1 UPMC for Life 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: , Version Number 6. This formulary was updated on September 24, For more recent information or other questions, please contact UPMC for Life Member Services at or, for TTY users, , from 8 a.m. to 8 p.m., seven days a week,* or visit Y0069_15_2002 Accepted
3 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 UPMC Health Plan. When it refers to plan or our plan, it means UPMC for Life. This document includes a list of drugs (formulary) for our plan, which is current as of September 24, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from to time during the year. UPMC for Life has a contract with Medicare to provide HMO and PPO plans. Enrollment in UPMC for Life depends on contract renewal. This document may be available in an alternative format such as Braille, large print, or audio. Please call Member Services at , or, for TTY users, ,) from 8 a.m. to 8 p.m., seven days a week.* i
4 What is the UPMC for Life formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at our plan s network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 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. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access, for the remainder of the coverage year, to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits, and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of 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 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 September 24, To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If our plan makes non-maintenance drug changes to this formulary that were approved by the Centers for Medicare & Medicaid Services (CMS), we will notify members by mailing errata sheets that list the prescription drug, change made, and the effective date. This will enable members to have the most up-to-date information regarding the covered drugs on the plan s formulary. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 2. 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 Medications. If you know what your drug is used for, look for the category name in the list that begins on page number 2, then look under the category name for your drug. ii
5 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 103. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs 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. Turn to the page listed in the Index and find the name of your drug in the first column of the list. 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 ingredients 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: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides up to 30 tablets a month per prescription for Lansoprazole. This may be in addition to a standard one-month or three-month supply. 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, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 2. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan 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 UPMC for Life formulary? on page iv for information about how to request an exception. iii
6 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 Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the UPMC for Life formulary? You can ask us 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, this drug will be covered at a pre-determined cost-sharing level, and you would 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 this drug is not on the specialty drug tier. 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, our plan limits 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. Generally, UPMC for Life will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug, or 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 us to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your 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. iv
7 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 to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor 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 that is 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 up to a 93-day transition supply, consistent with dispensing increment (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 pursue a formulary exception. In addition, all members who experience a level-of-care change are eligible for a transition supply. A level-of-care change is when a member changes from one treatment setting to another. For example, if a member is discharged from an inpatient facility to home on a non-formulary medication, the member will be eligible for a transition supply of that non-formulary medication. You can receive up to a 30-day supply of the medication (unless you have a prescription written for fewer days) after being discharged, to allow time for you and your physician to switch to a formulary alternative or request an exception. After your first 30-day supply, we will not pay for the drug, unless an exception was approved. Our transition policy applies only to those drugs that are Part D drugs. The transition policy cannot be used to cover non-part D drugs. For more information For more detailed information about your UPMC for Life prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about UPMC for Life, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day/7 days a week. TTY users should call Or, visit v
