Your 2020 Comprehensive Formulary - OptumRx

State Health Plan PPO Medicare Prescription Drug Plan (PDP) Your 2020 Comprehensive Formulary

Administered by OptumRx? Effective January 1, 2020

Please read: this document contains information about the drugs we cover in this plan. This comprehensive formulary was updated on August 28, 2019, and is a complete list of drugs covered by our plan. For more recent information or if you have questions, please contact:

OptumRx Member Services

Phone (toll-free): 1-866-635-5941

TTY users:

711

Hours of operation: 24 hours a day, 7 days a week

Website:



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 OptumRx. When it refers to "plan" or "our plan," it means State Health Plan PPO Medicare Prescription Drug Plan.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1, 2021. Optum Insurance of Ohio, Inc. is a Medicare-approved Part D sponsor and administers this plan through its pharmacy benefit manager, OptumRx, on behalf of your employer, union, or trustees of a fund. If you need this information in another language or alternate format (braille, large print, audio), please contact OptumRx at the number listed on your member ID card.

Formulary ID 20069 Version 7 S8841_20_MC-DS11_C_MCC

What is the Comprehensive Formulary? A formulary is a list of covered drugs selected by State Health Plan PPO in consultation with OptumRx and a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. This plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an OptumRx network pharmacy, and other plan rules are followed.

Can the formulary (drug list) change? Yes. If you are taking a drug on our 2020 formulary that is covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except when a new, less-expensive generic drug becomes available, or when new adverse information about the safety or effectiveness of a drug is released.

If we make a negative change to our formulary (i.e. add prior authorization, quantity limits, and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, when applicable), we must notify affected members. Members will receive a notice regarding the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe, or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

The enclosed formulary is current as of January 1, 2020. To get updated information about covered drugs, please contact OptumRx. You may also visit our website at where you will find the most up-to-date information about our list of covered drugs (formulary) by using the "Drug Information" tool (found under the "Member Tools" tab). Our contact information is shown on the front and back cover pages.

How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition

The formulary begins on page 7. The 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 Agents." If you know what your drug is used for, look for the category name in the list that begins on page 7. Then, look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins page 145. The Index provides an alphabetical list of all drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index.

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Formulary design

The formulary structure features generic drugs, preferred brand-name drugs, and non-preferred brand-name drugs.

Drug Tier Tier 1 Tier 2 Tier 3

Helpful Tips

Most generic drugs are listed under Tier 1 and have the lowest copayments.

Drugs listed under Tier 2 generally include preferred brand-name drugs that have lower copayments than non-preferred brand-name drugs.

Drugs listed under Tier 3 generally have higher copayments than preferred brandname drugs and may include some specialty or high-cost drugs*.

* High-cost (or some Specialty) drugs are those that cost $670 or more for up to a 30-day maximum supply. These types of drugs are labeled in the formulary as "NDS" under the Requirements/Limits column, and will not be dispensed in more than a 30-day supply.

Please refer to your Evidence of Coverage for more information.

What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization (PA)

You or your physician may need to get prior authorization for certain drugs. This means you will need to get approval from OptumRx before you fill your prescriptions. If you do not get approval, the drug may not be covered.

Quantity Limits (QL) Step Therapy (ST)

For certain drugs, there is a limit on the amount of the drug we will cover.

In some cases, it is required that you first try certain drugs to treat your medical condition before we 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.

To find out if your drug has any additional requirements or limits, look in the formulary that begins on page 7. You can also get more information about restrictions applied to specific covered drugs by visiting our website or by calling OptumRx. Our contact information, along with the date we last updated the formulary, is shown on the front and back cover pages.

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You can ask OptumRx to make an exception to these restrictions or limits, or for a list of other similar drugs that may treat your health condition. See the section "How do I request an exception to the formulary?" on page 4 for additional information.

What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact OptumRx and ask if your drug is covered. Our contact information, along with the date we last updated the formulary, is shown on the front and back cover pages.

If your drug is not covered, you have two options:

You can ask OptumRx for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered.

You can ask OptumRx to make an exception and cover your drug. See below for information about how to request an exception.

State Health Plan PPO offers supplemental coverage (also called WRAP coverage) on some prescription drugs not normally covered under Medicare Part D. Please contact OptumRx for any questions regarding your supplemental coverage.

How do I request an exception to the formulary? You can ask OptumRx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:

You can ask us to cover a drug even if it is not on our formulary. If approved, the drug will be covered at a predetermined cost-sharing level, and you will not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level. If approved, this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Please Note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

Generally, we will only approve your request for an exception if the drug is included on the plan's formulary, or if additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact OptumRx for an initial coverage decision for a formulary, tier, or utilization restriction exception. When you request a formulary, tier, or utilization restriction exception, you must submit a statement from your doctor (or other prescriber) supporting your request.

Generally, we must make our decision within 72 hours of getting your doctor's (or other prescriber's) supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor (or other prescriber).

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What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary, or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor (or other prescriber) to decide if you should switch to an appropriate drug that we cover or request a formulary exception. While you talk to your doctor (or other prescriber) to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 31-day transition supply, written for as many pills as necessary, unless you have a prescription written for fewer days. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you get a formulary exception.

If you are a current enrollee with a level-of-care change and you need a drug that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days) while you seek a formulary exception. If you are in the process of seeking an exception, we will consider allowing continued coverage until a decision is made.

For more information For more detailed information about your prescription drug coverage, please review your other plan materials. If you have questions about the plan, please call OptumRx. Our contact information, along with the date we last updated the formulary, is shown on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, 24 hours a day, 7 days a week. You may also visit .

