Formulary Guide Pharmacy Service administered by Express Scripts
Bring this with you to each doctor visit and
generics and preferred medications. Pharmacy Benefit Programs
Prescription drugs are an integral component of acomprehensive health maintenance plan. Pharmacy benefit programs at The Health Planare developed through recommendations ofparticipating physicians and pharmacists. Thisgroup of professional health care providers,known as the Pharmacy and TherapeuticsCommittee, evaluates therapeutic classes ofdrugs and recommends coverage guidelines forour pharmacy benefit programs. The committeeuses current medical and pharmaceutical literature along with recommendations of expertsin various clinical specialties in its evaluation ofour pharmacy benefit programs. The result is a listof drugs (formulary) to allow for the availability ofappropriate medications for our members’ needs. Also, the formulary and coverage guidelines allowprescription costs and your premium to bemaintained at affordable levels. Definitions Prescription —Drugs which can only be dispensed upon order (prescription) by a qualified provider of care. Additionally, only drugs which are labeled “Caution: Federal law prohibits dispensing without prescription” will be considered eligible. Generic Drug — A drug available as a chemically and therapeutically equivalent copy of a brand- name drug. It is usually available from several manufacturers. Brand Drug — A prescription item only available from a single-source supplier. Multi-Source Brand Drugs — Brand-name drugs which are manufactured by more than one producer. These agents are usually available as generic equivalents. Over-the-Counter Drugs (OTC) — Drugs which are not restricted to prescription-only status. These agents are available for purchase without physician approval and are not covered by The Health Plan. Home Delivery Service — Certain group benefit designs allow members to receive medications at home via the mail. (See your specific benefit rider for details.) How to Use Your Prescription Benefit
Please present your Health Plan Identification Card to the pharmacist with your prescription. You will be required to pay a co-payment (“co-pay”) at the time of service based on the prescription plan in which you are enrolled. Your co-payment levels are found under the pharmacy benefit section Pharmacy Benefit of your Summary of Benefits. Your ID card also contains important information to allow the pharmacy to correctly submit your claim to pharmacy benefits manager, Express Scripts. Additionally, information on how you may contact Express Scripts is included on the reverse side of your ID card. Coverage Management Rules Specialty Pharmacy Program Specialty drugs are those high-cost medications including drugs manufactured by biotechnology. Specialty drugs may be administered by injection, oral, transdermal, or inhaled. Specialty drugs are used to treat very specific diseases and require extensive management for safety and effectiveness. Dosages need to be monitored for effect and adjustments might be needed for adequate response to effectively treat the disease.
Specialty drugs require complex dispensingtechniques. As such, dispensing might be limitedto pharmacies with specific skills and distributionprograms to assure proper delivery of thesemedications.
Specialty drugs require prior authorizations toassure the patient is an appropriate candidate forthe drug. Additionally, oversight is an integralpart of the prior authorization process. The planwill monitor the use of the specialty drug for:
• Dose optimization • Appropriate monitoring (including required • Patient compliance to prescribed therapy • Proper disposal of ancillary material used in
the delivery of the medication (e.g., syringes)
• Drug interaction monitoring • Dispensing limited to 31-day supply • Prior authorization required prior to dispensing • Quantity limits may apply • Approval periods for authorization may vary
Diseases that are targeted to receive therapy withspecialty pharmacy drugs include, but are notlimited to, rheumatoid arthritis, severe chronicpsoriasis, multiple sclerosis, hepatitis C, hemophilia,certain cancers, growth deficiency, cystic fibrosis,Crohn’s disease, and organ transplant.
Coverage for these agents is provided under yourSpecialty Pharmacy benefit.
Co-insurance will apply. If you have a prescriptionrider with an annual cap, Specialty Pharmacyexpenses will not apply to the cap.
