Care Choices Medication Guide - Florida Blue

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Care Choices Medication GuideNovember 2021Please consider talking to your doctor about prescribing one of the f ormulary medications that are indicated ascovered under your plan; which may help reduce your out-of -pocket costs. This list may help guide you andyour doctor in selecting an appropriate medication for you.The drug f ormulary is regularly updated. Please visit www.f loridablue.com for the most up-to-date inf ormation.ContentsPreferred Medication ListIntroduction . IMedication list . IIChanges to the formulary. IIYour Share of Expenses .IIIPharmacy Benef its .IIIPharmacy Options . VIIUtilization Management Programs. IXCoverage Exception Process. XINotice . XIIUsing the Medication Guide. XIIIAbbreviation Key .XIVAnti-Inf ective Drugs . 1Biologicals.12Antineoplastic Agents .15Endocrine and Metabolic Drugs.22Cardiovascular Agents .37Respiratory Agents .51Gastrointestinal Agents .55Genitourinary Agents .59Central Nervous System Drugs .62Analgesics and Anesthetics .75Neuromuscular Drugs .83Nutritional Products .91Hematological Agents.94Topical Products . 103Miscellaneous Products. 113Index . 184To search f or a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Editin the drop-down menu and select Find/Search. Type in the word or phrase you are looking f or and click onSearch .3022-O FL HIM Prime Therapeutics LLC 11/2021

IntroductionFlorida Blue is pleased to present the Care Choices Medication Guide. This is a general guide that includes acomprehensive listing of medications that may be covered under your plan. Since coverage f or medicationvaries by the plan purchased by you or your employer, it’s important that you ref er to your plan documents forcomplete coverage details. When we ref er to “plan documents” we are ref erring to one or more of the f ollowing:Benef it Booklet, Certif icate of Coverage, Contract, Member Handbook or prescription drug endorsement.The Care Choices Medication Guide provides helpf ul tips on how to make the most of your pharmacy benef itsand details about the various coverage programs that are designed to provide safe and appropriate medicationwhen you need it. Changes in the f ormulary can occur over time and the most up -to-date listing can always bef ound by viewing the Medication Guide online at www.f loridablue.com or by calling the customer servicenumber listed on your member ID card. For the hearing impaired, call Florida TTY Relay service 711.If you are a current member, we encourage you to log on to your member account f or plan specific detailsabout your medication coverage. Go to www.f loridablue.com, click on the Members tab. Once registered, youcan look up a medication by name and compare your cost at dif ferent pharmacies. You’ll see notes thatindicate if a medication requires a prior authorization or is not covered by your plan.Si de se a hablar sobre esta guía en español con uno de nuestros representantes, por f avor llame al númerodeatención al cliente indicado en su tarjeta de asegurado y pida ser transf erido a un representante bilingüe.NOTE: The decision concerning whether a prescription medication should be prescribed must be made byyou and your physician. Any and all decisions that require or pertain to independent prof essional medicaljudgment or training, or the need f or, and dosage of, a prescription medication, must be made solely by youand your treating physician in accordance with the patient/physician relat ionship.Key Tips and Coverage GuidelinesBy f ollowing these simple guidelines, you will be assured that you are getting the maximum benef it f rom your plan. When you have your prescriptions f illed, ask your pharmacist if a generic equivalent is available.Generic medications are usually less expensive, and most generics are covered unless specif icallyexcluded under your plan documents.Brand name medications are covered on your plan only if they are included in the medication list.Brand name medications not listed in the medication list are not covered.If you are currently taking a medication, take a moment to review the medication list to determineif it is covered. If not, check with your doctor to understand available options.If you or your provider request a covered brand name medication when there is a generic available;you will be responsible f or: (1) the dif ference in cost between the generic medication and the brandnamemedication you received; and (2) the cost share applicable to the brand name medication you received, asindicated on your Schedule of Benef itsFlorida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of HealthOptions, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross BlueShield Association.Florida Blue November 2021 Care Choices MedicationI

