MDwise Formulary Introduction Hoosier Healthwise (HHW)

MDwise Formulary Introduction –Hoosier Healthwise (HHW)HHW members must use MDwise network pharmacies to access theirprescription drug benefit.How do I use the formulary?There are two ways to find your drug within the formulary:Medical ConditionDrugs in this formulary are grouped into categories depending on the type of medicalconditions that they are used to treat. For example, drugs used to treat a heart conditionare listed under the category “Cardiovascular Disease”. Then look under the categoryname for your drug.Alphabetical ListingThe Index provides an alphabetical list of all of the drugs included in this formulary.Both brand name drugs and generic drugs are listed in the Index. Look in the Index andfind your drug. Next to your drug, you will see the page number where you can findcoverage information. Turn to the page listed in the Index and find the name of yourdrug in the first column of the list. The formulary provides coverage information aboutdrugs covered by the plan. If you have trouble finding your drug in the list, turn to theIndex.All drugs are listed by their generic names and most common proprietary (branded)name. The Formulary may be accessed by using the Index, either by generic orproprietary name or by therapeutic drug category. In situations where an FDA-approvedgeneric equivalent is available, brand names are listed for reference purposes only, anddo not denote coverage for the brand name, unless specifically noted. All drugs are listedin each category in alphabetical order by generic name. Where an FDA-approved genericis available for the listed generic name, the generic name is bolded.

A generic drug has the same active-ingredient as the brand name drug. Generic drugsusually cost less than brand name drugs and are approved by the Food and DrugAdministration (FDA), which assures that the following conditions are met. The generic drug must contain the same active ingredients, be the same strength, andthe same dosage form as the brand name drug. The FDA has given an “A” rating compared to the brand name drug and thus thegeneric drug is determined to be therapeutically bioequivalent. When the above two criteria are met, a generic can be substituted with the fullexpectation that the substituted product will produce the same clinical effect andsafety profile as the prescribed product.Additional RequirementsSome covered drugs may have additional requirements or limits on coverage. Theserequirements and limits may include: Prior Authorization: MDwise requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval fromthe pharmacy benefits manager (MedImpact) before you fill your prescription. If youdon’t get approval, the drug may not be covered. Drugs that are subject to a priorauthorization will have a “PA” symbol next to the drug. Physicians and Pharmaciescall (844) 336-2677 or FAX: (858) 790-7100.Quantity Limits: For certain drugs, the plan limits the amount of the drug that iscovered. Drugs that are subject to a quantity limit will have a “QL” symbol next tothe drug.Refill Limitations: Prescriptions may be refilled when 75% or more of the days’supply has been used.Step Therapy: In some cases, the plan requires you to first try certain drugs to treatyour medical condition before it will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, we may not coverDrug B unless you try Drug A first. If Drug A does not work for you, we will thencover Drug B. Drugs that are subject to Step Therapy will have a “ST” symbol nextto the drug.Age Limit: In some cases, drugs are only available to a member in a select agecategory. Drugs that are subject to an Age Limit will have an “AGE” symbol next tothe drug.Gender Limit: Some drugs are only available to members of a certain gender. Drugsthat are available to only a certain gender will have a “G” symbol next to the drug.You can find out if your drug has any additional requirements or limits by looking in theformulary starting on the next page.If you have any additional questions, please visit our website at mdwise.org or contact thecustomer service center at (844) 336-2677.

