2021 Your Prescription Drug List/Formulary Effective January 1, 2021 Please read: For a complete list of covered drugs This document contains or if you have questions: information about the drugs • Call a customer care representative covered under your pharmacy toll-free at (855) 828-9834 (TTY 711). benefit plan. • Visit www.HealthSelectRx.com — Locate an OptumRx in-network pharmacy — Look up possible lower-cost medication alternatives — Compare medication pricing and options SM HealthSelect of Texas 1 Your Prescription Drug List / Formulary This formulary outlines the most commonly prescribed medications covered under your plan’s prescription drug benefits. The formulary is also known as the Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the formulary is giving you choices so you and your doctor can choose the best course of treatment for you. Go to www.HealthSelectRx.com for complete and up-to-date drug information Since the formulary may change, we encourage you to visit our website, www.HealthSelectRx.com and click on Prescription Drug List. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons. 2 Understanding your Prescription Drug List/formulary What is a formulary? This document is a list of prescription Where differences exist between this medications covered by your plan for their formulary and your benefit plan documents, safety, cost and effectiveness. Medications the benefit plan documents will rule. This are listed by categories or class and may not be a complete list of medications, are placed into cost levels known as and not all medications listed may be tiers. It includes both brand and generic covered under your plan. Please look at prescription medications approved by the the Master Benefit Plan Document (MBPD) U.S. Food and Drug Administration (FDA). provided by your plan for full details. How do I use my formulary? You and your doctor can consult the formulary to help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed on this document, it may not be covered by the HealthSelect Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program. Please visit www.HealthSelectRx.com and click on Prescription Drug List for the most up to date list of medications covered under your plan. If you have any questions, call a customer care representative toll-free at (855) 828-9834 (TTY 711). What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your plan. This is how much you will pay when you fill a prescription. The HealthSelect of Texas Prescription Drug Program has different copays assigned depending on which tier a drug is. The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for each drug tier that applies once the annual combined medical and pharmacy deductible is met. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor. 3 When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call a customer care representative, 24 hours a day, 7 days a week toll-free at (855) 828-9834 (TTY 711). Why are some medications excluded from coverage? A medication may be excluded from coverage under your prescription drug plan when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication that is more cost-effective. What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an appeal to cover an excluded medication by calling a customer care representative toll-free at (855) 828-9834 (TTY 711). 4 Medication Tips What is the difference between brand-name and generic medications? An OTC medication may be the right treatment option for some conditions. Talk Generic medications contain the same to your doctor about available OTC options. active ingredients (what makes the Even though these medications may not be medication work) as brand-name medications, covered under your pharmacy benefit, they but they often cost less. Once the patent of may cost less than prescription medications a brand-name medication ends, the FDA covered under your prescription drug plan. can approve a generic version with the same active ingredients. What if my doctor writes a brand-name prescription? If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. What if I am taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary. Optum Specialty Pharmacy can provide most of your specialty medications along with helpful programs and services. Call Optum Specialty Pharmacy at (855) 427-4682 and have your prescriptions delivered right to your home or doctor’s office. 5 Reading your formulary The formulary give your choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol). Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your prescription drug plan has multiple tiers. Please note: If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Drug Tier Includes Helpful Tips Tier 1 Lower-cost, commonly used Use Tier 1 drugs for the lowest Lowest Cost generic drugs. Some low- out-of-pocket costs. cost brands may be included. Tier 2 Many common brand-name Use Tier 2 drugs, instead of Tier 3, to Mid-range Cost drugs, called preferred brands. help reduce your out-of-pocket costs. Tier 3 Mostly higher-cost brand Many Tier 3 drugs have lower-cost Highest Cost drugs, also known as non- options in Tier 1 or 2. Ask your doctor preferred brands. if they could work for you. Tier E Excluded May be excluded from coverage or subject to prior authorization. Lower- cost options are available and covered. Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you. PA Prior Authorization – Your doctor is required to provide additional information before the drug will be covered by your prescription drug plan. ST Step Therapy – Requires you to first try a cost-effective medication before the more expensive medication will be covered. QL Quantity Limit – Limits the amount of a medication that will be covered under your prescription drug plan. SP Specialty Medication – Drugs that are used in the treatment of rare or complex conditions and are typically injected or infused, are high cost, have special delivery and storage requirements, or require close monitoring or care coordination with your doctor. E Excluded – Drugs that are not covered by your health plan. Lower-cost options are available and covered. 6 Table of Contents Analgesics - Drugs for Pain.................................................................................................................................9 Analgesics - Drugs for Pain and Inflammation.................................................................................................. 14 Anesthetics........................................................................................................................................................17 Anti-Addiction / Substance Abuse Treatment Agents....................................................................................... 20 Antibacterials.....................................................................................................................................................20 Anticoagulants...................................................................................................................................................25 Anticonvulsants - Drugs for Seizures................................................................................................................ 26 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 28 Antidepressants.................................................................................................................................................29 Antiemetics - Drugs for Nausea and Vomiting.................................................................................................