The list of specialty drugs is available at www. Healthplan.org
Drugs requiring prior authorization Certain medications are eligible for coverage only after a patient-specific approval has been authorized. Patient-specific criteria may include age, gender, and clinical conditions determined by the physician for authorization to be granted for a specific drug. Your physician must contact The Health Plan for information on specific drugs and the procedures for authorization. The physician (provider) information phone number is 800-624-6961 extension 7914. Quantity per dispensing event (QPC rules) Generally, The Health Plan allows dispensing of approved medications up to a 31-day supply per co-pay at the retail pharmacy network. Quantity per dispensing event rules (QPC) set thresholds that reduce exposure to unnecessary cost, without creating obstacles to access for most members. Drugs that are subject to QPC rules usually have specific limitations for use approved by the FDA. Examples include drugs to treat migraine headaches. These drugs, known as “triptans,” are to be used in specific doses up to a defined number of headaches per month. The QPC rules allow this specific number of triptan medications to be dispensed per 31-day benefit period. To inquire about QPC limits to request an exemption, have your provider contact pharmacy services at 800-624-6961 extension 7914. Non-Formulary Coverage Review Certain non-formulary medications are eligible for coverage only after a patient-specific approval has been authorized. Patient-specific criteria may include age, gender, and clinical conditions determined by the physician for authorization to be granted for a specific drug. Your physician must contact The Health Plan for information on specific drugs and the procedures for authorization. The physician (provider) information phone number is 800-624-6961 extension 7914. Generic difference policy (co-payment policy for multi-source drugs) If a prescription order specifies that a brand-name drug must be dispensed when the generic equivalent is available, or the prescription order allows for generic substitution and the member elects to have the prescription filled with a brand-name drug instead, the member must pay the brand co-payment plus the difference between The Health Plan cost of a brand name and its generic equivalent (i.e., The Health Plan only pays for the generic cost). Please note: Non- Formulary brand versions of generic drugs require coverage review as outlined above. Out-of-Area Emergencies
In situations of emergency need for a prescriptionoutside The Health Plan service area, pleasecontact Express Scripts for the location of aparticipating pharmacy in that area. Present your Health Plan Identification Card with theemergency prescription and pay your co-payment. If no pharmacy in the area participates withExpress Scripts, purchase the emergencyprescription and send your receipt to The HealthPlan. You will be reimbursed in full, less yourapplicable co-payment, for the prescriptionprovided the prescription meets the guidelinesspecified in this document.
Exclusions and Limitations The following will not be covered or paid for by The Health Plan: • The charge for any prescription refill other
than the number set by the prescriber. Additionally, no refills dispensed more thanone year from the date of the originalprescription.
• The charge for any prescription, oral or topical,
that is prescribed for cosmetic purposes.
• The charge for any medications not FDA-
approved for use in the general population.
• Off label use of a drug which is not medically
accepted. The Health Plan uses the sameguidelines as CMS for determining whether aproposed use is medically accepted. • The charge for a drug not prescribed by a
Health Plan qualified provider except in anemergency situation.
• The charge for any medication covered by any
Workers’ Compensation or occupationaldisease laws, any other group policy, orgovernment program which is not The HealthPlan's program.
• Vitamins are not covered. Prenatal vitamins • Certain preventative medications such as folic
benefit. Please contact The Health Plan fordetails. • Dental-related prescriptions such as, but
not limited to, oral fluorides, dental mouthwashes, devices used in dental therapy. Certain oral fluoride products may be coveredas a preventative medication. Contact TheHealth Plan for coverage details. • Prescriptions related to smoking cessation.
Your prescription benefit may providecoverage of some smoking cessation productsas preventative medications. Coverage ofthese products may be limited to certainformulary drugs as determined by The HealthPlan. • Prescriptions for drugs or devices used to • Prescriptions used to treat sexual dysfunction,
either oral or topical, or devices used forimpotence.
• Appliances and therapeutic devices which
may require a prescription are not covered. These include, but are not limited to,garments, splints, bandages, or bracesregardless of intended use.
Pain Management Program and Opiate/Opioid Management
Pain is considered chronic if it results from achronic pathological process, has recurredperiodically over months or years, or persistslonger than expected after an illness or injury. Typically, pain is considered chronic if it haspersisted for 6 months or more.
Components of the management programinclude: surveillance, evaluation of patientsseeking treatment for chronic pain and formularymanagement. Formulary management involvespreferring certain drugs for chronic paintreatment, limiting acute dosing to sufficientquantities to treat breakthrough pain, steptherapies (preferred drugs must be tried beforenon-preferred drugs) and prior authorization.
The acute use of opiate agents for moderate tosevere pain from acute injury/medical treatmentor surgical procedure will be limited. Totalallowable dosing of all opiate pain agents will bea maximum of 90 days of treatment per year. If apatient reaches 90 days of therapy, the coverageof the pain agents will be suspended, pendingreview for chronic pain management.
