AvMed Commercial 5-Tier Medication Formulary PDF

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AvMed Commercial 5-Tier Medication Formulary 2018 (04/01/2018) INTRODUCTION... 4 DRUG LIST PRODUCT DESCRIPTIONS... 4 DEFINITIONS... 5 BENEFIT COVERAGE AND LIMITATIONS... 6 Coverage... 6 Prior Authorization
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AvMed Commercial 5-Tier Medication Formulary 2018 (04/01/2018) INTRODUCTION... 4 DRUG LIST PRODUCT DESCRIPTIONS... 4 DEFINITIONS... 5 BENEFIT COVERAGE AND LIMITATIONS... 6 Coverage... 6 Prior Authorization Process... 6 Member Initiated Prior Authorization Process... 6 Quantity Limit Exception... 7 Progressive Medication Program (Step Therapy)... 7 Non-Formulary Medication Requests... 7 Tier Description... 7 Common Medical Exclusions... 7 Mandated Generic Substitution... 8 Health Care Reform - Preventive Medications... 8 TRANSITION OF CARE... 9 HOW CAN I SAVE MONEY ON PRESCRIPTIONS?... 9 HOW CAN I ORDER A FREE ONETOUCH DIABETIC METER SYSTEM?... 9 MAIL-SERVICE PRESCRIPTIONS... 9 MEDICATIONS PRE-PACKAGED AS A 3-MONTH SUPPLY... 9 CONTACT INFORMATION... 9 LEGEND NOTICE ANALGESICS NSAIDs NSAIDs, COMBINATIONS NSAIDs, TOPICAL COX-2 INHIBITORS GOUT OPIOID ANALGESICS NON-OPIOID ANALGESICS ANTI-INFECTIVES ANTIBACTERIALS ANTIFUNGALS ANTIMALARIALS ANTIRETROVIRAL AGENTS ANTITUBERCULAR AGENTS ANTIVIRALS MISCELLANEOUS ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ANTIMETABOLITES HORMONAL ANTINEOPLASTIC AGENTS IMMUNOMODULATORS KINASE INHIBITORS TOPOISOMERASE INHIBITORS MISCELLANEOUS CARDIOVASCULAR ACE INHIBITORS ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS ADRENOLYTICS, CENTRAL ALDOSTERONE RECEPTOR ANTAGONISTS ALPHA BLOCKERS ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ANTIARRHYTHMICS ANTILIPEMICS BETA-BLOCKERS BETA-BLOCKER/DIURETIC COMBINATIONS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS DIGITALIS GLYCOSIDES DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS DIURETICS HEART FAILURE NITRATES PULMONARY ARTERIAL HYPERTENSION MISCELLANEOUS CENTRAL NERVOUS SYSTEM ANTIANXIETY ANTICONVULSANTS ANTIDEMENTIA ANTIDEPRESSANTS ANTIPARKINSONIAN AGENTS ANTIPSYCHOTICS ATTENTION DEFICIT HYPERACTIVITY DISORDER FIBROMYALGIA HUNTINGTON'S DISEASE AGENTS HYPNOTICS MIGRAINE MOOD STABILIZERS MULTIPLE SCLEROSIS AGENTS MUSCULOSKELETAL THERAPY AGENTS MYASTHENIA GRAVIS NARCOLEPSY POSTHERPETIC NEURALGIA (PHN) PSYCHOTHERAPEUTIC-MISCELLANEOUS ENDOCRINE AND METABOLIC ACROMEGALY ANDROGENS ANTIDIABETICS CALCIUM REGULATORS CARNITINE DEFICIENCY AGENTS CONTRACEPTIVES ENDOMETRIOSIS ESTROGENS ESTROGEN/PROGESTINS ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS GAUCHER DISEASE GLUCOCORTICOIDS GLUCOSE ELEVATING AGENTS HUMAN GROWTH HORMONES HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS PHENYLKETONURIA TREATMENT AGENTS PHOSPHATE BINDER AGENTS POTASSIUM-REMOVING AGENTS PROGESTINS SELECTIVE ESTROGEN RECEPTOR MODULATORS THYROID AGENTS VASOPRESSINS MISCELLANEOUS GASTROINTESTINAL ANTIDIARRHEALS ANTIEMETICS ANTISPASMODICS CHOLELITHOLYTICS H2 RECEPTOR ANTAGONISTS INFLAMMATORY BOWEL DISEASE IRRITABLE BOWEL SYNDROME LAXATIVES OPIOID-INDUCED CONSTIPATION PANCREATIC ENZYMES PROSTAGLANDINS PROTON PUMP INHIBITORS SALIVA STIMULANTS STEROIDS, RECTAL ULCER THERAPY COMBINATIONS MISCELLANEOUS GENITOURINARY BENIGN PROSTATIC HYPERPLASIA URINARY ANTISPASMODICS VAGINAL ANTI-INFECTIVES MISCELLANEOUS HEMATOLOGIC ANTICOAGULANTS HEMATOPOIETIC GROWTH FACTORS IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS PLATELET AGGREGATION INHIBITORS PLATELET SYNTHESIS INHIBITORS STEM CELL MOBILIZERS MISCELLANEOUS IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS AUTOIMMUNE AGENTS DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) IMMUNOMODULATORS IMMUNOSUPPRESSANTS NUTRITIONAL/SUPPLEMENTS ELECTROLYTES VITAMINS AND MINERALS RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ANTICHOLINERGICS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ANTIHISTAMINES, LOW SEDATING ANTIHISTAMINES, SEDATING ANTITUSSIVES ANTITUSSIVE COMBINATIONS BETA AGONISTS CYSTIC FIBROSIS LEUKOTRIENE MODULATORS MAST CELL STABILIZERS NASAL ANTIHISTAMINES NASAL STEROIDS/COMBINATIONS PHOSPHODIESTERASE-4 INHIBITORS PULMONARY FIBROSIS AGENTS STEROID/BETA AGONIST COMBINATIONS STEROID INHALANTS XANTHINES MISCELLANEOUS TOPICAL DERMATOLOGY MOUTH/THROAT/DENTAL AGENTS OPHTHALMIC OTIC WEBSITES INDEX INTRODUCTION The AvMed Commercial 5-Tier Medication Formulary was developed to serve as a guide for prescribers, pharmacists, health care professionals and members in the selection of cost-effective medication therapy. AvMed recognizes that medication therapy is an integral part of effective health management. Due to the vast availability of medication options, a reasonable program for medication selection and use is warranted. This document reflects the expert opinion and effort of