2 Tier 2018 Formulary (List of covered drugs)

[Pages:89]2 Tier 2018 Formulary (List of covered drugs)

For current information on the GenericsAdvantageRx Drug List, visit pharmacy. Effective: October 1, 2018

?2018 HealthPartners

What's the GenericsAdvantageRx drug list?

This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a team of experts every three months for new medicines, safety alerts and other updates.

Who decides what's on the drug list?

The HealthPartners Pharmacy and Therapeutics Committee manages the list. This team of experts is focused on safety, effectiveness and affordability. Visit pharmacy for more information.

How do you use the drug list?

The medicines on the drug list are listed in alphabetical order by type of medicine starting on page 3.

Generic medicines are in lowercase italics (e.g., cephalexin) and are just as safe and effective as brand medicines but cost you less. Some generic medicines are very low-cost.

Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.

The Tier Status can be used to determine how much a medicine will cost you. For exact cost information, ? Find the tier status for your medicine. ? Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or, ? Log on to your myHealthPartners account to check your pharmacy benefits.

? Tier 1 ? Formulary Generics & Brands

? Tier 2 ? Specialty Generics & Brands

What's a Specialty Medicine?

Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require more management, have a high price and aren't always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan tab to check your benefits for specialty medicines.

What do the abbreviations in the More details column mean?

This column gives special information about the medicine you're searching for. The abbreviations let you know there might be a special program or rule for the medicine. Use this key to help you navigate the drug list:

? Prior Authorization Required ? Step Therapy Required ? Age Edit ? Gender Edit Female ? Gender Edit Male

PA ST AE GE Female GE Male

? Quantity Limit

QL

? Smoking Cessation Benefit

SC

? Trial Drug Program

TD

? Weight Loss Benefit

WL

? Oncology Benefit

ONC

Why do you need prior authorization (PA) for some medicines?

Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your pharmacy benefits.

What's Step Therapy (ST)?

Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest brand, generic or specialty copay or coinsurance.

What's an Age Edit (AE)?

An age edit means some medicines are only covered if you're within a specific age range. If you're not in the approved age range, you or your doctor will need to request approval from HealthPartners for your medicine to be covered.

What's a Gender Edit (GE)?

A gender edit means some medicines are covered for males or females only. If you're not in the approved gender group, you or your doctor will need to request approval from HealthPartners for your medicine to be covered.

What's a Quantity Limit (QL)?

This means HealthPartners limits the amount of the medicine you'll get each time you fill your prescription. The quantity limit may be less than the days supply listed in your contract or Summary Plan Description.

What's the Trial Drug Program (TD)?

The trial drug program is for new prescriptions for certain medicines that may not be well tolerated due to:

? Side effects ? High cost ? High potential for waste Your first 6 fills of a trial drug may be limited to less than a month supply. If the medicine works well, you'll get the rest of your month supply. If a copay applies to the medicine, you'll pay no more than one copay for each one month supply.

What's the Weight Loss Benefit (WL)?

This type of medicine may have limits on the amount you get or may not be covered under all plans. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan tab to check your benefits for weight loss. Weight Loss medicines are listed on the drug list under the Weight Loss medicine category.

What's the Oncology Benefit (ONC)?

These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you're only responsible for your regular generic or brand pharmacy copay or coinsurance.

The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (10/18) ?2018 HealthPartners

List of Covered Drugs

Table of Contents

Alcohol Dependency.................................................................................................................................................6 Allergy ....................................................................................................................................................................... 6 Alpha-1 Antitrypsin Deficiency................................................................................................................................ 7 Anti-Addiction/Substance Abuse Treatment Agents.............................................................................................. 7 Anti-Infective............................................................................................................................................................ 7 Arthritis ................................................................................................................................................................... 15 Asthma & Copd.......................................................................................................................................................16 Behavioral Health...................................................................................................................................................18 Birth Control........................................................................................................................................................... 22 Bleeding Disorders................................................................................................................................................. 27 Blood Modifier........................................................................................................................................................27 Blood Thinner......................................................................................................................................................... 30 Bone Health............................................................................................................................................................ 31 Cancer..................................................................................................................................................................... 32 Corticosteroids....................................................................................................................................................... 35 Cough & Cold.......................................................................................................................................................... 36 Cystic Fibrosis......................................................................................................................................................... 36 Dementia................................................................................................................................................................ 37 Diabetes .................................................................................................................................................................. 37 Ear Conditions........................................................................................................................................................ 40 Enzyme Replacement............................................................................................................................................. 41 Eye Conditions........................................................................................................................................................ 41 Gout........................................................................................................................................................................ 44 Heart Health........................................................................................................................................................... 44 Hereditary Angioedema......................................................................................................................................... 50 Idiopathic Pulmonary Fibrosis............................................................................................................................... 51 Immune Deficiency.................................................................................................................................................51 Immune Suppressant............................................................................................................................................. 52 Kidney Failure......................................................................................................................................................... 52 Men's Health.......................................................................................................................................................... 53 Migraine ..................................................................................................................................................................53 Mouth & Throat......................................................................................................................................................54 Multiple Sclerosis................................................................................................................................................... 54 Muscle Relaxant..................................................................................................................................................... 55 Other Conditions.................................................................................................................................................... 55 Pain......................................................................................................................................................................... 57 Parkinson's ..............................................................................................................................................................60 Pulmonary Hypertension....................................................................................................................................... 61 Seizures / Epilepsy..................................................................................................................................................61 Skin Conditions....................................................................................................................................................... 64 Sleep Disorders.......................................................................................................................................................68 Smoking Cessation................................................................................................................................................. 68 Stomach / Gastrointestinal.................................................................................................................................... 68 Thyroid .................................................................................................................................................................... 72 Urinary & Bladder Health.......................................................................................................................................72 Vaccines.................................................................................................................................................................. 72