Medication ListThe Medication Guide includes the Pref erred Medication List and some commonly prescribed Non -Pref erredprescription medications. The Pref erred Medication List ref lects the current recommendations of Florida Blueand is developed in conjunction with Prime Therapeutics’ National Pharmacy & Therapeutics Committee.NOTE: This is not a complete listing of all covered prescriptions medications. Florida Blue reserves the rig ht t omodif y (add, remove or change) the tier or apply limits of coverage to any prescription medication in thisMedication Guide at any time.For your out-of -pocket expenses to be as low as possible, please consider asking your doctor to prescribe genericmedications, or if necessary, brand name medications that are included on the List. This will help ensure that yourcovered medications are allowed and reimbursed under your plan. In addition, consider using a participatingpharmacy to obtain your covered medications because your out-of-pocket expenses should be lower than if youused a non- participating pharmacy.To save the most money on medications, share this Medication Guide with your doctor or health care provider ateach visit so he or she is aware of the drugs listed and cost impacts when you discuss medication options.Changes to the formularyThis guide includes the medication list which ref lects the current recommendations of Florida Blue and isdeveloped in conjunction with Prime Therapeutics’ Natio nal Pharmacy & Therapeutics Committee. Florida Bluereserves the right to add or remove or change the tier of any medication in this Medication Guide at any time.The medication list is reviewed quarterly to examine new medications and new inf ormation abou t medicationsthat are already on the market concerning saf ety, ef fectiveness and current use in therapy.There are varying reasons changes are made to the medications listed in the Care Choices Medication Guide: The tier level of a brand name medication included on the medication list may increase(change to a higher tier) when an FDA-approved bioequivalent generic medication becomesavailable. Newly marketed prescription medications may not be covered until the Pharmacy & TherapeuticsCommittee has had an opportunity to review the medication, to determine whether the medication willbe covered and if so, which tier will apply based on saf ety, efficacy and the availability of otherproducts within that class of medications. Go to New To Market Drug List f or the most up-to-dateinf ormation.The most up-to-date inf ormation about modifications to the medications listed in this medication guide can bef ound by:Going to www.f loridablue.com. Click on the Members tab Click on the Login Now button and either Login or Register Once Logged in, click on My Plan, then select Pharmacy under Additional Items Under Pharmacy Resources, click on Medication Guide & Specialty Pharmacy Under Medication Guide/Approved Drug Lists, click Care Choices MedicationGuide Updated medication guides are posted periodically throughout the year.Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of HealthOptions, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross BlueShield Association.Florida Blue November 2021 Care Choices MedicationII

Formulary addition requestPhysicians may request the addition of a medication to the f ormulary list by submitting a written request toFlorida Blue.Please mail to:Florida BlueAttn: Pharmacy ProgramsP.O. Box 1798 Jacksonville,FL 32231-0014Your Share of ExpensesYour cost share will depend on which cost share tier the medication is assigned. You can determine your o ut -o f pocket amount f or medication by reviewing your Schedule of Benef its. If your plan includes a Deductible, you mayhave to satisf y that amount bef ore the costs of your medications are covered.If you or your provider requests a covered brand name medication when there is a generic medication available;you will be responsible f or: the dif ference in cost between the generic medication and the brand name medication; andthe cost share applicable to brand name medication, as indicated on your Schedule of Benef its.Example: If your drug copay is 10 f or generic and 40 f or brand, and you choose a brand name drugwhen a generic is available, here is what you might pay.Dif f erence in Drug Cost is 70 (Brand Drug Cost 120- Generic Drug Cost 50) Brand Co-Pay 40 110 is Your Total CostYour cost share f or HIV/AIDS drugs f ollows the OIR Saf e Harbor Guidelines. To determine the cost share f or yourHIV/AIDS drug check here2021 Safe Harbor Guidelines for HIV/AIDS DrugsNOTE: If you have a deductible, you must meet your deductible prior to the cost shares listed to applyPharmacy BenefitsThe pharmacy benef it has three parts/components, called Tiers. This means that covered medications must beincluded in one of the f ollowing Tiers, unless specifically excluded by your plan:Tier 1: Preventive Prescription Drugs and Supplies (USPSTF)Tier 2: Condition Care Generic Prescription Drugs and SuppliesTier 3: All Other Generic Prescription Drugs and SuppliesTier 4: Condition Care Brand Name Prescription Drugs and SuppliesTier 5: Pref erred Brand Name Prescription Drugs and SuppliesTier 6: Non-Pref erred Brand Name Prescription Drugs and SuppliesTier 7: Specialty Generic and Brand Name Prescription Drugs and SuppliesFlorida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of HealthOptions, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross BlueShield Association.Florida Blue November 2021 Care Choices MedicationIII

