Your Prescription Drug Program

2013

Southwest www.upmchealthplan.com

The information in this booklet was current at the time it was printed. For the most up-to-date information, please go to our website at www.upmchealthplan.com. Select Members on the homepage. On the Members page, select Medical Assistance from the left column.

Table of Contents Your Prescription Drug Program................................................................................................................................................................ 1 Six-Prescription Limit..................................................................................................................................................................................... 1 Pharmacy Copayments................................................................................................................................................................................ 2 Plan Exclusions............................................................................................................................................................................................... 3 Dispensing Limitations................................................................................................................................................................................. 3 Temporary Supplies...................................................................................................................................................................................... 4 Generic Medications..................................................................................................................................................................................... 4 Step Therapy................................................................................................................................................................................................... 4 Step Therapy Medications.......................................................................................................................................................................... 4 Prior Authorization........................................................................................................................................................................................ 5 Prior Authorization Medications................................................................................................................................................................ 5 Quantity Limits............................................................................................................................................................................................... 6 Once-Daily Medications.............................................................................................................................................................................12 Pharmacies for Prescriptions.....................................................................................................................................................................12 Complaints, Grievances, and Fair Hearings...........................................................................................................................................13 Pharmacy Benefit Questions......................................................................................................................................................................13 UPMC for You Prescription Drug Formulary..........................................................................................................................................13 UPMC for You Over-the-Counter Formulary........................................................................................................................................25 Brand/Generic Reference Guide..............................................................................................................................................................29

Your Prescription Drug Program

Your doctor should order medications for you from the formulary. If your doctor writes you a prescription for a non-formulary medicine, he or she will need to contact Pharmacy Services at 1-800-979-UPMC (8762) for a medical exception. You will not be able to get the medication until we authorize the exception.

The UPMC for You Prescription Drug Formulary is a list of Food and Drug Administration (FDA) approved medications. This list has been developed by UPMC for You doctors and pharmacists. UPMC for You provides coverage (pays for) for medications on the formulary (drug list). The drugs on the formulary were selected because they are safe, work well, and cost less than other drugs that have the same level of effectiveness. For your convenience, there is a list of prescription medications and a list of over-the-counter (OTC) medications. These lists are in alphabetical order. The UPMC for You formulary includes the most commonly used drugs. It does not include every medication your doctor might prescribe. UPMC for You covers many other drugs besides the ones listed in the formulary.

You can get some over-the-counter medications when your doctor writes a prescription for them. Please refer to the UPMC for You Over-the-Counter formulary in this book, on pages 25-28, for a listing of covered products. If you have any questions, call Member Services at 1-800-286-4242. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 pm. TTY users should call toll-free 1-800-361-2629.

Six-Prescription Limit

conditions. This is called a Benefit Limit Exception (BLE). UPMC for You can grant a BLE if: • You have a serious chronic illness or health condition and without the additional prescription, your life would be in danger; or

Some prescription drugs covered by UPMC for You that are prescribed or ordered by your doctor (including originals and refills of existing prescriptions) are covered up to a maximum of six (6) prescriptions per calendar month. A six-prescription limit per month applies to members in the Adult and General Assistance benefit categories. The limit does not apply to members who meet any of the following criteria.

• You have a serious chronic illness or health condition and without the additional prescription, your health would get much worse; or • You would need more expensive health care services if the exception is not granted; or

The six prescription limit does not apply to:

• It would be against federal law for UPMC for You to deny the prescription.

• Members under the age of 21 • Pregnant women (including through the post-partum period)

Some exceptions will be automatic.

• Nursing facility and Intermediate Care facility residents

A benefit limit exception will happen automatically at the pharmacy if your prescription is for a drug that treats the conditions listed below. For the drugs that treat the conditions with an asterisk (*), UPMC for You must have a record of your illness for the BLE to happen automatically.

Certain medications are exempt from the limit. Your pharmacist will let you know if your medications are exempt. In some instances, UPMC for You can approve more than six (6) prescriptions if you have serious chronic illnesses or other serious health

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Drugs used to treat

Drugs used to Stop migraine headaches Suppress the immune system Reduce stomach acid for patients with gastrointestinal bleeding, Barrett’s esophagitis or Zollinger Ellison*

Abnormal or irregular heartbeat Angina Asthma or COPD (chronic obstructive pulmonary disease) Bipolar disorder Cancer Depression for patients with depression Diabetes Enzyme deficiencies Glaucoma Hemophilia Hepatitis High blood pressure for patients with angina, heart disease, heart attack, stroke, kidney disease, diabetes, or glaucoma HIV/AIDS Immune deficiency Infection for patients with HIV/AIDS, cancer, organ transplant, sickle cell anemia, or diabetes Multiple sclerosis Nausea and vomiting for patients with cancer or pancreatitis* Opiate dependency Parkinson’s disease Pulmonary hypertension Serious mental illness Thyroid disorders

How do you get an exception? If your prescription is not automatically approved at the pharmacy, you, your doctor, or other health care provider who prescribed the drug can ask UPMC for You for a Benefit Limit Exception (BLE). To ask for a BLE, the doctor or other health care provider who prescribed the drug must explain why you need the exception by either: • Faxing the UPMC for You “Pharmacy Benefit Limit Exception Request Form” to UPMC Health Plan Pharmacy Services at 412-454-7722, or • Calling 1-800-979-UPMC (8762) for urgent requests. Once UPMC for You receives the needed information, you will receive a response to the request within 24 to 72 hours. You and your doctor will get a written notice of the decision. If the request for an exception is denied, the written notice will explain how to appeal the denial. If you have been receiving the drug and your request for an exception is denied, and you file a complaint, grievance or request a fair hearing that is hand delivered or postmarked within 10 days of the written notice of the decision, you can get your drug while you wait for a decision about your appeal.

