Mvp health care formulary eff. march 1, 2012

MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 1 MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 2 2012 Prescription Drug FormularyEffective March 1, 2012 Your physician is the person best suited to help you make decisions about prescription drugs, and the prescription drug information below is intended for consumer guidance only. This information relates to the Prescription Drug Formulary, generally, and may not describe your particular coverage. Your Certificate of Coverage or Summary Plan Description determines your benefits, limitations and excl usions.
Drug coverage and copayment/coinsurance for each tier is based upon the specific rider chosen by the employer group.
While every effort has been made to insure accuracy, some information may be out of date. The Formulary is subject to change based on decisions made by the Pharmacy & Therapeutics (P&T) committee. New drugs are not covered until reviewed by the P&T committee. Medications with an over-the- counter equivalent are not a covered benefit. Brand name drugs may be subject to additional member costs when a generic equivalent is available.
Your employer may have limited your coverage of certain prescription drugs. In the case of some drugs, the Plan limits coverage to a specific quantity or a specific course of treatment. The Plan may also require prior authorization on some cover ed drugs. If you need more information about policies regarding a specific drug, consult your physician or contact the Customer Care Center. If the medication you take is not listed below, contact the Customer Care Center at the phone number listed on your identification card. The Prescription Drug Formulary does not apply to members who receive coverage through an Indemnity plan. Some members have a three-tier prescription benefit for which copay levels are described below.
Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
ACE Inhibitors**
(blood pressure
lowering, includes
HCTZ combination
products)
Adrenal Hormones
Adrenergic
Antagonists**
Alzheimer’s
Agents**
Androgens
(male hormones)
ARBs/Renin
Inhibitors**
(includes HCTZ
combination products)
Anti-Anxiety
Agents**
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 3 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Antiarrhythmics**
(heart rhythm)
Antibiotics
Anticoagulants
Anticonvulsants**
(seizures)
Antidepressants**
be subject to prior authorization or step therapy as indicated Step therapy edits apply (must have failed tPrior authorization required when obtained at a pharmacy **All drugs in the category are available through Mail Service Obtain through CuraScript Specialty Pharmacy Does not require a prescription drug rider for MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 4 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Antiemetics
(nausea)
Antifungal
Antihistamines**
Antihistamine/
Decongestant
Combinations
Antihypertensive
Combinations**
(blood pressure
lowering)
Antimalarials
Antimycobacterials** ethambutol
Antiparasitics
Antiplatelet
Agents**
Antipsychotics**
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 5 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Antiretrovirals/HIV
Antispasmodic
Agents**
Antitussives &
Expectorants
Antiviral
Arthritis
Benign Prostatic
Hypertrophy
(BPH) Agents**
(prostate)
Beta-Blocking
Agents**
(blood pressure
lowering)
Blood Modifiers
Botulinum Toxins
Calcium Channel
Blocking Agents
(blood pressure
lowering)
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 6 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Cancer Drugs
Oforta#,+Purinethol*Soltamox*Sprycel#,+Sutent#,+Sylatron#,+Tarceva#,+ Glycosides**
CNS Stimulants
Contraceptives
(Oral/Topical/
Cough/Cold
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 7 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Diabetic Agents:
Insulin**
HumulinHumulin PenLantus/SolostarLevemirNovolinNovolin PenNovologNovolog MixNovolog PenRelion Diabetic Agents:
PrandinPrandiMetRiometSymlinTradjentaVictoza Diabetic
Meters & Strips
Digestants/
Enzymes**
Diuretics**
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 8 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Erectile
Dysfunction
Fertility Agents
Gaucher’s Disease
GI: Ulcer/
Heartburn
Agents**
GI: Inflammatory
Bowel & Misc.
Growth Failure
Replacement
Therapy**
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 9 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Immunoglobulin
Flebogamma#GamaSTAN#Gammagard#Gamunex/C#Hizentra#Iveegam#Octagam#Privigen#Vivaglobin# Immunomodulators
suppressants**
Interferons/
For Hepatitis
Intranasal
Corticosteroids**
Lipid/Cholesterol
Lowering Agents**
Migraine Agents
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 10 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Miscellaneous
(in various classes)
MS Agents
Muscle Relaxants
Narcotic
Antagonists
Nitrates/Angina
Others**
NSAIDS**
(pain & inflammation, etodolac/XL
arthritis)
Ophthalmic:
Anti-Infective
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 11 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Ophthalmic:
Glaucoma
Agents**
Ophthalmic:
Steroids,
Antiinflammatory
& Misc. Agents
Osteoporosis/
Paget’s Agents
Otic Preparations
Pain Relievers
(narcotic)
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 12 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Pain Relievers:
Miscellaneous**
Parkinson’s
Potassium
Supplements**
Kaochlor-EffKaon ClKlor-Con 25 meqK-LyteK-TabMicro-K Prostate Cancer
EligardFirmagonJevtana#Lupron DepotProvenge#TrelstarVantasViadurZoladex Respiratory:
Beta Agonists
(Oral, Inhaled)
Respiratory:
Corticosteroids**
Respiratory:
Leukotriene
Modifiers**
Respiratory:
Miscellaneous
Sedative/
Hypnotics
(sleep aids)
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 13 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Cessation Agents
Thyroid**
Antifungals
Anti-Infectives
Topical/Oral/
Injectable
Antipsoriatic &
Antiseborrheic
Miscellaneous
Topical Scabicides/
Pediculicides
Topical Steroids
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy MVP_Health_Care_Formulary3-1-12_March Form 2/21/2012 2:17 PM Page 14 Drug Category
MEDICAL (M)
The lowest copay choice and usually includes
The mid-range copay choice
The highest copay choice and includes all other
generic drugs.
and includes covered brand covered brand name drugs. Prior authorization
name drugs because of
is required for 2 tier riders.
their overall value.
Topical/Oral
Acne Products
Urinary Tract
Management
+Obtain through CuraScript Specialty Pharmacy M Does not require a prescription drug rider for coverage but may be subject to prior authorization or step therapy as indicated **All drugs in the category are available through Mail Service st Step therapy edits apply (must have failed Prior authorization required when obtained at a pharmacy www.mvphealthcare.com

Source: http://www.mvpselectcare.com/rx/documents/current-formulary.pdf