OGB Pharmacy Benefits Program Full Formulary …

1 OGB Pharmacy Benefits Program Full Formulary administered by MedImpact April 2020 Foreword A Formulary is a list of both generic and brand-name prescription drugs that are preferred by a prescription drug Program . The purpose of the MedImpact Formulary is to provide your doctors and pharmacists with a method to evaluate the safety and effectiveness of commercially available prescription drugs. The MedImpact Formulary i s developed by MedImpact Healthcare Systems Pharmacy and Therapeutics (P&T) and Formulary Committees. The committees meet quarterly, and more often if needed, t o review new and existing medications and select drugs to be included in the Formulary based on safety and usefulness. Therefore, the Formulary may change during the plan year. Please contact MedImpact at ( 800) 910-1831 if you have any questions regarding the Formulary .

2 The MedImpact P&T and Formulary Committees use the following criteria in the evaluation of the drugs they review fo r inclusion in the Formulary : Drug safety How well the drug works Comparison of therapeutic Benefits to current Formulary agents of similar use Minimization of therapeutic duplication between similar medications Cost effectivenessHow to Use the Formulary The MedImpact Formulary includes three important components. Understanding these components and how they work together can help you save money. drugs are listed on the Formulary in alphabetical order by their generic names and/or most commonbranded name. If an FDA-approved generic equivalent is available, the generic name is generic drug is the same as a brand-name drug in terms of: Active ingredient(s) Dosage Safety Strength Quality The way it works The way it is taken The way it should be usedSavings Tip: When a generic drug is available, it s worth a conversation with your doctor to determine if this alternative will effectively treat your condition.

3 Drugs are assigned to a cost tier. The cost tier is designed to help you understand how much yourprescription may Tip: The lower the tier, the lower your out-of-pocket cost. TIER 0: Essential health benefit (EHB) Zero Copay/Preventive medications TIER 1: Preferred generic medications ( Formulary agents) TIER 2: Preferred medications ( Formulary agents) TIER 3: Non-preferred medications (non- Formulary agents) TIERS 4, 5, and 6: specialty medications 2 OGB Pharmacy Benefits Program Full Formulary Savings Tip: If your prescribed drug is identified as Tier 2 or 3, ask your doctor if there is a Tier 1 generic drug that will effectively treat your condition. The table below shows your costs for prescription drugs at the various tiers, both before and after you meet the out-of-pocket threshold: Before You Meet the Out-of-Pocket Threshold*, You (per 31 day supply) After You Meet the Out-of-Pocket Threshold*, You (per 31 day supply) Generic (Tier 1) 50% up to $30 $0 co-pay Preferred (Tier 2) 50% up to $55 $20 co-pay Non-Preferred (Tier 3) 65% up to $80 $40 co-pay specialty (Tiers 4/5/6) 50% up to $80 $40 co-pay *Your out-of-pocket threshold is $1,500 90-day fill option at retail or mail order network pharmacies: For maintenance medications, 90-day prescriptions may be filled for the applicable coinsurance with a maximum that is two and a half times the maximum copayment.

4 For example, if your share of the cost of a generic drug is $30, you can fill your 30-day prescription for $30 or a 90-day prescription for $75. 3. If a drug has prescribing guidelines, those guidelines are identified with the following symbols: Symbol Guideline Description AGE Age Edit Coverage may depend on patient age G Gender Edit Coverage may depend on patient gender PA Prior Authorization Requires specific physician request process QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period ST Step Therapy Coverage may depend on previous use of another drug Please refer to the prescribing guideline appendix within this document for details regarding specific agents. As you can see, the Formulary includes important and potentially cost-saving information.

5 3 OGB Pharmacy Benefits Program Full Formulary Savings Tip: Schedule time with your doctor to review this Formulary and all of your prescription drugs. It s always a good idea to periodically review your prescription drugs with your review could possibly save you money. Benefit Coverage and Limitations The Formulary applies only to drugs prescribed in an outpatient setting. It does not apply to medications used in inpatient settings. If you have specific questions regarding your coverage, you can contact MedImpact at (800) 910-1831. Depending on your specific prescription Program Benefits , the following topics may apply: SubstitutionWhen available and not prohibited by any existing state statutes, you will be required to use FDA approvedgeneric drugs in all situations, regardless of any brand name you or your doctor request a brand name drug in place of an approved generic drug, you will be requiredto pay the difference in cost between the brand and the generic.

6 If your doctor determines that there is adocumented medical need for the brand drug equivalent, a request for coverage may be made using themedication request Benefit DesignYour Pharmacy benefit is a tier benefit design, which means you share the cost of prescription drugs basedon the drug s tier and copayment or coinsurance. In most instances,preferred generic drugs will be coveredin a separate, lower tier (low copay); preferred branded drugs listed on the Formulary will be covered undera higher tier; and drugs not on the Formulary will be covered under a separate non-preferred drug copaytier. specialty drugs will be covered under the highest tier (highest copay). Essential healthbenefit/preventive medications, if available on the Formulary (applies to new and non-grandfathered plans),will be covered at no cost to TherapyStep Therapy is used to promote cost-effective pharmaceutical management when there are multipleeffective drugs to treat a condition.

7 Drugs that are listed in the Formulary as Step Therapy (ST) require oneor more prerequisite first step drugs to be tried before progressing to the second step drug. Most drugsthat call for step therapy require that you fill a generic drug before filling a brand name drug. The overallcost of the generic drug is usually lower than the brand named drug. If medically necessary, a second stepdrug can be obtained without first trying a first step drug by submitting a completed Medication RequestForm. Each request will be reviewed on an individual patient basis. Approval will be given if adocumented medical need exists. The following basic guidelines would be used to evaluate whethermedical need exists to approve a higher-tier drug: The use of the first step drug is not recommended for the patient.

8 The first step drug is not suited for the present patient care need, and the drug selected is required forpatient safety. The use of the first step drug may provoke an underlying condition, which would be detrimentalto patient As Written (DAW Penalty)If you or your doctor requests a brand-name medicine when a generic alternative is available, yourprescription cost will be higher. You will pay the brand copay plus the difference in cost between thebrand-name and the generic medicine. The penalty amount does not count toward the out-of-pocketmaximum; you ll pay this penalty even after you ve met the out-of-pocket Member ReimbursementsWhen you file a claim for reimbursement, the amount refunded will be limited to the rate contracted at thepharmacy minus your applicable copay, which may be less that the actual retail price paid.

9 4 OGB Pharmacy Benefits Program Full Formulary 5. Medication Request Process Depending on your Pharmacy Benefits Program design, a prior authorization process may be required: A. Coverage Exceptions Your prescription drug Program allows coverage for drugs and medications approved by the Food and Drug Administration (FDA) or its successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories. Drugs that are listed in the Formulary with a Prior Authorization (PA) designation require evaluation before they will be filled. You and your doctor must request the PA review and the review will be evaluated based on your individual situation. If your request does not meet the guidelines established by the P&T Committee, the request will not be approved; however, alternative therapy may be recommended.

10 The prior authorization process allows your doctor to request coverage of a non- Formulary or non-covered drug. Your doctor may request prior authorization for a certain quantity, dosage, or dosage form of a drug that is not covered under your Pharmacy benefit. Prior authorizations are completed by your doctor on a Medication Request Form. Most prior authorization requests are handled within two business days. Once your prior authorization is approved then your drug will be covered under your Pharmacy benefit. If your request is not approved, you will receive a letter explaining why the request was not approved and the steps you can take to appeal the decision. Compound Drugs: All compound drugs that cost more than $400 per prescription require prior authorization through MedImpact.