CARE1ST HEALTH PLAN 2017 FORMULARY

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1 CARE1ST HEALTH PLAN 2017 FORMULARY FORMULARIO DE MEDICAMENTOS LIST OF COVERED DRUGS LISTA DE MEDICAMENTOS CUBIERTOS Counties / Condados: El Paso, Fresno, Los Angeles, Merced Orange, Riverside, San Bernardino, San Diego, San Joaquin, Santa Clara & Stanislaus PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN. Care1st Health Plan is a HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY:711), 8 a.m. - 8 p.m., 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY:711), de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. HPMS Approved Formulary , Version 23 This formulary was updated on 11/01/2017.The Formulary may change at any time. You will receive notice when necessary. For more recent information or other questions, please contact Care1st Health Plan at or, for TTY users, 711, seven days a week, 8:00 a.m. - 8:00 p.m., or visit Este formulario se actualizó el 11/01/2017.El Formulario puede cambiar en cualquier momento. Recibirá un aviso cuando sea necesario. Para obtener información más reciente o si tiene preguntas, comuníquese con Care1st Health Plan al , los usuarios de TTY deben llamar al 711, de 8:00 a. m. a 8:00 p. m., los siete días de la semana, o visite H5928_17_004_RX_REV Accepted H5928_17_004_RX_REV S Accepted

2 Note: to existing members: This formulary has changed since last year. When this drug list (formulary) refers to we, us, or our, it means Care1st Health Plan. When it refers to plan or our plan, it means Care1st AdvantageOptimum Plan (HMO), or Coordinated Choice Plan (HMO), or Care1st TotalDual Plan (HMO SNP). This document includes list of the drugs (formulary) for our plan which is current as of 11/01/2017. For 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, 2018, and from time to time during the year. What is the Care1st Health Plan Formulary? A formulary is a list of covered drugs selected by Care1st Health 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. Care1st Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Care1st Health Plan 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 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 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, 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 11/01/2017. To get updated information about the drugs covered by Care1st Health Plan, please contact us. Our contact information appears on the front and back cover pages. How does Care1st Health Plan let me know about changes to the Formulary? Every month Care1st Health Plan mails you a report called the Explanation of Benefits, or EOB. The EOB tells you the total amount you have spent on your prescription drugs and the total amount we have paid for each of your prescription drugs during the month. Along with your EOB, we will send you a Formulary Change Insert if there have been any recent changes to our formulary. Even if you have not recently filled any prescriptions, please carefully review this document when you receive it so you know if the formulary has changed. Please keep your Formulary Change Inserts. Filing them with your formulary will make sure you always have current information at hand about your covered drugs. In addition, copies of the formulary ii

3 change inserts will be posted on our web site at under Notice of Formulary Change. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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, Cardiac Drugs. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. 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 101. 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? Care1st Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient 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: Care1st Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Care1st Health Plan before you fill your prescriptions. If you don t get approval, Care1st Health Plan may not cover the drug. Quantity Limits: For certain drugs, Care1st Health Plan limits the amount of the drug that Care1st Health Plan will cover. For example, Care1st Health Plan provides 30 capsules per prescription for Namenda XR. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Care1st Health 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, Care1st Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Care1st Health 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 3. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. 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. iii

4 You can ask Care1st Health 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 Care1st Health Plan s formulary? on page iv for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Care1st Health Plan pays for certain OTC drugs. Care1st Health Plan will provide these OTC drugs at no cost to you. The cost to Care1st Health Plan of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap. BRAND NAME STRENGTH GENERIC NAME DOSAGE FORM LORATADINE 10 MG LORATADINE TABLET LORATADINE 5 MG/5ML LORATADINE ORAL SOLUTION LORATADINE 10 MG LORATADINE TAB RAPDIS FEXOFENADINE 60 MG FEXOFENADINE TABLET FEXOFENADINE 180 MG FEXOFENADINE TABLET 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 Care1st Health 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 Care1st Health 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 Care1st Health Plan. You can ask Care1st Health 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 Care1st Health Plan s Formulary? You can ask Care1st Health Plan 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 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, Care1st Health 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. iv