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Formulary The formulary below provides information about your covered drugs. If you have trouble finding your drug in the list, turn to the Index that begins on page 145.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., COZAAR), and generic drugs are listed in lower-case italics (e.g., atenolol). The abbreviations in the "Requirements/Limits" column tell you if there are any special requirements for coverage of your drug

Requirements/Limits B/D NDS PA QL ST

Helpful Tips

This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Non-Extended Days' Supply. This prescription drug is not available for an extended days' supply.

Prior Authorization. Our plan requires you or your physician to get prior authorization for certain drugs. This means you will need to get approval from OptumRx before you fill your prescriptions. If you do not get approval, your drug may not be covered.

Quantity Limit. For certain drugs, our plan limits the amount of the drug that will be covered.

Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medical condition before we 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.

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Drug Name

Analgesics

Analgesics

allzital oral tablet

bupap oral tablet

butalbitalacetaminophen oral capsule

butalbitalacetaminophen oral tablet

butalbital-apap-caffeine oral capsule

butalbital-aspirincaffeine oral capsule

butalbital-aspirincaffeine oral tablet

capacet oral capsule 50-325-40 mg

esgic oral capsule

fioricet oral capsule

FIORINAL ORAL CAPSULE

marten-tab oral tablet 50-325 mg

phrenilin forte oral capsule

tencon oral tablet

vanatol lq oral solution

zebutal oral capsule

Nonsteroidal Antiinflammatory Drugs

ANAPROX DS ORAL TABLET

ARTHROTEC ORAL TABLET DELAYED RELEASE

CALDOLOR INTRAVENOUS SOLUTION

CAMBIA ORAL PACKET

CELEBREX ORAL CAPSULE

Drug Tier Requirements/ Limits

3

PA; NDS

3

PA; NDS

1

PA

1

PA

1

PA

1

PA

1

PA

1

PA

1

PA

3

PA

3

PA

1

PA

1

PA

1

PA

3

PA; NDS

1

PA

3 3

3

3

3

QL (60 EA per 30 days)

Drug Name

Drug Tier Requirements/ Limits

celecoxib oral capsule

1

QL (60 EA per 30 days)

DAYPRO ORAL TABLET

3

diclofenac epolamine transdermal patch

1

PA; QL (60 EA per 30 days)

diclofenac potassium oral tablet

3

diclofenac sodium er

oral tablet extended

3

release 24 hour

diclofenac sodium oral tablet delayed release

3

diclofenac sodium transdermal gel 1 %

1

QL (1000 GM per 30 days)

diclofenac sodium transdermal gel 3 %

3

diclofenac-misoprostol

oral tablet delayed

3

release

diflunisal oral tablet

1

DUEXIS ORAL TABLET

3

QL (90 EA per 30 days); NDS

EC-NAPROSYN ORAL

TABLET DELAYED

3

RELEASE

ec-naproxen oral tablet delayed release

1

etodolac er oral tablet

extended release 24

1

hour

etodolac oral capsule

1

etodolac oral tablet

1

FELDENE ORAL CAPSULE

3

fenoprofen calcium oral capsule

1

fenoprofen calcium oral tablet

1

fenortho oral capsule

1

FLECTOR TRANSDERMAL PATCH

3

PA; QL (60 EA per 30 days)

flurbiprofen oral tablet

1

7

Drug Name

Drug Tier Requirements/ Limits

ibu oral tablet

1

ibuprofen oral suspension

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

INDOCIN ORAL SUSPENSION

3

INDOCIN RECTAL SUPPOSITORY

3

indomethacin er oral

capsule extended

1

release

indomethacin oral capsule

1

indomethacin sodium

intravenous solution

1

reconstituted

ketoprofen er oral

capsule extended

1

release 24 hour

ketoprofen oral capsule

1

ketorolac tromethamine injection solution

1

ketorolac tromethamine intramuscular solution

1

ketorolac tromethamine oral tablet

1

QL (20 EA per 30 days)

lodine oral tablet

3

NDS

meclofenamate sodium oral capsule

1

mefenamic acid oral capsule

1

meloxicam oral tablet

1

MOBIC ORAL TABLET

3

nabumetone oral tablet

1

NALFON ORAL CAPSULE

3

nalfon oral tablet

3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG

3

NDS

Drug Name

Drug Tier Requirements/ Limits

NAPRELAN ORAL

TABLET EXTENDED RELEASE 24 HOUR

3

750 MG

NAPROSYN ORAL SUSPENSION

3

NAPROSYN ORAL TABLET 500 MG

3

naproxen dr oral tablet delayed release

1

naproxen oral suspension

1

naproxen oral tablet

1

naproxen sodium er oral

tablet extended release

1

24 hour

naproxen sodium oral tablet 275 mg, 550 mg

1

oxaprozin oral tablet

1

piroxicam oral capsule

1

profeno oral tablet 600 mg

1

QMIIZ ODT ORAL TABLET DISPERSIBLE

3

salsalate oral tablet

1

SPRIX NASAL SOLUTION

3

QL (5 EA per 30 days); NDS

sulindac oral tablet

1

TIVORBEX ORAL CAPSULE

3

tolmetin sodium oral capsule

1

tolmetin sodium oral tablet

1

VIMOVO ORAL TABLET DELAYED RELEASE

PA; QL (60 EA

3

per 30 days);

NDS

VIVLODEX ORAL CAPSULE

3

VOLTAREN TRANSDERMAL GEL

3

QL (1000 GM per 30 days)

ZIPSOR ORAL CAPSULE

3

NDS

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