2019 FORMULARY GUIDE

2019 FORMULARY GUIDE

(Employee groups)

Pharmacy Benefits Management

Table of Contents

Overview ......................................................................................................................................................iii Important Phone Numbers............................................................................................................................iii Understanding Coverage and Cost-Sharing .................................................................................................iii

Formulary ................................................................................................................................................iii Understanding Our Symbols ........................................................................................................................ iv

Prior Authorization .................................................................................................................................. iv Step Therapy............................................................................................................................................iv Quantity Limits ........................................................................................................................................ iv About Generic Drugs.................................................................................................................................... iv How to Fill Your Prescription Medications................................................................................................... v Medication Supplies Not Covered by IU Health Plans ............................................................................ vi Formulary Listing ......................................................................................................................................... 1

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Pharmacy Benefits Management

Overview

This guide provides an overview of your pharmacy benefit. It explains the tiers for drug coverage, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more.

Important Phone Numbers

Pharmacy Services - 844.432.0704.

Understanding Coverage and Cost-Sharing

Formulary The Formulary, also known as your Preferred Drug List, is a list of prescription drugs that are covered under your plan. The inclusion of specific medications on the IU Health Plans formulary is based on the medication's effectiveness, safety, and value.

The formulary offers a wide selection of generic and brand name prescription drugs suggested by the Pharmacy and Therapeutics (P&T) Committee, a group of physicians and pharmacists who researches and evaluates medications. The formulary is periodically reviewed and updated throughout the year in order to ensure that our benefits package consistently and adequately meets your needs.

When you need a prescription medication, you and your doctor can choose from five different levels of the formulary. These are Preferred Generics ? Tier 1, Generics ? Tier 2, Preferred Brands ? Tier 3, Non- Preferred Brands ? Tier 4 and Specialty ? Tier 5. Each level has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars.

Preferred Generic Medications ? Tier 1 have the lowest copayment/co-insurance. Generic drugs offer the same level of safety and quality as their brand-name equivalents. They have the same amount of active ingredients as brand-name medications. You are required to use a generic version of the drug if one is available.

Generic Medications ? Tier 2 have low copayment/co-insurance. Generic drugs offer the same level of safety and quality as their brand-name equivalents. They have the same amount of active ingredients as brand-name medications. You are required to use a generic version of the drug if one is available.

Preferred-Brand medications ? Tier 3 have the middle level copayment/co-insurance. These drugs are brand medications and "preferred" because of their value and effectiveness.

Non-Preferred Brand and Generic medications ? Tier 4 have a higher copayment/co-insurance level. These medications are brand and generic drugs that are more expensive and have similar effectiveness as tier 3 medications.

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Pharmacy Benefits Management

Specialty and High cost medications ? Tier 5 have the highest copayment/co-insurance level. These also include Specialty medications which usually treat complex and rare conditions. These drugs can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant).

Non-Formulary medications may be covered if the formulary medications do not work for you. If you require a Non-Formulary medication, your doctor may request coverage for the Tier 4 or Tier 5 copayment by making a request for an exception.

Understanding Our Symbols

Prior Authorization You will see the symbol "PA" next to certain drugs on our formulary tables. This is called prior authorization. Prior authorization helps ensure that you're using the best drugs in the safest way.

If you are currently taking or recently prescribed one of these drugs, please discuss possible alternatives or have your doctor request authorization by calling 844.432.0704.

Drugs that require prior authorization are often: Newer drugs for which the Health Plan wants to track usage. Non-formulary drugs which require the use of formulary drugs prior to coverage. These drugs are not used as a standard first option in treating a medical condition. Drugs with potential side effects that the Health Plan wants to monitor for patient safety. Drugs categorized as specialty medications.

Step Therapy You will see the symbol "ST" (Step Therapy) next to certain drugs on the formulary tables in this booklet. Step therapy ensures you are taking the most effective medication at the best cost. This means trying the least expensive medications usually generic medications or drugs that are considered as the standard first-line treatment.

How step therapy works Step 1: When your prescribed drug is impacted by step therapy, first you will be asked to try generic or first-line treatment drugs. The drug recommended will be approved by the Food and Drug Administration (FDA) as providing the same health benefit at a much lower cost. Step 2: If the generic drug in step 1 does not work for you, then you will have coverage for a brand-name drug. For more information on step therapy call 844.432.0704.

Quantity Limits The symbol "QL" next to the drugs in this formulary booklet stands for Quantity Limits. To ensure you are getting the most cost-effective dose for your medication, a quantity limit or dose duration may be placed on certain drugs. These limits are based on FDA guidelines, clinical literature, and manufacturer's instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs.

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Pharmacy Benefits Management

For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day.

Prescriptions for specialty medications are limited to a 30-day supply. For more information on quantity limits or dose durations call 844.432.0704.

About Generic Drugs

Generic drugs have the same active ingredients as their brand-name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection for 20 years. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you.

Generic drugs have the same active ingredients as brand-name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand-name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works.

The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand-name drug.

How to Fill Your Prescription Medications

Short-term medications These are drugs you need immediately. This includes medications used to treat short term infections, or to relieve pain temporarily. You can fill these prescriptions at network pharmacies accepting CVS prescriptions. Locate the nearest retail network pharmacy by calling 844.432.0704. To fill your prescription, present your member ID card and written prescription and pay your copayment/co- insurance as described above.

Long-term medications These are drugs you take on a regular basis. These could be drugs to treat asthma, high blood pressure, diabetes, etc. These medications can be mailed to your home for up to a 90-day supply.

Specialty medications Specialty medications treat specific medical conditions such as cancer, hemophilia, hepatitis, multiple sclerosis, psoriasis, pulmonary arterial hypertension, respiratory syncytial virus, rheumatoid arthritis, and more. You can fill these prescriptions:

Through IU Health Pharmacy

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