Table of ContentsAllergy. 3Antiemesis/Antivertigo.6Asthma And Copd. 6Autonomic Nervous System Disorders. 11Behavioral Health - Antidepressants. 12Behavioral Health - Other.14Cardiovascular Disease - Arrhythmia.23Cardiovascular Disease - Cardiac Stimulant.23Cardiovascular Disease - Hypertension. 23Cardiovascular Disease - Lipid Irregularity. 28Cardiovascular Disease - Miscellaneous Agents. 35Cardiovascular Disease - Vasodilation. 35Contraception/Oxytocics. 36Cough And Cold. 41Dermatology - Acne. 51Dermatology - Antiinfective. 53Dermatology - Antiinflammatory. 58Dermatology - Antipruritic Drugs. 60Dermatology - Miscellaneous. 60Dermatology - Pigmentation Disorders. 72Dermatology - Psoriasis/Eczema. 72Diabetes. 75Ear - General Disorders. 80Electrolyte Regulation. 81Endocrine Disorder - Fertility.83Endocrine Disorder - Other. 84Endocrine Disorder - Thyroid. 86Eye - General Disorders.87Eye - Glaucoma. 90Eye - Miscellaneous. 91Fluid Replacement. 92Gout And Related Diseases. 92Hematological Disorders. 92Hormonal Deficiency. 96Immunization. 98Immunosuppression/Modulation. 99Infectious Disease - Bacterial.100Infectious Disease - Fungal.102Infectious Disease - Miscellaneous. 103Infectious Disease - Parasitic. 104Infectious Disease - Viral. 104Inflammatory Disease. 108Local Anesthesia. 116Lower Gastrointestinal Disorders - Bowel Inflammat. 116Lower Gastrointestinal Disorders - Other. 118Medical Supplies. 123Miscellaneous Agents. 132Neoplastic Disease. 132Neurological Disease - Miscellaneous. 137Oral/Pharyngeal Disorders. 139Other Drugs.139Other Respiratory Disorders. 202Pain Management - Analgesics. 202Parkinsons Disease. 209Seizure Disorder. 210Skeletal Muscle Disorder. 212Smoking Cessation. 213Upper Gastrointestinal Disorders - Digestive. 2131

Upper Gastrointestinal Disorders - Spastic Disease. 215Upper Gastrointestinal Disorders - Ulcer Disease.215Urinary Tract - Functional Disorders. 218Vaginal Disorders. 220Vitamin And/Or Mineral Deficiency. 221Weight Reduction. 2762

DrugStatusNotesAllergy2Nd Gen Antihistamine & DecongestantCombinationsAll Day Allergy-DTier 1Allergy and Congestion ReliefTier 1Allergy Complete-DTier 1Allergy Relief D12Tier 1Allergy Relief D-24hrTier 1Allergy Relief,Nasal DecongestTier 1Allergy Relief-D (cetirizine)Tier 1Allergy-Congest Relief-D(fexo)Tier 1cetirizine-pseudoephedrineTier 1Clarinex-D 12 HOURTier 2fexofenadine-pseudoephedrineTier 1lorata-dine DTier 1Loratadine-DTier 1ST; QL (2 EA per 1 day)Allergenic Extracts, TherapeuticsOralairTier 2Palforzia (Level 1)Tier 2Palforzia (Level 2)Tier 2Palforzia (Level 3)Tier 2Palforzia (Level 4)Tier 2Palforzia (Level 5)Tier 2Palforzia (Level 6)Tier 2Palforzia (Level 7)Tier 2Palforzia (Level 8)Tier 2Palforzia (Level 9)Tier 2Palforzia (Level 10)Tier 2Palforzia (Level 11 Up-Dose)Tier 2Palforzia Initial DoseTier 2Palforzia Level 11 MaintenanceTier 2PAAntihistamines - 1St GenerationAhist (chlorcyclizine)Tier 2Ala-Hist IRTier 1Aller-ChlorTier 1Aller-G-TimeTier 1Allergy (chlorpheniramine)Tier 1Allergy (diphenhydramine) oral capsuleTier 1Allergy (diphenhydramine) oral tabletTier 1Allergy oral liquidTier 1Allergy Relief(chlorpheniramn) oral tabletTier 1Allergy Relief(diphenhydramin)Tier 1Allergy-TimeTier 13