Prior authorization will be required for allextended-release opiate medications for chronicpain management. Formulary Guide Benefit reminders • Use a participating retail pharmacy to fill your prescriptions. You’ll pay only your co-payment up front. • Use Express Scripts for medications you take on a long-term basis. You’ll generally pay less for up to a 90-day supply. And your order can be conveniently delivered to your home or office. • Express Scripts may contact your doctor about your prescription. If you have a prescription for a nonpreferred medication, but a preferred alternative exists, Express Scripts may contact your doctor to ask whether the preferred drug would be right for you. • Your plan may have certain coverage limits.
If you submit a prescription for a medicationthat has coverage limits (e.g., for specific usesor for a specific days’ supply), the participatingpharmacy will let you know that more information will be needed from your doctor.
Visit Express-Scripts.com for more informationabout your prescription drug plan or to find aparticipating retail pharmacy near you. The Health Plan Formulary Member Guide What is this guide?
This guide contains a list of generic and brand-name drugs that are preferred by your health plan. • You will pay the lowest co-payment for • You will pay a higher co-payment for
brand-name drugs that are included on yourplan’s list of preferred drugs (“preferred”). • You will pay the highest co-payment
for brand-name drugs not included on yourplan’s list of preferred drugs (“nonpreferred”),and some high-cost preferred drugs. • Certain brand-name drugs that have a generic
equivalent are not covered unless authorizedthrough coverage review by The Health Plan.
• In some cases, your plan sponsor may not
cover certain medications listed in this member guide. • This information was in effect at the time of
printing and may be subject to change. Follow these easy steps to save money on prescription drugs:
doctor to consider prescribing one ofthe less expensive generic or preferredbrand-name drugs in this guide. Table of Contents Allergy/Asthma/Respiratory 2 generic drugs 3 preferred drugs (on your plan’s drug list) 16 nonpreferred drugs (not on your plan’s drug list) Alzheimer’s Disease Medications 4 generic drugs 5 preferred drugs (on your plan’s drug list) Antibiotics/Antifungals/Anti-Infectives 4 generic drugs 5 preferred drugs (on your plan’s drug list) 16 nonpreferred drugs (not on your plan’s drug list) Behavioral Health Medication 6 generic drugs 7 preferred drugs (on your plan’s drug list) 16 nonpreferred drugs (not on your plan’s drug list) Blood Pressure/Heart/ Cholesterol-Lowering Medications 8 generic drugs 9 preferred drugs (on your plan’s drug list) 16 nonpreferred drugs (not on your plan’s drug list) Diabetes Management 10 generic drugs 11 preferred drugs (on your plan’s drug list) 16 nonpreferred drugs (not on your plan’s drug list) Migraine/Headache Medications 10 generic drugs 11 preferred drugs (on your plan’s drug list) 16 nonpreferred drugs (not on your plan’s drug list) Visit Express-Scripts.com for more information. Table of Contents, cont. Miscellaneous CNS Medications 14 generic drugs OB-GYN/Hormone Replacement/Birth Control 12 generic drugs 13 preferred drugs (on your plan’s drug list) 17 nonpreferred drugs (not on your plan’s drug list) Osteoporosis (Bone Problems) 12 generic drugs 13 preferred drugs (on your plan’s drug list) 17 nonpreferred drugs (not on your plan’s drug list) Overactive Bladder Medications 12 generic drugs 13 preferred drugs (on your plan’s drug list) Pain Relievers 14 generic drugs 15 preferred drugs (on your plan’s drug list) Stomach Problems 14 generic drugs 15 preferred drugs (on your plan’s drug list) 17 nonpreferred drugs (not on your plan’s drug list)
You and your doctor can look for a medication eitherby its therapeutic category or through the alphabeticalindex in the back. Keep in mind that you’ll pay moremoney for a nonpreferred medication that is not onyour plan’s drug list.*
*See your Prescription Drug Benefit brochure for informationabout your prescription drug costs. Allergy/Asthma/Respiratory Medications Lower-Cost Generics
2 ** Covered under medical benefit, co-insurance applies. Allergy/Asthma/Respiratory Medications Preferred Brands
ForadilIntal InhalerNasonexPerforomist**ProAir HFAPulmicort FlexhalerPulmozyme**Qvar
