊǯĊǯ¶W¶iiMLLN¶HKpt ZDODQJED\DG7XPDZDJVD 77< QiK OƭvNRMñಬKµGttOQLK 77< Ordeór Number: Z8188-MCA R 11/16 Dept of Ins. Filing Number: Z8188-MCA R9/16 QUESTIONS ABOUT YOUR BENEFITS OR OTHER INQUIRIES ABOUT YOUR HEALTH INSURANCE SHOULD BE DIRECTED TO MEDICAL MUTUAL’S CUSTOMER CARE DEPARTMENT AT 1-800-382-5729. Nondiscrimination Notice Medical Mutual of Ohio complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex in its operation of health programs and activities. Medical Mutual does not exclude people or treat them differently because of race, color, national origin, age, disability or sex in its operation of health programs and activities. Q Medical Mutual provides free aids and services to people with disabilities to communicate effectively with us, such as qualied sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, etc.). Q Medical Mutual provides free language services to people whose primary language is not English, such as qualied interpreters and information written in other languages. If you need these services or if you believe Medical Mutual failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, with respect to your health care benets or services, you can submit a written complaint to the person listed below. Please include as much detail as possible in your written complaint to allow us to effectively research and respond. Civil Rights Coordinator Medical Mutual of Ohio 2060 East Ninth Street Cleveland, OH 44115-1355 MZ: 01-10-1900 Email: [email protected] You can also le a civil rights complaint with the U.S. Department of Health and Human Services, Ofce for Civil Rights. U.S. Department of Health and Human Services Q Electronically through the Ofce for Civil Rights Complaint Portal available at: 200 Independence Avenue, SW Room 509F ocrportal.hhs.gov/ocr/portal/lobby.jsf Q ByWashington, mail at: DC 20201-0004 U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F (800) 368-1019 (TDD: (800) 537-7697) HHH Building Washington, DC 20201-0004 Q By phone at: (800) 368-1019 (TDD: (800) 537-7697) Q Complaint forms are available at: hhs.gov/ocr/ofce/le/index.html Products marketed by Medical Mutual may be underwritten by one of its subsidiaries, such as Medical Health Insuring Corporation of Ohio or Consumers Life Insurance Company. High Performance Plus Formulary What is the High Performance Plus When you visit your doctor or health provider, formulary? ask him or her to review this formulary at The High Performance Plus formulary is a list of MedMutual.com/2017drugs so he or she can medications covered by your plan. It includes a see what medications are covered by your plan. variety of clinically effective medications that may cost you less than other options used to What if my doctor prescribes a medication treat the same condition. The formulary that is not on the High Performance Plus includes five tiers: formulary? 1. Generic (lowest out-of-pocket cost) Talk with your doctor or health provider to see if 2. Preferred brand the formulary includes a medication to treat 3. Non-preferred brand your condition. In most cases, your provider will 4. Specialty (highest out-of-pocket cost) find one that meets your needs. 5. Preventive ($0 out-of-pocket cost) In the rare instance that none of the covered Refer to your Certificate or Benefit Book for medications is appropriate for you and a non- information about your cost share, including formulary medication is required, your provider copays, coinsurance and/or deductibles. Not all can contact Express Scripts at (800) 753-2851 tiers apply to all plans. and ask for a formulary coverage review. Your provider will receive a form to fill out and fax If you are a member of a plan that includes a back to Express Scripts. Express Scripts will preferred pharmacy network (e.g., CLE-Care), send you and your doctor a letter confirming if those preferred pharmacies may offer lower coverage is approved (usually within three cost sharing to help you save money. Check business days of receiving the necessary your benefit materials for more details. information). If an exception is made based on medical necessity, you will only pay your plan’s If a medication is not listed on this formulary, it applicable cost share (e.g., non-preferred will generally not be covered under the plan, brand, specialty). If your provider does not and you will pay the full cost. request a coverage review and you fill a prescription for a non-formulary medication, you How do I use the High Performance Plus will pay the full cost. formulary? Covered medications are organized two ways in How can I find a covered alternative if my the High Performance Plus formulary: medication is not on the formulary? 1. By condition If you cannot find your current medication on 2. By name the High Performance Plus formulary, you can find covered alternatives in two ways: If you know what your medication is used to 1. Visit MedMutual.com/member and log in to treat, you can look it up by condition in the front My Health Plan. of the document. If you don’t know what • Click Benefits & Coverage, then condition it is used to treat, you can look for it in Prescription Drug Benefits. the alphabetical Index at the back of the • Click the Sign on to Express Scripts document. button. Once you are redirected to the Express Scripts website, click Manage Prescriptions, then Save with My Rx Does the High Performance Plus formulary Choices. include contraceptives? • Type the name of your medication in the Yes. Certain prescription contraceptives are Search bar to see covered alternatives. included on the High Performance Plus formulary at a $0 cost share. Prior 2. Call the Rx Member Services number on authorization, step therapy and quantity limit your Medical Mutual ID card. A Member programs may apply. If your provider feels none Services Representative can offer covered of the covered contraceptives on the High clinically appropriate alternatives. Performance Plus formulary is right for you, he or she may contact our pharmacy benefit Does the High Performance Plus formulary manager to request a formulary coverage include generics? review. If an exception is made to cover a non- Yes. The High Performance Plus formulary formulary contraceptive based on medical includes a large variety of generic medications necessity, Medical Mutual will cover that to help you pay less out of pocket. Generics are contraceptive. You will pay your plan’s shown in lower-case italic letters. applicable cost share. Generic medications are approved by the U.S. Do I have to use mail order for my Food and Drug Administration (FDA) as having maintenance medications? the same active ingredient as their brand-name If you are a member of a CLE-Care plan, you counterparts. In addition, the FDA requires must fill mail-order medications through the generics to be just as safe and strong as their MetroHealth Central Fill Pharmacy. Visit brand-name counterparts so you get the same metrohealth.org/pharmacy for more information medical benefit. and to download a form. Does the High Performance Plus formulary If you are NOT a member of a CLE-Care plan, include brand medications? you may be required to use mail order for your Yes. The High Performance Plus formulary maintenance medications