Medications that are not coveredYour pharmacy benef it may not cover select medications. Some of the reasons a medication may not be coveredare: The medication has been shown to have excessive adverse ef f ects and/or saf er alternatives The medication has a pref erred f ormulary alternative or over-the-counter (OTC)alternative The medication is no longer marketed The medication has a widely available/distributed AB rated generic equivalent f ormulation The medication has been repackaged — a pharmaceutical product that is removed f rom theoriginal manuf acturer container (Brand Originator) and repackag ed by another manuf acturer with adif f erent NDC The medication is not covered because of safety or effectiveness concerns.In addition to any drug not listed in the medication guide, a list of certain medications that are not covered maybe f ound at Medications Not Covered List.NOTE: To determine the medication exclusions that apply to your plan, check your plan documents. Coveragedetails are also available to you by logging into the member section of www.f loridablue.com.Condition Care Rx ProgramThe Condition Care Rx Program is designed to help manage the cost of medications used to treat certain chronicconditions and encourage medication adherence. You can purchase medications at a reduced cost using theCondition Care Rx Program. Check your Schedule of Benef its to determine the applicable cost share.A list of medications that are part of the Condition Care Rx Value Program may be f ound at:Condition Care Rx Program Value List.NOTE: Coverage details may also be available to you by logging into the member section of www.f loridablue.com.Generic drugsFlorida Blue encourages the use of generic medications as a way to provide high-quality medications atreduced costs. Generic medications are as saf e and ef f ective as their brand name counterparts and areusually considerably less expensive.A Food and Drug Administration (FDA) approved generic medication maybe substituted f or its brand namecounterpart because it: Contains the same active ingredient(s) as the Brand medication Is identical in strength, dosage f orm, and route of administration Is therapeutically equivalent and can be expected to have the same clinical ef f ect and safety profileCheck with your doctor or health care provider to determine if switching to a generic medication is appropriate f or youOral Chemotherapy DrugsOral chemotherapy drugs are drugs prescribed by a physician to kill or slow the growth of cancerous cells ina manner consistent with the national accepted standards of practice. A list of these drugs can b e f o und at :Oral Chemotherapy Drug List.Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of HealthOptions, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross BlueShield Association.Florida Blue November 2021 Care Choices MedicationIV

Over-the-counter (OTC) medicationsAn over-the-counter medication can be an appropriate treatment f or some conditions and may offer a lowercost alternative to some commonly prescribed medications. Your pharmacy benef it may provide coverage f orselect OTC medications. Some groups may customize their pharmacy plan to exclude coverage f or OTCmedications, so it is important to check your plan documents to determine if OTC medications are coveredunder your plan. Only those OTC medications prescribed by your physician and designated on the f ormularywith “OTC” in parenthesis f ollowing the medication name are eligible f or coverage.NOTE: Check your plan documents to determine if this benef it applies to your plan. Coverage details are alsoavailable to you logging into the member section of www.f loridablue.com.Patient Protection and Affordable Care Act (ACA) Preventive Services Preventive Medications – Certain preventive care services, medications, and immunizations arecovered at no cost share when purchased at a participating pharmacy. A list of medications c ov eredunder this benef it may be f ound at: Preventive Medications ListImmunizations- Certain vaccines which are covered under your preventive benef its can beadministered by pharmacists that are certif ied. Not all pharmacies provide services f or vaccineadministration. It is important to contact the pharmacy prior to your visit to ensure availability andadministration of the vaccine. Otherwise contact your doctor for availability and administration of thevaccine. A list of vaccines that are covered under your pharmacy benef its may be f ound at: PharmacyBenef it Vaccines List.Women’s Preventive Services – Certain contraceptive medications or devices (e.g., oralcontraceptives, emergency contraceptive, and diaphragms) are covered at no cost share whenpurchased at a participating pharmacy. A list of medications and devices covered under this benef itmay be f ound at: Women’s Preventive Services ListTier Exception Requests for Contraceptives & HIV Pre-Exposure Prophylaxis (PrEP)If , f or medical reasons, you need a contraceptive or HIV PrEP medication that is not included on th ese PreventiveService list(s), you may request an exception to waive the otherwise applicable cost sharing f or your medication.To request an exception, your doctor must complete and submit request online at covermymeds.com or by faxusing the Exception Request Forms in links below.Contraceptives Tier Exception Request FormHIV PrEP Tier Exception Request FormSpecialty Pharmacy medicationsSpecialty Pharmacy medications are high-cost injectable, inf used, oral or inhaled medications that generallyrequire close supervision and monitoring of the patient’s therapy.NOTE: Check your plan documents f or inf ormation on how Specialty Pharmacy medications are covered onyour plan. Coverage details are also available by calling the customer service number listed on your memberID card.Specialty Medications are divided into two categories: Self -Administered Specialty Medications – Patients administer these Specialty Pharmacymedications themselves. Because these medications are intended to be self -administered, thesemedications may not be covered if administered in a physician’s office. If these medications are notobtained f rom a participating specialty pharmacy, out-of-network coverage is not available. Acurrent listing of Self - Administered Specialty Medications can be f ound here.Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of HealthOptions, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross BlueShield Association.Florida Blue November 2021 Care Choices MedicationV