8 UPMC for Life Formulary The formulary that begins on the next page provides coverage information about the drugs covered by UPMC for Life. If you have trouble finding your drug on the list, turn to the Index that begins on page 103. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., VENTOLIN HFA) and generic drugs are listed in lower-case italics (e.g., bupropion). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Formulary Drug Tiers The formulary drug tier table provides the tier description (e.g., generic) and member cost-sharing for prescription drugs on each drug tier. Please refer to the tables below based on the plan you are a member of, UPMC for Life HMO or PPO plan. For additional information on your plan, please refer to the Evidence of Coverage, or contact Member Services at , from 8 a.m. to 8 p.m., seven days a week. TTY users should call , from 8 a.m. to 8 p.m., seven days a week.* UPMC for Life drug tiers and cost-sharing amounts for 2015: Western Pennsylvania Region: UPMC for Life HMO Rx UPMC for Life HMO Rx Enhanced Drug Tier Drug Tier Description Member Cost-Sharing (30- or 90-day supply) Number 1 Generic drug tier $8 copay for a 30-day retail supply $24 copay for a 90-day retail supply $16 copay for a 90-day mail-order supply 2 Preferred Brand drug tier $45 copay for a 30-day retail supply $135 copay for a 90-day retail supply $ copay for a 90-day mail-order supply 3 Non-preferred Brand drug tier $95 copay for a 30-day retail supply $285 copay for a 90-day retail supply $285 copay for a 90-day mail-order supply 4 Specialty drug tier 33% coinsurance for a 30-day retail or mailorder supply (only) 5 Select Care drug tier $0 copay for a 30-day retail supply $0 copay for a 90-day retail supply Select $0 generic drugs $0 copay for a 90-day mail-order supply NOTE: Drugs are provided in a Long-term Care Facility up to a 31-day supply. vi
9 UPMC for Life drug tiers and cost-sharing amounts for 2015: Western Pennsylvania Region: UPMC for Life HMO Deductible with Rx UPMC for Life PPO High Deductible with Rx UPMC for Life PPO Rx Enhanced Drug Tier Drug Tier Description Member Cost-Sharing (30- or 90-day supply) Number 1 Generic drug tier $10 copay for a 30-day retail supply $30 copay for a 90-day retail supply $20 copay for a 90-day mail-order supply 2 Preferred Brand drug tier $45 copay for a 30-day retail supply $135 copay for a 90-day retail supply $ copay for a 90-day mail-order supply 3 Non-preferred Brand drug tier $95 copay for a 30-day retail supply $285 copay for a 90-day retail supply $285 copay for a 90-day mail-order supply 4 Specialty drug tier 33% coinsurance for a 30-day retail or mailorder supply (only) 5 Select Care drug tier $0 copay for a 30-day retail supply $0 copay for a 90-day retail supply Select $0 generic drugs $0 copay for a 90-day mail-order supply NOTE: Drugs are provided in a Long-term Care Facility up to a 31-day supply. vii
10 UPMC for Life drug tiers and cost-sharing amounts for 2015: Lancaster County Region: UPMC for Life HMO Deductible with Rx UPMC for Life PPO High Deductible with Rx Drug Tier Drug Tier Description Member Cost-Sharing (30- or 90-day supply) Number 1 Generic drug tier $10 copay for a 30-day retail supply $30 copay for a 90-day retail supply $20 copay for a 90-day mail-order supply 2 Preferred Brand drug tier $45 copay for a 30-day retail supply $135 copay for a 90-day retail supply $ copay for a 90-day mail-order supply 3 Non-preferred Brand drug tier $95 copay for a 30-day retail supply $285 copay for a 90-day retail supply $285 copay for a 90-day mail-order supply 4 Specialty drug tier 33% coinsurance for a 30-day retail or mail-order supply (only) 5 Select Care drug tier $0 copay for a 30-day retail supply $0 copay for a 90-day retail supply Select $0 generic drugs $0 copay for a 90-day mail-order supply NOTE: Drugs are provided in a Long-term Care Facility up to a 31-day supply. viii
11 List of Abbreviations B/D: This prescription 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. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the 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. 1