5 Generally, Care1st Health Plan 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 us 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. 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 91-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 circumstances where a beneficiary is changing from one treatment setting to another, Care1st Health Plan will ensure a fast process for approving non-formulary Part D drugs. This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy. Examples of level of care changes are: beneficiaries who are discharged from a hospital to a home; beneficiaries who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary; beneficiaries who end a long-term care facility stay and return to the community; and, beneficiaries who are discharged from psychiatric hospitals with medication regimens that are highly individualized. Care1st Health Plan s After Hours Service will provide pharmacies with access to representatives of the plan who have the ability to override pharmacy claims processing issues. This access will allow pharmacies to obtain prescription claims overrides at the point-of-sale and ensure that beneficiaries receive reliable access to medications. For more information For more detailed information about your Care1st Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. v

6 If you have questions about Care1st Health Plan, 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 1-800MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Care1st Health Plan s Formulary The formulary below provides coverage information about some of the drugs covered by Care1st Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 101. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ELIQUIS) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Care1st Health Plan has any special requirements for coverage of your drug. Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in Los Angeles and Orange Counties: Tier Copayment/Coinsurance 30 day supply 90 day supply $0.00 $0.00 Description Tier 1 Preferred Generic Generic $5.00 $12.50 Preferred Brand $40.00 $ Non-Preferred Brand $80.00 $ Specialty Tier 33% Coinsurance 33% Coinsurance Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in San Diego: Tier Copayment/Coinsurance 30 day supply 90 day supply $0.00 $0.00 Description Tier 1 Preferred Generic Generic $7.00 $17.50 Preferred Brand $45.00 $ Non-Preferred Brand $90.00 $ Specialty Tier 33% Coinsurance 33% Coinsurance vi

7 Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in Fresno County: Tier Description Copayment/Coinsurance 30 day supply 90 day supply Tier 1 Preferred Generic $0.00 $0.00 Generic $5.00 $12.50 Preferred Brand Non-Preferred Brand Specialty Tier $40.00 $ $80.00 $ % Coinsurance 33% Coinsurance Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in Santa Clara County: Tier Description Copayment/Coinsurance 30 day supply 90 day supply Tier 1 Preferred Generic $0.00 $0.00 Generic $5.00 $12.50 Preferred Brand Non-Preferred Brand Specialty Tier $40.00 $ $80.00 $ % Coinsurance 33% Coinsurance Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in El Paso County: Tier Description Copayment/Coinsurance 30 day supply 90 day supply Tier 1 Preferred Generic $0.00 $0.00 Generic $8.00 $20.00 Preferred Brand Non-Preferred Brand Specialty Tier $30.00 $75.00 $75.00 $ % Coinsurance 33% Coinsurance vii

8 Copayments/Coinsurance for members of Coordinated Choice Plan (HMO) in Fresno, Los Angeles, Merced, Orange, Riverside, San Bernardino, San Diego, Santa Clara and El Paso Counties: Tier Description Copayment/Coinsurance 30 day supply 90 day supply Tier 1 Preferred Generic $0.00 $0.00 Generic 25% Coinsurance 25% Coinsurance Preferred Brand Non-Preferred Brand Specialty Tier 25% Coinsurance 25% Coinsurance 25% Coinsurance 25% Coinsurance 25% Coinsurance 25% Coinsurance Copayments/Coinsurance for members of Care1st TotalDual Plan (HMO SNP) in Los Angeles, Orange, San Bernardino and, San Diego*: Tier Description Copayment/Coinsurance 30 day supply 90 day supply Tier 1 Preferred Generic $0.00 $0.00 Generic $0.00 to $3.30 copay, or 15% or 25% coinsurance $0.00 to $3.30 copay, or 15% or 25% coinsurance Preferred Brand $0.00 to $8.25 copay, or 15% or 25% coinsurance $0.00 to $8.25 copay, or 15% or 25% coinsurance Non-Preferred Brand $0.00 to $8.25 copay, or 15% or 25% coinsurance $0.00 to $8.25 copay, or 15% or 25% coinsurance Specialty Tier $0.00 to $8.25 copay, or 15% or 25% coinsurance $0.00 to $8.25 copay, or 15% or 25% coinsurance * Please refer to your Low Income Subsidy rider for the exact cost that applies to you. Requirements/Limits Legend Abbreviation QL ST Description Prior authorization required. Quantity limit Step therapy Requires a prior authorization to perform a Part B vs. Part D coverage determination. viii

