2021 - ilmeridian.com

[Pages:341]2021

Medicaid Formulary

ILLINOIS

2021 Illinois Medicaid Formulary

Version 272 Updated: 10/01/2021

2 This formulary is up to date through its date of publication, 10/01/2021.

Introduction MeridianHealth (Meridian) is pleased to give an updated 2021 Medicaid formulary as a reference and tool for providers, pharmacists, and patients. The purpose of the Meridian formulary is to help providers choose clinically fit and cost-effective products for their patients. This document has facts about the drugs we cover in this plan.

The MeridianRx Pharmacy and Therapeutics (P&T) Committee The MeridianRx P&T Committee is made up of providers, pharmacists, and health professionals. The clinical information within the formulary mainly came from medical literature and is reviewed and approved by the P&T Committee.

Notice The information contained in this formulary is given by Meridian, only for the convenience of medical providers. This formulary is not meant to be a substitute for the knowledge, expertise, skill, and judgment of the medical provider in his or her choice of prescription drugs. Meridian assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should see the drug manufacturer's product literature or standard references for more detailed information.

Preface The Meridian formulary is organized in sections. Each section includes therapeutic groups named by either drug class or disease state. Brand and common names are included as a reference to help in product recognition. Brand name drugs are capitalized (e.g., CONCERTA) and generic drugs are listed in lower-case italics (e.g., methylphenidate HCL).

Meridian will not cover prescription drugs that are prescribed for experimental, investigational, or non-FDA approved indications, dosages, or routes of administration.

Formulary Components The Meridian formulary contains covered medications without authorization, medications that must meet step therapy protocol, medications that need prior authorization, specialty medications, and medications that have quantity limits. Members will not be charged a co-pay when Meridian covers a medication.

Generic Substitution Meridian is a mandatory generic plan. The Illinois Department of Healthcare and Family Services (HFS) has mandated that some brand medications are to be covered over the generic medication. Generic medication will be dispensed when available.

Covered Medications without Authorization Meridian covers many medications without requiring authorization. These medications include many prescription and over-the-counter medications (with a valid prescription).

3

Tier Descriptions

Tier Number

Tier Name

1

Preferred

2

Preferred with Prior Authorization

Tier Description

The Illinois Department of Healthcare and Family Service (HFS) preferred drug list (PDL) mandated coverage. No prior authorization required. Products may have quantity limitations, gender restrictions, specialty restrictions, and/or age limitations.

HFS PDL mandated coverage. Prior authorization required. In some cases, will need the trial and failure of preferred agent(s). Products may also have additional approval criteria, quantity limitations, gender restrictions, specialty restrictions, and/or age limitations.

HFS PDL mandated coverage. Prior

authorization required. In most cases will need

3

Non-Preferred

the trial and failure of two or more preferred agent(s). Products may also have additional

approval criteria, quantity limitations, gender

restrictions, and/or age limitations.

Additional products that Meridian covers for the

benefit of its members. Some products may

4

Supplemental Coverage require prior authorization, have quantity

limitations, gender restrictions, step therapy,

specialty restrictions, and/or age limitations.

Non-Covered Benefits Non-covered benefits include medications used for cosmetic purposes, to promote fertility, for sexual dysfunction, for experimental or investigational purposes, or medications that are not licensed for use in the United States.

Prior Authorization (PA) Drugs indicated with "PA" need prior authorization for coverage. Details of PA criteria are listed next to the drug name. Please call the MeridianRx Help Desk at 855-580-1688 or fax a completed prior authorization form to 855-580-1695. All prior authorization requests will be reviewed within 24 hours.

4

Please note: A prior authorization is NOT required on any anticonvulsant medications for members with a diagnosis of epilepsy or seizure disorder. Diagnosis code must be given at point of sale or within records.

Step Therapy (ST) Drugs with an "ST" need step therapy for coverage. The required step is listed next to the drug name.

Specialty Medications (SP) All specialty medications noted as "SP" are to be filled at contracted, in-network specialty pharmacies.

Quantity Limits (QL) Drugs with a "QL" have a set quantity limit imposed. These limits are based on FDArecommended dosing guidelines. The quantity limit is listed next to the drug name. All medications have a maximum of 30 days per prescription.