* Prior Authorization Required ** Covered under medical benefit, co-insurance applies. Medications listed in boldface have generic equivalents. Alzheimer’s Disease Medications Lower-Cost Generics Antibiotics/Antifungals/Anti-Infectives Lower-Cost Generics Alzheimer’s Disease Medications Preferred Brands Antibiotics/Antifungals/Anti-Infectives Preferred Brands
**Quantity limitations may apply. ***Covered under medical benefit, co-insurance applies. Medications listed in boldface have generic equivalents. Behavioral Health Medications Lower-Cost Generics
imipramine HClimipramine pamoatelorazepamloxapine succinatemaprotiline HClmirtazapine tablet
Behavioral Health Medications Preferred Brands
** Requires trial of generic or other preferred brand for patients new to therapy. Medications listed in boldface have generic equivalents. Blood Pressure/Heart/ Cholesterol-Lowering Medications Lower-Cost Generics Blood Pressure/Heart/ Cholesterol-Lowering Medications Preferred Brands
ExforgeExforge HCTLovazaMicardisMicardis HCTMultaqPradaxaRanexaTekamloTekturna
Diabetes Management Lower-Cost Generics Migraine/Headache Medications Lower-Cost Generics Diabetes Management Preferred Brands
Januvia**Juvisync**Kombiglyze XR**LantusLevemirNovolinNovolog, Mix
* Prior Authorization Required**Requires initial attempt on metformin or generic metformin combination product prior
Migraine/Headache Medications Preferred Brands
Quantity limits apply to migraine medications. OB-GYN/Hormone Replacement/ Birth Control Lower-Cost Generics
*Three copayments charged for 90-day supply of drug. Osteoporosis (Bone Problems) Lower-Cost Generics Overactive Bladder Medications Lower-Cost Generics OB-GYN/Hormone Replacement/ Birth Control Preferred Brands
EnjuviaNuvaRingOrtho EvraOrtho Tri-Cyclen LoPrefestPremarin TabletPremarin Vaginal CreamPremphasePremproVivelle Patch
Osteoporosis (Bone Problems) Preferred Brands Overactive Bladder Medications Preferred Brands
Myrbetriq Medications listed in boldface have generic equivalents. Pain Relievers Lower-Cost Generics Stomach Problems Lower-Cost Generics Miscellaneous CNS Medications Lower-Cost Generics Pain Relievers Preferred Brands
No preferred brand products inthis category. All brands andgenerics require priorauthorization
* Requires higher preferred co-payment. Stomach Problems Preferred Brands Miscellaneous CNS Medications Preferred Brands
There are no preferred brands currently available for this category.
*Requires higher preferred co-payment. Nonpreferred drugs require formulary coverage review. Medications listed in boldface have generic equivalents. Nonpreferred Medications Allergy/Asthma/Respiratory Behavioral Health Medications Medications Blood Pressure/Heart/ Cholesterol-Lowering Medications Antibiotics/Antifungals/ Anti-Infectives Diabetes Management
Apidra Solostar®Glyset®Humalog, Mix®Humulin®Jentadueto®Tradjenta®
* Prior authorization may be required.
16 ** Covered under medical benefit; coinsurance applies. Nonpreferred Medications OB-GYN/Hormone Replacement/ Birth Control
Osteoporosis (Bone Problems) Stomach Problems Aciphex®*
* Prior authorization may be required.
amitriptyline HCl.6amlodipine besylate.8amlodipine besylate/
Index, cont. Index, cont. Index, cont. M Macrodantin® .16 Index, cont. N nabumetone.14
niacin extended release.8nifedipine.8nifedipine tablet, sustained
Premarin Tablet.13Premarin Vaginal Cream .13
For additional information on benefits provided by The Health Plan, please visit www.healthplan.org.
This guide does not contain a complete list of formulary and nonformulary drugs. It only lists the most commonly prescribed drugs. For an updated and complete listing of your prescriptionbenefit, you can visit the “Benefit highlights” section of our website, Express-Scripts.com, andclick on “Learn about formularies.”
2013 Express Scripts Holding Company. All rights reserved.
PEDIATRICPHARMACOTHERAPYA Monthly Newsletter for Health Care Professionals from theChildren’s Medical Center at the University of Virginia Doxycycline for Pediatric Infections Marcia L. Buck, Pharm.D., FCCP T traditionally been limited in young children because of their ability to cause permanent staining of developing teeth. However, the Doxycycline is considered the antibiotic of in
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