AvMed's Pharmacy and Therapeutics (P&T) Committee, which is comprised of practicing physicians and pharmacists representing different specialties. The P&T Committee continually reviews new and existing medications to ensure this medication formulary remains responsive to the needs of our members and health care professionals. The criteria used by the P&T Committee to evaluate medication selection for the formulary includes, but is not limited to: medication safety profile, medication efficacy and effectiveness data, comparison of similar prescription or overthe-counter (OTC) medications with equivalent indications and/or use while minimizing potential duplications, and assessment of equitable cost of medication. The medication formulary is a fluid document, which is continually reviewed and modified based on the current clinical opinion of AvMed's P&T Committee. This dynamic process does not allow this document to be completely accurate at all times. To accommodate regular changes, an updated electronic version of this formulary is available online at AvMed welcomes your input and feedback on the information provided in this document. DRUG LIST PRODUCT DESCRIPTIONS Products are listed by generic name with brand name for reference only. Boldface type indicates that the drug is available as a generic. If a brand-name product is listed in the Brand column, the listed Tier applies to the brand-name drug. If no brand-name drug is listed, the Tier applies to the generic product. To assist in understanding which specific strengths and dosage forms are on the AvMed Commercial 5-Tier Medication Formulary, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the formulary. Any exceptions are noted. Products on the AvMed Commercial 5-Tier Medication Formulary include all strengths and dosage forms of the cited brand-name product. pregabalin Lyrica Oral capsules, oral solution and all strengths of Lyrica would be included in this listing. When a strength or dosage form is specified, only the specified strength and dosage form is on the AvMed Commercial 5- Tier Medication Formulary. Other strengths/dosage forms of the reference product are not. acyclovir caps, tabs The acyclovir capsules and tablets are on the AvMed Commercial 5-Tier Medication Formulary. From this entry, the acyclovir ointment cannot be assumed to be on the list unless there is a specific entry. Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR. sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the AvMed Commercial 5-Tier Medication Formulary. Dosage forms on the AvMed Commercial 5-Tier Medication Formulary will be consistent with the category and use where listed. neomycin/polymyxin B/hydrocortisone Cortisporin Since Cortisporin is listed only in the OTIC section, it is limited to the otic solution and suspension. From this entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the AvMed Commercial 5-Tier Medication Formulary. 4 DEFINITIONS Brand Medication - A prescription medication that is usually manufactured and sold under a name or trademark by a pharmaceutical manufacturer, or a medication that is identified as a Brand medication by AvMed's Pharmacy Benefits Manager (PBM). Brand Additional Charge - The additional charge that must be paid if you or your prescriber choose a brand medication when a generic equivalent is available. The charge is the difference between the cost of the brand medication and the generic medication. This charge must be paid in addition to the applicable Non-Preferred brand copay. Generic Medication - A prescription medication that has the same active ingredient as a brand medication or is identified as a generic medication by AvMed's Pharmacy Benefits Manager. Generic products approved by the United States Food and Drug Administration (FDA) are just as effective and safe as the brand-name products. Generic medications contain identical active ingredients, have the same indication for use, meet the same manufacturing standards, and are identical in strength and dosage form as brand-name medications. Maintenance Medication - A medication that has been approved by the FDA, for which the duration of therapy can reasonably be expected to exceed one year. Participating Pharmacy - A pharmacy (retail, mail service, or specialty pharmacy) that has entered into an agreement with AvMed to provide prescription drugs to AvMed members and has been designated by AvMed as a participating pharmacy. Preferred Medication List - The listing of preferred medications as determined by AvMed's P&T Committee based on clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi-tiered list establishes different levels of copay for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been reviewed by AvMed's P&T Committee. Prescription Medication - A medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state