DRUG FORMULARY QUALIFIED HEALTH PLANS EFFECTIVE JANUARY 1, 2017 LAST UPDATED DECEMBER 1, 2017 INTRODUCTION As a general rule, generic drugs have the lowest This is the Health Alliance Drug Formulary for member copayment. Typically, when a generic Qualified Health Plans (also known as the health enters the market the brand drug moves to Tier 3. insurance “exchange” plans). In order to assist Members who choose the brand name after the members and providers in choosing prescription release of a generic version may pay the copayment drugs for treatment, we encourage members to show plus the difference in cost between the brand and this list to their physicians and pharmacists. In generic drug. Generic drugs can help members save addition, we encourage prescribers to use this list on out-of-pocket medication costs. when considering treatment options. Final decisions regarding treatment options are made between the Generic Equivalent vs. Generic Alternative physician and patient. Generic equivalents are medications that contain the same active ingredient, with the same strength The formulary is subject to change at any time. and dosage form as the brand medication. Generic Members can access the most up-to-date version of equivalents are as safe and effective and produce this list by visiting HealthAlliance.org. Members the same results as the brand counterpart. can also log in to YourHealthAlliance.org to check specific drug coverage and pricing information. The Generic alternatives can produce the same formulary does not provide information about an intended effect on the body as the comparable individual’s specific coverage. Please refer to your brand. Generic alternatives are medications that plan documents for complete coverage details. work like a particular brand drug and are used to treat the same condition. However, the active HOW TO USE THIS LIST ingredient in a generic alternative is different from This drug list is organized in sections by drug the brand medication. class or medical condition. Within each section are subsections to help locate medications. Talk to Your Doctor Most drugs listed, whether generic or brand, are If your doctor writes a prescription for a brand formulary drugs. drug that does not have a generic equivalent, consider asking if an appropriate generic alternative To search within the PDF, choose the search is available. function, enter a drug name and click “search” or “find.” You can also search using the index, which As a patient, you can tell your pharmacist you lists drugs alphabetically. are interested in generics. In most situations, your pharmacist can substitute a generic equivalent for Generics its brand counterpart without a new prescription Like brand drugs, generic drugs go through an from your doctor. approval process by the Food and Drug Administration (FDA) and must meet similar For more information on generics, visit standards of effectiveness and chemical make-up as AskForGenerics.org. branded drugs. Drugs to Treat Multiple Conditions The main difference between the reference brand Doctors use some drugs to treat more than one drug and its generic equivalent is that the generic medical condition. Within this document, each drug often costs much less. is listed according to its first FDA-approved use. Please check the index if you do not find your medication in the therapeutic class that corresponds to your condition. ph-formularyintroQHP-1217 COVERAGE AND LIMITATIONS B. Documented allergy to a formulary drug, with no other formulary choices Tier Information C. Successfully maintained condition on a specific A drug’s copayment tier indicates what you will drug where switching to an alternative drug may pay for the medication with each fill. cause a health risk: o Antiarrhythmics • The majority of generics are Tier 1. These are o Theophylline products your least expensive prescription drugs. o Seizure medications • Preferred brand-name drugs are Tier 2, the o Antipsychotics lowest brand tier. o Antidepressants • Non-preferred brand-name drugs are Tier 3. • Specialty drugs are in Tiers 4, 5, and 6. o Preferred Specialty drugs are Tier 4 Physicians—Requesting a Medical o Non-Preferred Specialty drugs are Tier 5 Exception o Non-Formulary Specialty drugs are Tier 6 To request a Medical Exception for a medication • Preventive drugs are Tier 7. These are covered on behalf of a member, or to request further at no charge as defined in the plan policy. information, please call the Health Alliance Pharmacy department at 1-800-851-3379, option 4, Your pharmacy benefit includes coverage for or log in to YourHealthAlliance.org. the majority of prescription drugs, though some exclusions may apply. Contraceptive Coverage Under Preventive Health Wellness Benefit Utilization Management A female member age 10–50 years old has coverage Some drugs on this list require utilization of some FDA-approved contraceptives for no out- management (UM), i.e. preauthorization, managed of-pocket cost. dose limitations and step-therapy. If UM applies to a drug, it is indicated with one of the following Free contraceptives are listed