9 Abbreviation LA GC MO Note This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or call Member Services at TTY/TDD users should call 711. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and through some of our network retail pharmacies. For more information call Member Services. Nota para miembros actuales: este formulario ha sido modificado con respecto al del año pasado. Cuando esta lista de medicamentos (formulario) dice nosotros, nos o nuestro/a, hace referencia a Care1st Health Plan. Cuando dice plan o nuestro plan, hace referencia a Care1st AdvantageOptimum Plan (HMO), o Coordinated Choice Plan (HMO), o Care1st TotalDual Plan (HMO SNP). Este documento incluye una lista de medicamentos (formulario) para nuestro plan que se encuentra en vigencia a partir del 11/01/2017. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de última actualización del formulario, aparece en las páginas de la portada y la portada posterior. Como norma general, debe usar las farmacias de la red para disfrutar del beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias o los copagos/el coseguro pueden cambiar el 1 de enero de 2018 y, ocasionalmente, durante el año, Qué es el Formulario de Care1st Health Plan? Un formulario es una lista de medicamentos cubiertos seleccionados por Care1st Health Plan con la colaboración de un equipo de proveedores de salud, que representa los tratamientos recetados que se cree que son parte necesaria de un programa de tratamiento de calidad. Por lo general, Care1st Health Plan cubrirá los medicamentos incluidos en el formulario, siempre y cuando el medicamento sea médicamente necesario, el medicamento recetado se obtenga en una farmacia de la red de Care1st Health Plan y se cumpla con otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos, revise nuestra Evidencia de cobertura. Puede cambiar el Formulario (lista de medicamentos)? En general, si usted está tomando un medicamento de nuestro Formulario para 2017 que estaba cubierto al comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2017, excepto cuando esté disponible un nuevo medicamento genérico de menor costo o cuando se dé a conocer nueva información adversa acerca de la seguridad o eficacia del medicamento. Otros tipos de cambios del formulario, como la eliminación de un medicamento de nuestro formulario, no afectarán a los miembros que actualmente estén tomando el medicamento. Permanecerá disponible al mismo costo compartido para aquellos miembros que lo tomen para el resto del año de cobertura. Consideramos que es importante que tenga acceso continuo a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan durante el resto del año de cobertura, salvo en los casos en los que usted podría ahorrar más dinero o que nosotros podríamos garantizarle su seguridad. Si retiramos medicamentos de nuestro formulario, agregamos autorizaciones previas, límites de cantidad o restricciones en tratamientos escalonados en relación con un medicamento o si pasamos un medicamento a un nivel superior de costo compartido debemos notificar sobre el cambio a los miembros afectados por el ix

10 cambio al menos 60 días antes de que entre e n vigencia dicho cambio, o cuando el miembro solicite una repetición del surtido del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 60 días. Si la Administración de Alimentos y Medicamentos (FDA) considera que un medicamento del formulario es inseguro o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro formulario y les informaremos a los miembros que toman el medicamento en cuestión. El formulario adjunto está en vigencia desde el 11/01/2017. Para obtener información actualizada sobre los medicamentos cubiertos por Care1st Health Plan, póngase en contacto con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. Cómo me informa Care1st Health Plan sobre los cambios en el Formulario? Todos los meses, Care1st Health Plan le envía por correo un informe que se denomina la Explicación de beneficios o EOB. La EOB le informa el monto total que gastó en sus medicamentos recetados y el monto total que nosotros pagamos por cada uno de sus medicamentos recetados durante el mes. Junto con su EOB, le enviaremos un Anexo de cambios del Formulario en caso de que haya habido cambios recientes en el formulario. Incluso si no ha obtenido medicamentos recetados recientemente, revise con atención este documento cuando lo reciba para saber si el formulario ha cambiado. Conserve los Anexos de cambios del Formulario. Si los archiva con el formulario, se asegurará de tener siempre la información actualizada sobre sus medicamentos cubiertos a mano. Además, se publicarán copias de los anexos de cambios del formulario en nuestro sitio web debajo de Notice of Formulary Change (Aviso sobre cambios en el Formulario). Cómo utilizo el Formulario? Existen dos formas de encontrar su medicamento en el formulario: Afección médica El formulario comienza en la página 1. Los medicamentos de este formulario se agrupan en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran en la categoría, Medicamentos para afecciones cardíacas. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página número 1. Luego, busque el medicamento debajo del nombre de la categoría. Listado alfabético Si no está seguro de qué categoría consultar, debe buscar su medicamento en el Índice que comienza en la página 101. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos aparecen en el Índice. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar la información de cobertura. Vaya a la página que se indica en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Care1st Health Plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la Administración de Alimentos y Medicamentos (FDA) dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. Generalmente, los medicamentos genéricos cuestan menos que los medicamentos de marca. x