Drugs used to prevent

Additional information on how to file an appeal or how to request a BLE can be found in your Member Handbook.

Blood clots Pregnancy Seizures for patients with seizure disorder

*UPMC for You must have a record of your illness for the BLE to happen automatically.

Pharmacy Copayments

Pharmacy copayments do not apply to pregnant women (including through the post-partum period), recipients under the age of 18, nursing facility residents, and those who reside in an Intermediate Care Facility for the Mentally Retarded and Other Related Conditions (ICF/MR/ORC). Pharmacy copayments also do not apply to emergency supplies, family planning supplies, and recipients eligible under the Breast and Cervical Cancer Prevention and Treatment coverage group and Titles IV-B Foster Care and IV-E Foster Care and Adoption Assistance.

Some members may need to pay a small amount to the pharmacist for their medications. This is called a copayment. The pharmacist will let you know if a copayment applies to you. You cannot be denied a prescription drug if you cannot pay the copayment. Tell your pharmacist if you cannot afford to pay. Your pharmacy can still try to collect the copayment.

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Copayment information for members in the General Assistance Benefit category

Drugs, including immunizations, dispensed by a physician are excluded from copayments.

If you have pharmacy benefits, brand-name prescription drugs and brand-name over-the-counter drugs are $3 for each new prescription or refill.

You do not have to pay a copayment for certain drugs: anti-hypertensives (high blood pressure drugs), anti-neoplastics (cancer drugs), anti-diabetics (diabetes drugs), anti-convulsants (epilepsy drugs), cardiovascular preparations (heart disease drugs), antiParkinson’s agents (Parkinson’s disease drugs), AIDS drugs, anti-glaucoma agents (glaucoma drugs), antipsychotics (drugs for psychosis), and anti-depressants (drugs for depression).

If you have pharmacy benefits, generic prescription drugs and generic over-the-counter drugs are $1 for each new prescription or refill. Drugs, including immunizations, dispensed by a physician are excluded from copayments

If you have questions about copayments or which benefit you are eligible for, please call Member Services at 1-800-286-4242. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 pm. TTY users should call toll-free 1-800-361-2629.

Copayment information for members in the Adult Benefit category If you have pharmacy benefits, brand-name prescription drugs and brand-name over-the-counter drugs are $3 for each new prescription or refill. If you have pharmacy benefits, generic prescription drugs and generic over-the-counter drugs are $1 for each new prescription or refill.

Plan Exclusions

Antibiotics, controlled substances, and specialty medications are limited to a maximum 30-day supply per copayment.

The following medications are not covered under the Medical Assistance Program:

• Controlled substances are drugs with high abuse potential and have a schedule II-V classification according to the Drug Enforcement Agency (DEA) and Food and Drug Administration (FDA).

• DESI drugs • Drugs from manufacturers not participating in the Fee-for-Service (FFS) Medical Assistance Drug Rebate Program • Erectile dysfunction medications • Experimental/investigational medications • Drugs used for cosmetic purposes • Drugs used for fertility purposes • Weight loss drugs

• Specialty drugs are high-cost medications used to treat complex diseases. These medications usually require specialized handling and close monitoring by a doctor. Please ask your pharmacist or call our Member Services representatives to determine which drugs can be filled for a 90-day supply.

Dispensing Limitations

A medication may be refilled when 85% of the medication has been used. Authorizations for medications that are lost/misplaced, stolen, or destroyed/damaged must be reviewed by the UPMC for You Pharmacy Services Department.

Prescriptions must be dispensed by a network pharmacy. Some network pharmacies can provide up to a 90-day supply of maintenance drug for one copayment. Please ask your pharmacist or call our Member Services representatives to see if your pharmacy participates in this program. • A maintenance drug is one that you take on a regular basis for a chronic or long-term condition. 3

Temporary Supplies

counterparts and are just as safe and effective. Doctors are encouraged to prescribe generic medications whenever clinically appropriate. If your doctor prescribes a drug by brand name, your pharmacist will give you a generic version of that drug. If your doctor thinks you need the brand-name version of the drug, your doctor will need to call Pharmacy Services at 1-800-979-UPMC (8762). Representatives are available Monday through Friday from 8 a.m. to 5 p.m.

UPMC for You will respond to all requests for exceptions within 24 hours. If a decision cannot be made in 24 hours, you will receive one of the following: • A 15-day supply of medication if your prescription qualifies as an ongoing medication. • A 72-hour supply of medication if you have an immediate need for it.

Generic Medications UPMC for You requires that generic medications be given to you when available. Generic drugs have the same active ingredients as their brand-name

Step Therapy Some medications listed on the UPMC for You formulary require specific medications to be used before you can receive the step therapy medication. The step therapy medications are automatically covered if we have a record that the required medication has been tried first. If there is no record that the required medication has been tried, your doctor is required to consult with UPMC for You Pharmacy Services before your pharmacy plan will cover the step therapy medication. The drugs are as follows:

Step Therapy Medications Actos

Clozapine (