Fill Limit (FL) Drugs indicated with an "FL" have a set fill limit imposed. The fill limit is listed next to the drug name. These medications are limited to a number of fills in a set amount of time.

Day Supply Limit (DS) Drugs indicated with a "DS" have a set day supply limit imposed. The day supply limit is listed next to the drug name. These medications are limited to a certain day supply in a set amount of time.

Gender Restriction (GR) Drugs indicated with a "GR" have a set gender restriction imposed. The gender restriction is listed next to the drug name. These medications are limited to either males or females.

Age Limit (AL) Drugs indicated with an "AL" have a set age limit imposed. The age limit is listed next to the drug name. These medications are limited to a specific age range.

Benefit Exception To request non-formulary medication(s), fax a completed Formulary Exception form asking for an exception to the formulary. This request needs to have relevant clinical documentation showing trial and failure of all formulary agents. It should also have information showing the medication is the standard of care for the indication provided (peer-reviewed journal articles may be required).

Please call the MeridianRx Help Desk at 855-580-1688 or fax a completed Formulary Exception form to 855-580-1695.

5

Pharmacy Benefit Management Meridian uses MeridianRx to manage each member's pharmacy benefit. MeridianRx provides Meridian with a pharmacy network, pharmacy claims management services, and claims adjudication. This formulary is up to date through the date of publication. Please notify MeridianRx of any mistakes in the formulary. A copy of this formulary can be mailed upon request. Contact MeridianRx Help Desk at 855-580-1688 or email info@.

6

UM Criteria Code SP PA ST FL QL DS GR AL

UM Criteria Legend

UM Criteria Description Specialty Medication

Prior Authorization Required Step Therapy Required Fill Limit Quantity Limit Days Supply Limit Gender Restriction Age Limit

7

Formulary: Illinois Medicaid Formulary - Version: 272 - Effective Date: 10/01/2021

Drug List

Covered Prescription Drugs

Drug Name

ADDERALL 10 MG TABLET (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL 12.5 MG TABLET (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL 15 MG TABLET (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL 20 MG TABLET (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL 30 MG TABLET (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL 5 MG TABLET (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL 7.5 MG TABLET (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL XR 10 MG CAPSULE (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL XR 15 MG CAPSULE (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL XR 20 MG CAPSULE (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL XR 25 MG CAPSULE (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL XR 30 MG CAPSULE (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADDERALL XR 5 MG CAPSULE (use dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate)

ADZENYS ER 1.25 MG/ML SUSP (amphetamine)

ADZENYS XR-ODT 12.5 MG TABLET (amphetamine)

ADZENYS XR-ODT 15.7 MG TABLET (amphetamine)

ADZENYS XR-ODT 18.8 MG TABLET (amphetamine)

ADZENYS XR-ODT 3.1 MG TABLET (amphetamine)

ADZENYS XR-ODT 6.3 MG TABLET (amphetamine)

ADZENYS XR-ODT 9.4 MG TABLET (amphetamine)

ADHD / ANTI-NARCOLEPSY AGENTS : AMPHETAMINES

Drug Status

Criteria

PA,QL

Prior Authorization required. Limited to 90 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 90 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 90 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 90 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 90 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 90 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 90 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 60 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 60 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 60 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 60 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 60 EA per 30 days.

PA,QL

Prior Authorization required. Limited to 60 EA per 30 days.

PA,QL PA,QL PA,QL PA,QL PA,QL PA,QL PA,QL

Prior Authorization required. Limited to 90 EA per 30 days. Prior Authorization required. Limited to 90 EA per 30 days. Prior Authorization required. Limited to 90 EA per 30 days. Prior Authorization required. Limited to 90 EA per 30 days. Prior Authorization required. Limited to 90 EA per 30 days. Prior Authorization required. Limited to 90 EA per 30 days. Prior Authorization required. Limited to 90 EA per 30 days.

SP Specialty Medication

PA Prior Authorization Required

ST Step Therapy

Required

DS Days Supply

Limit

FL Fill Limit

QL Quantity

Limit

GR Gender Restriction

AL Age Limit

8

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

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

Google Online Preview   Download