11 Mi cobertura tiene alguna restricción? Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales en la cobertura. Estos requisitos y límites pueden incluir lo siguiente: Autorización previa: Care1st Health Plan exige que usted o su médico obtengan una autorización previa para determinados medicamentos. Esto significa que debe contar con la aprobación de Care1st Health Plan antes de obtener los medicamentos recetados. Si no obtiene la autorización, es posible que Care1st Health Plan no cubra el medicamento. Límites de cantidad: para determinados medicamentos, Care1st Health Plan limita la cantidad del medicamento que cubrirá Care1st Health Plan. Por ejemplo, Care1st Health Plan suministra 30 por medicamento recetado para Namenda XR. Esto puede ser complementario a un suministro estándar para un mes o tres meses. Tratamiento escalonado: en algunos casos, Care1st Health Plan requiere que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que Care1st Health Plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces Care1st Health Plan cubrirá el medicamento B. Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el formulario que empieza en la página 3. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos ingresando en nuestro sitio web. Hemos publicados documentos en línea que explican nuestra autorización previa y las restricciones en tratamientos escalonados. También puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de última actualización del formulario, aparece en las páginas de la portada y la portada posterior. Puede pedirle a Care1st Health Plan que haga una excepción a estas restricciones o límites o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección, Cómo solicito una excepción al formulario de Care1st Health Plan? en la página xii para obtener información sobre cómo solicitar una excepción. Qué son los medicamentos de venta libre (OTC)? Los medicamentos de venta libre son medicamentos no recetados que, por lo general, no cubre el plan de medicamentos recetados de Medicare. Care1st Health Plan cubre determinados medicamentos de venta libre. Care1st Health Plan le proporcionará estos medicamentos de venta libre sin costo. El costo de estos medicamentos de venta libre para Care1st Health Plan no se tiene en cuenta para los costos totales de los medicamentos de la Parte D (es decir, el monto que usted paga no se tiene en cuenta para la etapa del período sin cobertura). xi

12 NOMBRE DE MARCA CONCENTRACIÓN NOMBRE GENÉRICO FORMA DE DOSIFICACIÓN LORATADINA 10 MG LORATADINA COMPRIMIDO LORATADINA 5 MG/5 ML LORATADINA SOLUCIÓN ORAL LORATADINA 10 MG LORATADINA COMP. DIS. RÁP. FEXOFENADINA 60 MG FEXOFENADINA COMPRIMIDO FEXOFENADINA 180 MG FEXOFENADINA COMPRIMIDO Qué sucede si mi medicamento no está en el Formulario? Si su medicamento no figura en este formulario (Lista de medicamentos cubiertos), primero debe ponerse en contacto con el Departamento de Servicios para los miembros y preguntar si su medicamento está cubierto. Si resulta que Care1st Health Plan no cubre su medicamento, tiene dos opciones: Puede pedirle al Departamento de Servicios para los miembros una lista de medicamentos similares cubiertos por Care1st Health Plan. Al recibir la lista, muéstresela a su médico y pídale que le recete un medicamento similar cubierto por Care1st Health Plan. Puede pedirle a Care1st Health Plan que haga una excepción y cubra su medicamento. Consulte a continuación cómo solicitar una excepción. Cómo solicito una excepción al Formulario de Care1st Health Plan? Puede solicitar a Care1st Health Plan que haga una excepción a las reglas de cobertura. Hay varios tipos de excepciones que puede solicitarnos que hagamos. Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor. Puede pedirnos que cubramos un medicamento del Formulario a un nivel de costo compartido más bajo si este medicamento no está en el nivel de medicamentos especializados. Si se aprueba, esto reduciría el monto que usted debe pagar por su medicamento. Puede pedirnos que no apliquemos restricciones o límites en su medicamento. Por ejemplo, para un medicamento determinado, Care1st Health Plan limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción al límite y cubramos una cantidad mayor. Generalmente, Care1st Health Plan solo aprobará su pedido de excepción si los demás medicamentos incluidos en el Formulario del plan, el medicamento de menor costo compartido o las restricciones de uso adicionales no fueran tan eficaces para tratar su afección médica o pudieran causarle efectos médicos adversos. xii