4

Vitamins And Minerals...........................................................................................................................................76 Weight Loss.............................................................................................................................................................78 Women's Health..................................................................................................................................................... 78

5

List of Covered Drugs

Drug Alcohol Dependency Alcohol Dependency

acamprosate oral tablet,delayed release (dr/ec) 333 mg disulfiram oral tablet 250 mg, 500 mg naltrexone oral tablet 50 mg

Allergy Allergy, Eye

azelastine ophthalmic (eye) drops 0.05 % cromolyn ophthalmic (eye) drops 4 % epinastine ophthalmic (eye) drops 0.05 % olopatadine ophthalmic (eye) drops 0.1 %

Allergy, Injection

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML

Allergy, Other Nasal

azelastine nasal aerosol,spray 137 mcg (0.1 %) ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %)

Allergy, Other Oral

GRASTEK SUBLINGUAL TABLET 2,800 BAU ODACTRA SUBLINGUAL TABLET 12 SQ-HDM RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT

Antihistamines, Oral

cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg promethazine oral syrup 6.25 mg/5 ml promethazine oral tablet 12.5 mg, 25 mg, 50 mg

Tier Status

Tier 1 Tier 1 Tier 1

Tier 1 Tier 1 Tier 1 Tier 1

Tier 1 Tier 1

Tier 1 Tier 1

Tier 1 Tier 1 Tier 1

Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1

GenericsAdvantageRx: October 1, 2018 6

More Details

PA PA PA QL; AE QL; AE QL; AE QL; AE QL; AE

Drug

Tier Status More Details

Corticosteroids, Nasal

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

Tier 1

fluticasone nasal spray,suspension 50 mcg/actuation

Alpha-1 Antitrypsin Deficiency

Tier 1

Alpha-1 Antitrypsin Deficiency

ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG

Tier 2

PA; Specialty

GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %)

PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG

Tier 2 Tier 2

PA; Specialty PA; Specialty

PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML

Tier 2

PA; Specialty

ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG

Anti-Addiction/Substance Abuse Treatment Agents

Tier 2

PA; Specialty

Anti-Addiction/Substance Abuse Treatment Agents

naloxone injection syringe 1 mg/ml

Tier 1

NARCAN NASAL SPRAY,NON-AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION

Anti-Infective

Tier 1

Antibiotics, Cephalosporins

cefadroxil oral capsule 500 mg

Tier 1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

Tier 1

cefadroxil oral tablet 1 gram

Tier 1

cefdinir oral capsule 300 mg

Tier 1

cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 1

cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

Tier 1

cefprozil oral tablet 250 mg, 500 mg

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML

Tier 1 Tier 1

cefuroxime axetil oral tablet 250 mg, 500 mg

Tier 1

GenericsAdvantageRx: October 1, 2018 7

Drug

cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml SUPRAX ORAL CAPSULE 400 MG

Antibiotics, Macrolides

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg azithromycin oral tablet 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg DIFICID ORAL TABLET 200 MG

Antibiotics, Other

clindamycin hcl oral capsule 150 mg, 300 mg clindamycin hcl oral capsule 75 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML linezolid oral suspension for reconstitution 100 mg/5 ml linezolid oral tablet 600 mg neomycin oral tablet 500 mg sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml sulfamethoxazole-trimethoprim oral tablet 40080 mg, 800-160 mg trimethoprim oral tablet 100 mg vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg vancomycin oral capsule 125 mg, 250 mg XIFAXAN ORAL TABLET 200 MG, 550 MG

Antibiotics, Penicillins

amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

GenericsAdvantageRx: October 1, 2018 8

Tier Status

Tier 1 Tier 1 Tier 1

More Details

QL

Tier 1

Tier 1 Tier 1

Tier 1

Tier 1

Tier 1

PA

Tier 1 Tier 1

Tier 1

Tier 1

Tier 1

PA

Tier 1

PA

Tier 1

Tier 1

Tier 1

Tier 1

Tier 1

Tier 1

Tier 1

PA

Tier 1 Tier 1

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download