12 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET INTRAVENOUS SUSPENSION 4 B/D; MO AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 4 B/D; MO amphotericin b injection recon soln 1 B/D; MO CANCIDAS INTRAVENOUS RECON SOLN 4 B/D; MO clotrimazole mucous membrane troche ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 3 MO fluconazole oral suspension for reconstitution fluconazole oral tablet fluconazole in dextrose(iso-o) intravenous piggyback fluconazole in nacl (iso-osm) intravenous piggyback flucytosine oral capsule 4 MO griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet itraconazole oral capsule 1 PA; MO; QL (120 per 30 days) ketoconazole oral tablet MYCAMINE INTRAVENOUS RECON SOLN 4 MO NOXAFIL INTRAVENOUS SOLUTION 4 PA NOXAFIL ORAL SUSPENSION 4 PA; MO NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral suspension nystatin oral tablet PA; MO; QL (93 per 30 days) ONMEL ORAL TABLET 3 PA; MO; QL (30 per 30 days) terbinafine oral tablet voriconazole intravenous solution voriconazole oral suspension for reconstitution 4 MO
13 voriconazole oral tablet 4 MO ANTIVIRALS abacavir oral tablet abacavir-lamivudine-zidovudine oral tablet 4 MO acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous recon soln 1,000 mg 1 B/D acyclovir sodium intravenous recon soln 500 mg 1 B/D; MO acyclovir sodium intravenous solution 1 B/D adefovir oral tablet 4 PA; MO amantadine hcl oral capsule amantadine hcl oral syrup amantadine hcl oral tablet APTIVUS ORAL CAPSULE 4 MO APTIVUS ORAL SOLUTION 4 ATRIPLA ORAL TABLET 4 MO BARACLUDE ORAL SOLUTION 4 PA; MO BARACLUDE ORAL TABLET 4 PA; MO cidofovir intravenous solution 4 B/D; MO COMPLERA ORAL TABLET 4 MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 MO didanosine oral capsule,delayed release(dr/ec) EDURANT ORAL TABLET 4 MO EMTRIVA ORAL CAPSULE 2 MO EMTRIVA ORAL SOLUTION 2 MO EPIVIR ORAL SOLUTION 2 MO EPIVIR HBV ORAL SOLUTION 3 PA; MO EPZICOM ORAL TABLET 4 MO famciclovir oral tablet foscarnet intravenous solution 1 B/D; MO FUZEON SUBCUTANEOUS RECON SOLN 4 MO 3
14 ganciclovir sodium intravenous recon soln 4 MO INTELENCE ORAL TABLET 100 MG, 200 MG 4 MO INTELENCE ORAL TABLET 25 MG 3 INVIRASE ORAL CAPSULE 3 MO INVIRASE ORAL TABLET 4 MO ISENTRESS ORAL POWDER IN PACKET 2 ISENTRESS ORAL TABLET 4 MO ISENTRESS ORAL TABLET,CHEWABLE 2 MO KALETRA ORAL SOLUTION 4 MO KALETRA ORAL TABLET MG 3 MO KALETRA ORAL TABLET MG 4 MO lamivudine oral tablet 100 mg 1 PA; MO lamivudine oral tablet 150 mg, 300 mg lamivudine-zidovudine oral tablet 4 MO LEXIVA ORAL SUSPENSION 3 MO LEXIVA ORAL TABLET 4 MO moderiba oral tablet moderiba dose pack oral tablets,dose pack 4 MO nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE 3 MO NORVIR ORAL SOLUTION 3 MO NORVIR ORAL TABLET 3 MO OLYSIO ORAL CAPSULE 4 PA; MO; QL (30 per 30 days) PREZISTA ORAL SUSPENSION 3 MO PREZISTA ORAL TABLET 150 MG, 75 MG 3 MO PREZISTA ORAL TABLET 600 MG, 800 MG 4 MO REBETOL ORAL SOLUTION 4 MO RELENZA DISKHALER INHALATION BLISTER WITH DEVICE RESCRIPTOR ORAL TABLET 3 MO 2 MO; QL (120 per 365 days) 4
15 RESCRIPTOR ORAL TABLET, DISPERSIBLE 3 MO RETROVIR INTRAVENOUS SOLUTION 3 REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 4 MO ribasphere oral capsule ribasphere oral tablet 200 mg ribasphere oral tablet 400 mg 1 ribasphere oral tablet 600 mg 4 MO ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine oral tablet SELZENTRY ORAL TABLET 4 MO SOVALDI ORAL TABLET 4 PA; MO; QL (30 per 30 days) stavudine oral capsule stavudine oral recon soln STRIBILD ORAL TABLET 4 MO SUSTIVA ORAL CAPSULE 3 MO SUSTIVA ORAL TABLET 4 MO SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML 4 PA; MO 4 PA; MO; LA TAMIFLU ORAL CAPSULE 30 MG 2 MO; QL (84 per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG 2 MO; QL (42 per 180 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML TIVICAY ORAL TABLET 4 MO TRUVADA ORAL TABLET 4 MO 2 MO; QL (525 per 180 days) TYZEKA ORAL TABLET 4 PA; MO valacyclovir oral tablet VALCYTE ORAL RECON SOLN 4 MO VALCYTE ORAL TABLET 4 MO 5
16 VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 3 MO 3 MO VIRACEPT ORAL TABLET 4 MO VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 3 MO VIRAZOLE INHALATION RECON SOLN 4 MO VIREAD ORAL POWDER 4 MO VIREAD ORAL TABLET 4 MO ZIAGEN ORAL SOLUTION 3 MO zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet CEPHALOSPORINS cefaclor oral capsule cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin injection recon soln 1 gram cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 500 mg cefazolin intravenous recon soln 1 cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml 6 1 cefdinir oral capsule cefdinir oral suspension for reconstitution cefepime injection recon soln cefepime in dextrose,iso-osm intravenous piggyback 1 1
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