13 Debe ponerse en contacto con nosotros para solicitarnos una decisión de cobertura inicial para una excepción al nivel del Formulario o a la restricción de uso. Cuando solicita una excepción al nivel del Formulario o a la restricción de uso, debe presentar una declaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas de recibida la declaración de respaldo de la persona autorizada a dar recetas. Puede solicitar una apelación acelerada (rápida) si usted o su médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le concede el trámite rápido de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas. Qué debo hacer antes de poder hablar con mi médico sobre el cambio de mis medicamentos o la solicitud de una excepción? Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están incluidos en el Formulario. También es posible que esté tomando un medicamento incluido en el Formulario pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su medicamento recetado. Debe hablar con su médico para decidir si debe cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al Formulario para que le cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado a seguir en su caso, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted sea miembro de nuestro plan. Para cada uno de los medicamentos que no están incluidos en el Formulario o si su capacidad para conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta para menos días) cuando acuda a una farmacia de la red. Después del primer suministro para 30 días, no seguiremos pagando estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días. Si reside en un establecimiento de cuidado a largo plazo, le permitiremos obtener una repetición del surtido hasta que le hayamos provisto un suministro de transición de 91 días, de manera consistente con el incremento de provisión (a menos que tenga una receta para menos días). Cubriremos más de una repetición del surtido de estos medicamentos para los primeros 90 días que sea miembro de nuestro plan. Si necesita un medicamento que no está en el Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días (a menos que tenga una receta para menos días) mientras solicita la excepción al formulario. En circunstancias en las que un beneficiario cambie de entorno de tratamiento, Care1st Health Plan garantizará un proceso rápido para la aprobación de medicamentos de la Parte D que no figuren en el formulario. Este proceso también se aplica a los medicamentos de la Parte D del formulario que requieren autorización previa o tratamiento escalonado. Algunos ejemplos de cambios en el nivel de atención son los siguientes: beneficiarios que reciben el alta del hospital y son trasladados a su hogar; beneficiarios que finalizan su estadía en un centro de atención de enfermería especializada (SNF) de la Parte A de Medicare y que necesitan cambiar al formulario de su plan de la Parte D; beneficiarios que finalizan su estadía en un establecimiento de cuidado a largo plazo y regresan a la comunidad; y beneficiarios que reciben el alta de hospitales psiquiátricos con regímenes de medicamentos altamente individualizados. El servicio fuera del horario de atención de Care1st Health Plan ofrecerá a las farmacias el acceso a representantes del plan que pueden anular problemas de procesamiento de reclamaciones de farmacias. Este acceso les permitirá a las farmacias obtener anulaciones de reclamaciones de medicamentos recetados en el punto de venta y garantizar que los beneficiarios tengan acceso confiable a los medicamentos. xiii

14 Para obtener más información Para obtener información más detallada sobre su cobertura para medicamentos recetados de Care1st Health Plan, revise su Evidencia de cobertura y otros materiales del plan. Si tiene preguntas sobre Care1st Health Plan, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de última actualización del formulario, aparece en las páginas de la portada y la portada posterior. Si tiene preguntas generales sobre la cobertura para medicamentos recetados de Medicare, llame a Medicare al MEDICARE ( ), las 24 horas, los 7 días a la semana. Los usuarios de TTY deben llamar al O bien, visite Formulario de Care1st Health Plan El formulario en la página siguiente brinda información sobre algunos de los medicamentos cubiertos por Care1st Health Plan. Si tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 101. La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca aparecen en letra mayúscula (por ejemplo, ELIQUIS), y los medicamentos genéricos aparecen en letra minúscula y cursiva (por ejemplo, simvastatina). La información en la columna Requisitos/Límites le indica si Care1st Health Plan tiene algún requisito especial para la cobertura de su medicamento. Los copagos/el coseguro para los miembros de Care1st AdvantageOptimum Plan (HMO) en los condados de Los Angeles y Orange: Copago/coseguro Nivel Descripción Suministro para 30 días Suministro para 90 días Nivel 1 Medicamentos genéricos $0.00 $0.00 preferidos Nivel 2 Medicamentos genéricos $5.00 $12.50 Nivel 3 Medicamentos de marca preferidos Medicamentos de marca no preferidos Medicamentos especializados Nivel 4 Nivel 5 $40.00 $ $80.00 $ Coseguro del 33% Coseguro del 33% Los copagos/el coseguro para los miembros de Care1st AdvantageOptimum Plan (HMO) en San Diego: Nivel Nivel 1 Nivel 2 Nivel 3 Copago/coseguro Suministro para 30 días Suministro para 90 días $0.00 $0.00 Descripción Medicamentos genéricos preferidos Medicamentos genéricos Medicamentos de marca preferidos xiv $7.00 $17.50 $45.00 $112.50

