LIST OF COVERED DRUGS (FORMULARY) - …

1 2018 LIST OF COVERED DRUGS ( formulary ) IlliniCare Health (Medicare-Medicaid Plan) Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the DRUGS you take. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. If you have questions, please call IlliniCare Health Member Services at 1-877-941-0482 (TTY: 711) from 8 to 8 , Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit Updated 11/2018 HPMS Approved formulary File Submission ID: 18479 Version Number: 15 H0281_18_LODR_Approved_09202017 Notice of Non-Discrimination.

2 IlliniCare Health - MMAI (Medicare-Medicaid Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. IlliniCare Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. IlliniCare Health: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact IlliniCare Health's Member Services at 1-877-941-0482 (TTY: 711) from 8 to 8 , Monday through Friday.

3 After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. If you believe that IlliniCare Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; IlliniCare Health's Member Services is available to help you. You can also file a civil rights complaint with the Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800 368 1019, (TDD: 1-800 537 7697).

4 Complaint forms are available at Language Services ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-941-0482 (TTY: 711).ATENCI N: si habla espa ol, tiene a su disposici n servicios gratuitos de asistencia ling stica. Llame al 1-877-941-0482 (TTY: 711). UWAGA: Je eli m wisz po polsku, mo esz skorzysta z bezp atnej pomocy j zykowej. Zadzwo pod numer 1-877-941-0482 (TTY: 711). 1-877-941-0482 TTY 711) : , . 1-877-941-0482 (TTY: 711) . PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-941-0482 (TTY: 711). 1-877-941-0482) :711.(ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

5 Звоните 1-877-941-0482 (TTY: 711).. 1-877-941-0482 : , : (TTY: 711). : 1-877-941-0482 (TTY: 711). CH : N u b n n i Ti ng Vi t, c c c d ch v h tr ng n ng mi n ph d nh cho b n. G i s 1-877-941-0482 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-877-941-0482 (TTY: 711). : 1-877-941-0482 (TTY: 711) : . ATTENTION: Si vous parlez fran ais, des services d'aide linguistique vous sont propos s gratuitement.

6 Appelez le 1-877-941-0482 (ATS: 711). : , , . 1-877-941-0482 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verf gung. Rufnummer: 1-877-941-0482 (TTY: 711). H0281_18_LODR_Approved_09202017 This is a list of DRUGS that members can get in IlliniCare Health. IlliniCare Health MMAI (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. The List of COVERED DRUGS and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year.

7 You can always check IlliniCare Health s up-to-date List of COVERED DRUGS online at Limitations and restrictions may apply. For more information, call IlliniCare Health Member Services at 1-877-941-0482 (TTY: 711), 8 to 8 , Monday through Friday or read the IlliniCare Health Member Handbook. Si usted habla espa ol, hay servicios de asistencia de idiomas disponibles para usted sin cargo. Llame al 1-877-941-0482 (TTY: 711), de lunes a viernes, de 8:00 a 8:00 Despu s del horario de atenci n, los fines de semana y los d as feriados, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el siguiente d a h bil. La llamada es gratuita. You can get this document for free in other formats, such as large print, braille, or audio. Call 1-877-941-0482 (TTY: 711), 8 to 8 , Monday through Friday.

8 After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. If you would like us to send you member materials on an ongoing basis in other formats, such as Braille or large print, or in a language other than English, please call Member Services at the number at the bottom of the page. Tell Member Services that you would like to place a standing request to get your materials in another format or language. If you have questions, please call IlliniCare Health at 1-877-941-0482 (TTY: 711), 8 to 8 ? , Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit i Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of COVERED DRUGS .

9 You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription DRUGS are on the List of COVERED DRUGS ? (We call the List of COVERED DRUGS the drug List for short.) The DRUGS on the List of COVERED DRUGS that starts on page 1 are the DRUGS COVERED by IlliniCare Health. These DRUGS are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. IlliniCare Health will cover all medically necessary DRUGS on the drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a IlliniCare Health network pharmacy. IlliniCare Health may have additional steps to access certain DRUGS (see question #5 below).

10 You can also see an up-to-date list of DRUGS that we cover on our website at or call Member Services at 1-877-941-0482 (TTY: 711), 8 to 8 , Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. 2. Does the drug List ever change? Yes. IlliniCare Health may add or remove DRUGS on the drug List during the year. Generally, the drug List will only change if: a cheaper drug comes along that works as well as a drug on the drug List now, or we learn that a drug is not safe. We may also change our rules about DRUGS . For example, we could: Decide to require or not require prior approval for a drug . (Prior approval is permission from IlliniCare Health before you can get a drug .)