and federal law. Prior Authorization - The process of obtaining approval for certain prescription drugs (prior to dispensing) according to AvMed's guidelines. The ordering prescriber must obtain approval from AvMed. The list of prescription drugs requiring prior authorization is subject to periodic review and modification by AvMed. To initiate a prior authorization, please visit our website at to obtain a Medication Exception Request Form (MER). Progressive Medication Program (Step Therapy) - Medications included in this program require trial of a first-line medication in order for a second-line medication to be covered under your pharmacy benefit. Coverage for a third-line medication requires trial of one or more first-line AND second-line medications. If for medical reasons you cannot use the first-line medication and require a second-line or third-line medication, your prescriber may request a prior authorization for you to have this medication covered. Certain medications may be grandfathered in for members who are controlled on a second-line or third-line medication. Self-Administered Injectable Medication - A medication that has been approved by the FDA for self-injection and is administered by subcutaneous injection. Prior authorization is required for all self-administered injectable medications, except Insulin. Specialty Medication - A self-injectable or high-cost oral medication approved by the FDA. These medications must be prescribed by a physician and dispensed by either a retail or participating specialty pharmacy, depending on the medication. The copayment levels for Specialty Medications apply regardless of provider. This means that you may be responsible for the appropriate copayment whether you receive your Specialty Medication from the pharmacy, at the physician's office or during home health visits. Specialty Medications are limited to a 30-day supply. Quantity Limit - Medications included in this program allow a maximum quantity per prescription and/or time period for one copay or coinsurance. Quantity limits are developed based upon FDA approved medication labeling and nationally recognized therapeutic clinical guidelines. If your prescription exceeds the quantity limit, a prior authorization will be required. 5 BENEFIT COVERAGE AND LIMITATIONS This medication formulary is for reference purposes only and does not guarantee nor define benefit coverage and limitations. Many members have specific benefits, which are not reflected in the AvMed Commercial 5-Tier Medication Formulary. You may contact AvMed's Member Engagement Department regarding any coverage questions by calling the number listed on the back of your card. Please note that the formulary process is dynamic and generally changes throughout the year. These changes typically occur due to, but not limited to, the following reasons: approval of new medications, availability of newly approved generics, changes in clinical data, and medication safety concerns. AvMed is not held responsible for payment in the event that either a medication was omitted or included in error, or that a medication was placed at an incorrect tier on this formulary. The following topics may or may not be applicable to individual members depending on member-specific benefit parameters. Coverage Your prescription medication coverage includes medications that require a prescription, are filled by an AvMed participating pharmacy, and are prescribed by your provider in accordance with AvMed's coverage criteria. AvMed reserves the right to make changes in coverage criteria for covered products and services. Coverage criteria are medical and pharmaceutical protocols used to determine coverage of products and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/pharmaceutical societies. Your retail prescription medication coverage includes up to a 30-day supply of a medication for the listed copay. In most cases, your prescription may be refilled after 75% of your previous fill has been used, and is subject to a maximum of 13 refills per year. Many plans have the opportunity to obtain a 90-day supply of a medication at a retail or mail pharmacy for a reduced amount. Please refer to your specific pharmacy benefits. Your mail-service prescription medication coverage includes up to a 90-day supply of most medications for the listed copay per your prescription benefits. If the amount of medication is less than a 90-day supply, such as a 75-day supply, you will still be charged the listed mail-service copay per your prescription benefits. Your specialty medication coverage extends to many self-injectable and high-cost oral medications approved by the FDA. These medications must be ordered by a prescriber and dispensed by a retail or specialty pharmacy, depending on the type of medication. The copayment levels for specialty medications apply regardless of provider. This means that you may be responsible for the appropriate copayment whether you receive your Specialty Medication from the pharmacy, at the physician's office or during home health visits. Specialty Medications are limited to a 30-day supply. Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty organizations, and/or evidence-based, statistically valid, clinical studies. This means that a medication-specific quantity limit may apply for medications that have an increased potential for over-utilization or an increased potential for a member to experience an adverse event at higher doses. Prior Authorization Process The prior authorization process requires the practitioner to provide information to support a requested exception request. These authorization requests must be submitted to AvMed by fax to using the Medication Exception Request Form. The Medication Exception Request Form is available at: https://www.avmed.org/documents/20182/ /commercial+medication+exception+request+form pdf/2bb997cd-15e7-4d98-9e57-d5cc4fcd5002. Information needed to make coverage determinations of medications requiring prior authorization may include lab values, prescription history, a statement of medical necessity and any other pertinent information to satisfy the established coverage guideline for the requested medication. Coverage determinations will be made within 1-2 business days if authorization is deemed urgent and within 3-5 business days if identified as standard or routine. Member Initiated Prior Authorization Process Members may request a prior authorization by directly contacting the AvMed Member Engagement Department at the number on their membership card. The member should have the prescriber information (phone number) and any pertinent information related to the request to provide to the Member Engagement Department. Members may also initiate the prior authorization process (Medication Exception) by logging into AvMed.org and then selecting Benefits , Physician Referrals & Authorizations and then selecting the link located under Prescription Medications . 6 Quantity Limit Exception Certain medications allow for a maximum quantity per prescription and/or time period for one copay or coinsurance. Medications with applicable quantity limits are noted on the formulary by QL . Quantity limits are developed based upon FDA-approved medication labeling and nationally recognized therapeutic clinical guidelines. If a prescription exceeds the quantity limit, the prescriber should provide a statement of medical necessity and request a prior authorization as described on page 6. For a current list of products subject to quantity limits please see our Quantity Limit web page. Progressive Medication Program (Step Therapy) Medications that require Step Therapy are noted on the formulary by ST . For a current list of products requiring this prior approval please see our Progressive Medication Program web page. Non-Formulary Medication Requests A request for a non-formulary medication requires documentation from the member's medical records and/or prescription claims history verifying the following: statement of medical necessity; contraindications to ALL other formulary alternatives; or therapeutic failure of adequate trials of one to three months of each and ALL other formulary alternatives. Non-formulary requests may be requested by the PRESCRIBER through the prior authorization process as described on page 6. Tier Description Each copay tier is assigned an established copayment, which is the amount you pay when you fill a prescription. Consult your benefit documents to determine your specific copayments, coinsurance, and/or deductibles that are part of your plan. You and your doctor decide which medication is most appropriate for you. Tier 1 - (Preferred Generics) - These are preferred generic medications and are in the low range for out-of-pocket expense. You should always consider Tier 1 medications if you and your doctor decide they are appropriate to treat your condition. Tier 2 - (Non-Preferred Generics) - These are non-preferred generic medications- or higher cost generic medications and are in the low to mid-range for out-of-pocket expense. Sometimes there are alternatives available in Tier 1 that may be appropriate to treat your condition. If you are currently taking a Tier 2 medication, ask your doctor whether there are lower copayment alternatives that may be right for your treatment. Tier 3 - (Preferred Brands) - These are preferred brand medications and are in the mid to higher range for out-ofpocket expense. Sometimes there are alternatives available in Tier 1 or Tier 2 that may be appropriate to treat your condition. If you are currently taking a Tier 3 medication, ask your doctor whethe
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