below: symbols in the column next to the drug name. • Tier 1 oral contraceptives • Limit of three units on condoms (male or • MDL- Managed Dose Limitations female) • PA- Preauthorization • Limit of 2.7 units of spermicidal product • ST- Step-Therapy Only one Tier 1 prescription drug (like a generic NOTE: Effective 8/1/17, most specialty oral contraceptive) or one over-the-counter (OTC) medications used during cancer treatment will product (like male and female condoms or require your doctor to submit for preauthorization spermicides) is covered per 30-day period for no through eviCore. Please click on the link below for cost to the member. a list of these medications: Brand-name contraceptives that are Tier 2 or eviCore Preauthorization List higher are covered with the appropriate member cost share/quantity restrictions according to the These medications are also indicated in our member’s plan. Specialty Drug List. Emergency contraception is covered at Tier 1 Medical Exception using generic levonorgestrel/ethinyl estradiol- Medical exception is a process for reviewing containing products. Brand-name emergency coverage for drugs not on our formulary. Members contraception is covered according to the may qualify for a medical exception if they meet member’s plan. one of these: Quantities above a 30-day supply, including A. Documented failure of all formulary drugs vacation overrides and commercially available within the same therapeutic class extended-cycle contraceptives (like Seasonale), are subject to appropriate member cost-sharing according to the member’s plan. General Exclusions Blood Glucose Monitors FREE By Mail A. Over-the-counter (OTC) medications and their Members with diabetes are eligible to receive a equivalents are not covered, unless otherwise FREE blood glucose meter if they choose one of the specified within the Formulary. Nicotine preferred meters listed below and obtain the meter smoking-cessation products (e.g., transdermal by mail. If a member picks up a blood glucose nicotine, nicotine gum, nicotine inhaler) meter at their local pharmacy, the member’s Tier 2 coverage is based on specific member benefits. copayment will apply when obtained with a B. Any drugs used for cosmetic purposes are not prescription. Free meters are limited to one meter covered. per member per year. The FreeStyle InsuLinx C. Experimental drugs, or any drug product used in System is limited to one meter every three years. an experimental manner, are not covered. D. Replacement of lost or stolen medication is not Freestyle Lite® and Freestyle InsuLinx® covered. ® E. Non-self-administered injectable drugs, unless FreeStyle Lite System FreeStyle Freedom Lite® System otherwise noted, are not covered through the ® pharmacy benefit. Refer to your description of FreeStyle InsuLinx System coverage materials for details. To get an Abbott product, call 1-866-224-8892 F. Foreign drugs and drugs not approved by the and use Offer Code ZD218BKX. FDA are not covered. Or visit www.choosefreestyle.com and enter G. Drugs used to treat erectile dysfunction. Offer Code ZD218BKX. InsuLinx systems are limited to one free PHARMACY SAVINGS PROGRAMS product per member every three years. Health Alliance offers members several programs to lower the drug costs and to help members take their Not all benefit plans include each of the programs medications safely and correctly. listed above. Please refer to your description of coverage documents for more detail or contact the Rxtra Pharmacy department at 1-800-851-3379, option 4. Health Alliance members with prescription coverage can save money based on where they have their 30-day-supply of prescriptions filled. CONTACT US Health Alliance Pharmacy Department 301 S. Vine St. The Rxtra program is simple. Urbana, IL 61801-3347 1-800-851-3379, option 4 • Preferred—At Preferred pharmacies, members can get hundreds of common prescriptions FREE. • Preferred Plus—At Preferred Plus pharmacies, members have the same benefits as the Preferred pharmacies mentioned above. In addition, simvastatin, pravastatin, ProAir and Ventolin HFA are FREE. For a list of participating pharmacies and available drugs in the Rxtra program, visit the pharmacy section of HealthAlliance.org. Retail 90 The Retail 90 program allows members to purchase a 90-day supply of maintenance medication at a discounted copayment from participating retail pharmacies. Because this is a voluntary program designed to increase flexibility, members who prefer may continue purchasing the traditional 30-day supply from their pharmacy with their regular copayment. Table of Contents ANTI-INFECTIVES . 1 PENICILLINS . 1 CEPHALOSPORIN . 1 FIRST GENERATION . 1 SECOND GENERATION . 1 THIRD GENERATION . 1 FOURTH GENERATION . 1 MACROLIDES . 1 TETRACYCLINES . 2 QUINOLONES . 2 AMINOGLYCOSIDES . 2 SULFONAMIDES . 2 ANTIMYCOBACTERIAL AGENTS . 2 ANTIFUNGALS . 2 ANTIVIRALS . 3 ANTIMALARIALS . 4 ANTHELMINTICS . 4 MISC. ANTI-INFECTIVES . 4 ANTINEOPLASTICS, ETC . 5 ALKYLATING AGENTS . 5 ANTIBIOTICS . 5 ANTINEOPLASTIC ENZYMES . 5 ANTIMETABOLITES . 5 ANGIOGENESIS INHIBITORS . 5 ANTIBODIES . 5 HORMONAL AGENTS .