15 Nivel 4 Nivel 5 Nivel Descripción Medicamentos de marca no preferidos Medicamentos especializados Copago/coseguro Suministro para 30 días Suministro para 90 días $90.00 $ Coseguro del 33% Coseguro del 33% Los copagos/el coseguro para los miembros de Care1st AdvantageOptimum Plan (HMO) en el condado de Fresno: Nivel 1 Nivel 2 Nivel Descripción Medicamentos genéricos preferidos Medicamentos genéricos Copago/coseguro Suministro para 30 días Suministro para 90 días $0.00 $0.00 $5.00 $12.50 Nivel 3 Nivel 4 Nivel 5 Medicamentos de marca preferidos Medicamentos de marca no preferidos Medicamentos especializados $40.00 $ $80.00 $ Coseguro del 33% Coseguro del 33% Los copagos/el coseguro para los miembros de Care1st AdvantageOptimum Plan (HMO) en el condado de Santa Clara: Nivel 1 Nivel 2 Nivel Descripción Medicamentos genéricos preferidos Medicamentos genéricos Copago/coseguro Suministro para 30 días Suministro para 90 días $0.00 $0.00 $5.00 $12.50 Nivel 3 Nivel 4 Nivel 5 Medicamentos de marca preferidos Medicamentos de marca no preferidos Medicamentos especializados $40.00 $ $80.00 $ Coseguro del 33% Coseguro del 33% Los copagos/el coseguro para los miembros de Care1st AdvantageOptimum Plan (HMO) en el condado de El Paso: Nivel 1 Nivel Descripción Medicamentos genéricos preferidos Copago/coseguro Suministro para 30 días Suministro para 90 días $0.00 $0.00 xv

16 Nivel 2 Nivel Descripción Medicamentos genéricos Copago/coseguro Suministro para 30 días Suministro para 90 días $8.00 $20.00 Nivel 3 Nivel 4 Nivel 5 Medicamentos de marca preferidos Medicamentos de marca no preferidos Medicamentos especializados $30.00 $75.00 $75.00 $ Coseguro del 33% Coseguro del 33% Los copagos/el coseguro para los miembros de Coordinated Choice Plan (HMO) en los condados de Fresno Los Angeles, Merced, Orange, Riverside, San Bernardino, San Diego, Santa Clara y El Paso: Nivel 1 Nivel 2 Nivel Descripción Medicamentos genéricos preferidos Medicamentos genéricos Copago/coseguro Suministro para 30 días Suministro para 90 días $0.00 $0.00 Coseguro del 25% Coseguro del 25% Nivel 3 Nivel 4 Nivel 5 Medicamentos de marca preferidos Medicamentos de marca no preferidos Medicamentos especializados Coseguro del 25% Coseguro del 25% Coseguro del 25% Coseguro del 25% Coseguro del 25% Coseguro del 25% Los copagos/el coseguro para los miembros de Care1st TotalDual Plan (HMO SNP) en Los Angeles, Orange, San Bernardino y San Diego*: Nivel Descripción Copago/coseguro Suministro para 30 días Suministro para 90 días Nivel 1 Medicamentos genéricos $0.00 $0.00 preferidos Nivel 2 Medicamentos genéricos Copago de $0.00 a $3.30 o coseguro del 15% o del 25% Copago de $0.00 a $3.30 o coseguro del 15% o del 25% Nivel 3 Nivel 4 Nivel 5 Medicamentos de marca preferidos Medicamentos de marca no preferidos Medicamentos especializados Copago de $0.00 a $8.25 o coseguro del 15% o del 25% Copago de $0.00 a $8.25 o coseguro del 15% o del 25% Copago de $0.00 a $8.25 o coseguro del 15% o del 25% Copago de $0.00 a $8.25 o coseguro del 15% o del 25% Copago de $0.00 a $8.25 o coseguro del 15% o del 25% Copago de $0.00 a $8.25 o coseguro del 15% o del 25% * Consulte su Cláusula adicional para subsidio por bajos ingresos por el costo exacto que se aplica a su caso. xvi

