Medicaid List of Covered Drugs (Formulary) 2019

Medicaid List of Covered Drugs (Formulary) 2019

UCare Connect (SNBC) Families and Children (Prepaid Medical Assistance Program (PMAP))

MinnesotaCare Minnesota Senior Care Plus (MSC Plus)

UCare Connect counties: Aitkin, Anoka, Becker, Benton, Blue Earth, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Cook, Cottonwood, Crow Wing, Dakota, Faribault, Fillmore, Hennepin, Houston, Isanti, Itasca, Jackson, Kandiyohi, Kittson, Koochiching, Lac Qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, Mille Lacs, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Polk, Ramsey, Red Lake, Redwood, Rice, Rock, Roseau, Scott, Sherburne, St. Louis, Stearns, Swift, Washington, Watonwan, Wilkin, Winona, Wright and Yellow Medicine.

Families and Children (PMAP) counties: Anoka, Blue Earth, Carver, Chippewa, Cottonwood, Dakota, Faribault, Fillmore, Freeborn, Hennepin, Houston, Isanti, Jackson, Kandiyohi, Lac qui Parle, Lake of the Woods, LeSueur, Lincoln, Lyon, Martin, Mower, Murray, Nicollet, Nobles, Olmsted, Ramsey, Redwood, Rice, Rock, St. Louis, Scott, Sibley, Swift, Washington, Watonwan, Winona, Wright, Yellow Medicine.

MinnesotaCare counties: Anoka, Big Stone, Blue Earth, Carver, Chippewa, Cottonwood, Dakota,

Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Isanti, Jackson, Kanabec, Kandiyohi, Lac qui Parle, Lake of the Woods, LeSueur, Lincoln, Lyon, McLeod, Martin, Meeker, Morrison, Mower, Murray, Nicollet, Nobles, Olmsted, Pipestone, Pope, Ramsey, Redwood, Renville, Rice, Rock, St. Louis, Scott, Sibley, Steele, Stevens, Swift, Todd, Traverse, Wadena, Waseca, Washington, Watonwan, Winona, Wright, Yellow Medicine.

Minnesota Senior Care Plus counties: Aitkin, Anoka, Becker, Benton, Blue Earth, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Faribault, Fillmore, Freeborn, Hennepin, Houston, Isanti, Jackson, Kandiyohi, Kittson, Koochiching, Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Polk, Ramsey, Red Lake, Redwood, Rice, Rock, Roseau, Scott, Sherburne, St. Louis, Stearns, Swift, Todd, Wabasha, Wadena, Washington, Watonwan, Winona, Wright, Yellow Medicine.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. MEMBERS MUST USE NETWORK

PHARMACIES TO RECEIVE PRESCRIPTION DRUG BENEFITS.

UCare, 500 Stinson Blvd, Minneapolis, MN 55413

UCare Customer Service: Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free. Hours of operation: 8 am to 5 pm, Monday through Friday. The call is free. For more information visit .

DHS Approved Date 10/04/2019

This list is subject to change and is not all-inclusive. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. Note to existing members: This list of covered drugs has changed since last year. Please review this document to make sure that it still has the drugs you take. Please contact UCare Customer Service with questions: Families and Children (PMAP), MinnesotaCare, and MSC+ Members: 612-676-3200 or 1-800-203-7225 toll free. UCare Connect: 612-676-3395 or 1-877-903-0061 toll free. TTY: 612-676-6810 or 1-800-688-2534 toll free. Hours of operation: 8 am to 5 pm, Monday through Friday. The call is free. For more information visit .

Other drug coverage: If you have Medicare, you need to get most of your prescription drugs through the Medicare Prescription Drug Program (Medicare Part D). You must be enrolled in a Medicare prescription drug plan to get these services.

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your heath plan Primary Care Provider (PCP) prior to the referral.

Table of Contents

What is a List of Covered Drugs?........................................................................................... ii Does the List of Covered Drugs ever change?..................................................................... ii How are drugs listed in the List of Covered Drugs?............................................................ ii What is a Preferred Drug List?............................................................................................... ii What are generic or biosimilar drugs?..................................................................................iii What are over-the-counter (OTC) drugs?.............................................................................iii What if a drug is not on the list of covered drugs?.............................................................iv Are there any restrictions on my coverage? .......................................................................iv Can I request an exception to the coverage restrictions?.................................................. v What will a prescription cost?................................................................................................ v Drug List (formulary) Key ....................................................................................................... v Drug List .................................................................................................................................. 1 Drug Index ........................................................................................................................... 119 Over-the-counter ................................................................................................................ 139

What is a List of Covered Drugs?

A list of covered drugs includes the prescription drugs covered by UCare.The drugs on the list are selected by UCare with the help of a team of doctors and pharmacists. UCare will generally cover the drugs listed in the list of covered drugs as long as the drug is medically necessary, the prescription is filled at a UCare network pharmacy and other requirements related to the drug are followed.

Does the List of Covered Drugs ever change?

The UCare list of covered drugs can change during the course of a calendar year. If changes occur which will impact the coverage of a medication you are taking, UCare will make reasonable efforts to contact you and your prescriber to inform you and your prescriber about the change and possible alternative medications which will be covered.

Examples of some changes that may occur are:

? A drug you are taking is no longer preferred.

? A drug is removed from the list of covered drugs due to safety reasons.

? Changes in prior authorization requirements.

How are drugs listed in the List of Covered Drugs?

There are two ways to find your prescription drugs in the formulary. You can search by medical condition associated with your drug or by alphabetical listing.

Search by Medical Condition

Drugs listed by medical condition begin on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions they are used to treat. If you know what your drug is used for, look for the category in the list that begins on page 1. Then look under the category name for your drug.

Search by Alphabetical Listing

If you are not sure what category to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information within the formulary.

What is a Preferred Drug List?

In Minnesota, all managed care organizations are required to follow the Department of Human Services' Preferred Drug List (PDL). The PDL is created by the Department of Human Services, in consultation with the Drug Formulary Committee, to let prescribers and members know about drugs or drug classes that are more or less cost effective. Generally, drugs that are listed on the PDL as preferred are more cost effective; and drugs that are listed as non-preferred on PDL are less cost effective. Preferred drugs are available to members with fewer restrictions. Non-preferred drugs will require a prior authorization. To receive a non-preferred drug, your doctor or health care provider must get prior authorization.

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