DrugStatusBanophen oral capsuleTier 1Banophen oral tabletTier 1carbinoxamine maleate oral liquidTier 1carbinoxamine maleate oral tablet 4 mgTier 1Children's Allergy (diphenhyd) oral liquidTier 1Children's Allergy (diphenhyd) oral tablet,chewableTier 1Children's DiphenhydramineTier 1chlorpheniramine maleate oral tabletTier 1chlorpheniramine maleate oral tablet extended releaseTier 1clemastine oral tablet 2.68 mgTier 1Complete AllergyTier 1Complete Allergy MedicineTier 1cyproheptadineTier 1Dayhist AllergyTier 1DiphedrylTier 1Diphenhist oral capsuleTier 1diphenhydramine HCl oral capsuleTier 1diphenhydramine HCl oral dropsTier 1diphenhydramine HCl oral liquidTier 1diphenhydramine HCl oral tabletTier 1ED Chlorped JrTier 1Histex (triprolidine)Tier 2Histex PDTier 2Histex PDXTier 2hydroxyzine HCl oral solutionTier 1QL (100 ML per 1 day)hydroxyzine HCl oral tablet 10 mg, 25 mgTier 1QL (4 EA per 1 day)hydroxyzine HCl oral tablet 50 mgTier 1QL (8 EA per 1 day)hydroxyzine pamoateTier 1QL (4 EA per 1 day)Karbinal ERTier 2ST; QL (960 ML per 30 days)PediaClear-8Tier 2PediaventTier 2promethazine injectionTier 1promethazine oralTier 1Siladryl SATier 1triprolidine HClTier 1Valu-Dryl AllergyTier 1Antihistamines - 2Nd Generation24HR Allergy ReliefTier 1All Day Allergy (cetirizine)Tier 1Aller-easeTier 1Allergy Relief (cetirizine) oral capsuleTier 1Allergy Relief (cetirizine) oral tabletTier 1Allergy Relief (fexofenadine) oral tablet 180 mgTier 14Notes

DrugStatusNotesAllergy Relief (levocetirizin)Tier 1Allergy Relief (loratadine)Tier 1cetirizineTier 1Child Allergy Relf(cetirizine)Tier 1Children's Allergy Relief(lor)Tier 1Children's Allergy(cetirizine)Tier 1Children's CetirizineTier 1Children's LoratadineTier 1Child's All Day Allergy(cetir)Tier 1desloratadine oral tabletTier 1QL (1 EA per 1 day)desloratadine oral tablet,disintegratingTier 1ST; QL (1 EA per 1 day)fexofenadine oral tabletTier 1levocetirizine oral solutionTier 1levocetirizine oral tabletTier 1loratadine oral solutionTier 1loratadine oral tabletTier 1loratadine oral tablet,disintegratingTier 1ST; QL (10 ML per 1 day)Nasal Antihistamineazelastine nasalTier 1QL (60 ML per 30 days)olopatadine nasalTier 1QL (30.5 GM per 30 days)Tier 1ST; QL (23 GM per 30 days)Nasal Antihistamine & Anti-Inflam. Steroid Comb.azelastine-fluticasoneNasal Anti-Inflammatory Steroids24 Hour Nasal AllergyTier 1Allergy Relief (fluticasone)Tier 1QL (16 ML per 30 days)Beconase AQTier 2ST; QL (25 GM per 30 days)budesonide nasalTier 1flunisolideTier 1QL (25 ML per 30 days)fluticasone propionate nasalTier 1QL (16 GM per 30 days)mometasone nasalTier 1QL (17 GM per 30 days)Nasal AllergyTier 1OmnarisTier 2ST; QL (5 GM per 12 days)QNASL nasal HFA aerosol inhaler 40 mcg/actuationTier 2ST; QL (4.9 GM per 30 days)QNASL nasal HFA aerosol inhaler 80 mcg/actuationTier 2ST; QL (10.6 GM per 30 days)SinuvaTier 2triamcinolone acetonide nasalTier 1XhanceTier 2STZetonnaTier 2ST; QL (6.1 GM per 30 days)Nasal Mast Cell Stabilizers Agentscromolyn nasalTier 1Nasal Allergy Symptom ControlTier 15