17 Explicación de los requisitos/límites Abreviatura QL ST Abreviatura LA GC MO Descripción Se requiere autorización previa. Límite de cantidad. Tratamiento escalonado. Se requiere autorización previa para tomar una determinación de cobertura de la Parte B en comparación con la Parte D. Nota Estos medicamentos recetados pueden estar disponibles solamente en determinadas farmacias. Para obtener más información, consulte su Directorio de proveedores o llame al Departamento de Servicios para los miembros al Los usuarios de TTY/TDD deben llamar al 711. Proporcionamos cobertura adicional para este medicamento recetado durante la etapa del período sin cobertura. Consulte la Evidencia de cobertura para obtener más información sobre esta cobertura. Medicamento de mantenimiento. Se encuentra disponible un suministro de este medicamento para 90 días como máximo a través de las farmacias de pedidos por correo de nuestra red de servicios y mediante algunas de las farmacias minoristas de nuestra red de servicios. Para obtener más información, llame al Departamento de Servicios para los miembros. xvii

18 2017 Care1st Medicare Drug Formulary Table of Contents Analgesics... 3 Anesthetics... 6 Anti-Addiction/Substance Abuse Treatment Agents... 7 Antianxiety Agents...7 Antibacterials... 8 Anticancer Agents...15 Anticonvulsants...21 Antidementia Agents...23 Antidepressants Antidiabetic Agents...26 Antifungals...29 Antigout Agents Antihistamines...31 Anti-Infectives (Skin And Mucous Membrane)...32 Antimigraine Agents Antimycobacterials...33 Antinausea Agents...34 Antiparasite Agents...34 Antiparkinsonian Agents...35 Antipsychotic Agents Antivirals (Systemic)...38 Blood Products/Modifiers/Volume Expanders Caloric Agents...44 Cardiovascular Agents Central Nervous System Agents Contraceptives...53 Dental And Oral Agents...56 Dermatological Agents...57 Devices...61 Enzyme Replacement/Modifiers...66 Eye, Ear, Nose, Throat Agents...67 Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists...72 Hormonal Agents, Stimulant/Replacement/Modifying...72 Immunological Agents Inflammatory Bowel Disease Agents...80 Irrigating Solutions...81 Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents...84 Replacement Preparations...84 Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents...88 Vasodilating Agents Vitamins And Minerals

19 2

20 2017 Care1st Medicare Drug Formulary CURRENT AS OF 11/1/2017 Covered Medications Formulary Status Notes-Restrictions Analgesics Analgesics, Miscellaneous acetaminophen-codeine #2 oral tablet GC; QL (120 EA per 30 days) acetaminophen-codeine #3 oral tablet GC; QL (120 EA per 30 days) acetaminophen-codeine #4 oral tablet GC; QL (120 EA per 30 days) acetaminophen-codeine oral solution GC; QL (1800 ML per 30 days) ascomp-codeine oral capsule GC; QL (180 EA per 30 days) ASTRAMORPH INJECTION SOLUTION 0.5 MG/ML astramorph injection solution 1 mg/ml ; GC butalbital-apap-caff-cod oral capsule mg ; GC; QL (180 EA per 30 days) butalbital-asa-caff-codeine oral capsule GC; QL (120 EA per 30 days) codeine sulfate oral tablet GC; QL (120 EA per 30 days) endocet oral tablet mg, mg, mg, mg GC; QL (120 EA per 30 days) endodan oral tablet GC; QL (120 EA per 30 days) FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 200 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 400 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 600 MCG, 800 MCG fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr hydrocodone-acetaminophen oral solution mg/15ml, mg/15ml, mg/15ml hydrocodone-acetaminophen oral solution mg/5ml, mg/10ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg hydromorphone hcl injection solution 10 mg/ml ; QL (120 EA per 30 days) ; QL (60 EA per 30 days) ; QL (30 EA per 30 days) ST; GC; QL (10 EA per 30 days) GC; QL (1800 ML per 30 days) QL (1800 ML per 30 days) GC; QL (120 EA per 30 days) GC; QL (120 EA per 30 days) 3

21 hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml ; GC hydromorphone hcl oral tablet 2 mg, 4 mg GC; QL (120 EA per 30 days) hydromorphone hcl oral tablet 8 mg GC; QL (90 EA per 30 days) hydromorphone hcl pf injection solution 10 mg/ml, 500 mg/50ml LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT ; GC ; QL (75 EA per 30 days) lorcet hd oral tablet GC; QL (120 EA per 30 days) lorcet oral tablet GC; QL (120 EA per 30 days) lorcet plus oral tablet mg GC; QL (120 EA per 30 days) meperidine hcl oral solution ; GC; QL (600 ML per 30 days) meperidine hcl oral tablet ; GC; QL (120 EA per 30 days) methadone hcl injection solution ; GC methadone hcl intensol oral concentrate GC; QL (120 ML per 30 days) methadone hcl oral concentrate GC; QL (120 ML per 30 days) methadone hcl oral solution 10 mg/5ml GC; QL (600 ML per 30 days) methadone hcl oral solution 5 mg/5ml GC; QL (1200 ML per 30 days) methadone hcl oral tablet GC; QL (120 EA per 30 days) methadose oral tablet soluble GC; QL (90 EA per 30 days) morphine sulfate (concentrate) oral solution 10 mg/0.5ml morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate (pf) injection solution 0.5 mg/ml ; GC morphine sulfate er oral tablet extended release 100 mg morphine sulfate er oral tablet extended release 15 mg, 30 mg morphine sulfate er oral tablet extended release 60 mg QL (180 EA per 30 days) GC; QL (180 ML per 30 days) GC; QL (30 EA per 30 days) GC; QL (90 EA per 30 days) GC; QL (60 EA per 30 days) morphine sulfate oral solution 10 mg/5ml GC; QL (1800 ML per 30 days) morphine sulfate oral solution 20 mg/5ml GC; QL (900 ML per 30 days) MORPHINE SULFATE ORAL TABLET QL (120 EA per 30 days) OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG ; QL (60 EA per 30 days) oxycodone hcl oral capsule GC; QL (120 EA per 30 days) oxycodone hcl oral concentrate 10 mg/0.5ml QL (120 EA per 30 days) 4

22 oxycodone hcl oral concentrate 100 mg/5ml GC; QL (120 ML per 30 days) oxycodone hcl oral solution GC; QL (250 ML per 30 days) oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 5 mg GC; QL (120 EA per 30 days) oxycodone hcl oral tablet 30 mg GC; QL (60 EA per 30 days) oxycodone-acetaminophen oral solution GC; QL (600 ML per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg GC; QL (120 EA per 30 days) oxycodone-aspirin oral tablet mg GC; QL (120 EA per 30 days) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG, 30 MG ; QL (60 EA per 30 days) reprexain oral tablet mg, mg QL (120 EA per 30 days) reprexain oral tablet mg GC; QL (120 EA per 30 days) tramadol hcl oral tablet GC; QL (240 EA per 30 days) tramadol-acetaminophen oral tablet GC; QL (240 EA per 30 days) Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule ; GC; MO diclofenac potassium oral tablet GC diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release GC DICLOFENAC SODIUM TRANSDERMAL GEL 1 % diflunisal oral tablet GC GC etodolac er oral tablet extended release 24 hour GC; MO etodolac oral capsule GC; MO etodolac oral tablet GC; MO fenoprofen calcium oral tablet GC flurbiprofen oral tablet GC ibuprofen oral tablet 400 mg, 600 mg, 800 mg GC; MO indomethacin er oral capsule extended release ; GC indomethacin oral capsule ; GC ketoprofen er oral capsule extended release 24 hour ketoprofen oral capsule GC ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml, 60 mg/2ml GC ; GC; QL (20 ML per 30 days) ; GC; QL (20 ML per 30 ketorolac tromethamine intramuscular solution days) 5

23 ketorolac tromethamine oral tablet ; GC; QL (20 EA per 30 days) meclofenamate sodium oral capsule GC meloxicam oral tablet GC; MO nabumetone oral tablet GC naproxen dr oral tablet delayed release GC; MO naproxen oral suspension GC; MO naproxen oral tablet GC; MO naproxen sodium oral tablet 275 mg, 550 mg GC; MO oxaprozin oral tablet GC piroxicam oral capsule GC sulindac oral tablet GC tolmetin sodium oral capsule GC tolmetin sodium oral tablet GC Anesthetics Local Anesthetics dermacinrx empricaine external kit lidocaine external ointment ; GC LIDOCAINE EXTERNAL TCH 5 % lidocaine hcl (pf) injection solution 0.5 %, 1 %, 4 % lidocaine hcl (pf) injection solution prefilled syringe 10 mg/ml lidocaine hcl external gel 2 % GC lidocaine hcl external solution GC ; GC lidocaine hcl injection solution 0.5 %, 1 %, 2 % ; GC lidocaine hcl mouth/throat solution lidocaine viscous mouth/throat solution GC lidocaine-prilocaine external cream ; GC lidopril external kit lidopril xr external kit liprozonepak external kit livixil pak external kit lp lite pak external kit medolor pak external kit prilolid external kit 6

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