o Self -administered injectable medications are designated in the Medication List with “inj”f ollowing the medication name (e.g., enoxaparin inj). No other Self -administeredinjectables will be covered unless such injectable is identif ied as a Specialty Drug in thisMedication Guide. Self - administered injectables will be subject to the Brand or Genericcost share, as described in your Schedule o f Benef its. Florida Blue reserves the right tochange the Self - administered injectables covered through your plan at any time and f orany reason.Provider-Administered Specialty Medications – These medications require the administration to beperf ormed by a physician. The Specialty Pharmacy medications are ordered by a provider andadministered in an of fice or outpatient setting. Provider-administered Specialty Pharmacy medicationsare covered under your medical benef it. These medications can be obtained f rom any in-networkhealth care provider. A current listing of Provider- Administered Specialty Medications can be f oundhere.NOTE: We have noted medications that may be covered as either Self -Administered and/or ProviderAdministered. Specialty Pharmacy products can be obtained as a pharmacy or medication benef it. Please checkyour handbook f or details.Medical Pharmacy Tier ProgramThe Medical pharmacy tier program provides cost share reductions and helps you save on provider-administeredmedications which are rendered in a physician’s of fice or outpatient setting. Provider-administered medications arecovered under your medical benef it. Medications in the Medical Pharmacy Tier Program may also be subject toPrior Authorization requirements. Florida Blue reserves the right to change the medications included in the MedicalPharmacy Tier Program at any time and f or any reason. Low tier: Lower cost provider-administered medications (e.g., preferred generic, biosimilar or othermedications, supplies, or devices) Standard tier: All other provider-administered medicationsA list of medications included in Low tier of the Medical Pharmacy Tier Program may be f oundhere: Medical Pharmacy Low Tier Drug ListNOTE: Check your plan documents to determine if the Medical Pharmacy Tier Program applies to your plan.Coverage details are also available to you by logging into the member section of www.f loridablue.com or by calling thecustomer service number listed on your ID card.Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of HealthOptions, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross BlueShield Association.Florida Blue November 2021 Care Choices MedicationVI

Pharmacy OptionsThere are two dif ferent types of pharmacies for you to be aware of as you decide where to get your prescriptionsf illed retail pharmacies and specialty pharmacies. To save the most money, bef ore you get a prescription filled,you should conf irm which pharmacy is considered ‘in-network’ f or that particular medication. Participating PharmacyoRetail Pharmacy Network – Non-Specialty ‘Generic’ medications and ‘Brand Name’medications listed in the Medication Guide can be f illed at these pharmacies at a lowercost to you than other pharmacies in your area. If you go to a non-participating pharmacy,your prescription will cost you more. For members associated with a Small Group BlueCare HMO planYour plan may have a Pref erred Pharmacy Network within the Retail PharmacyNetwork. The Pref erred Pharmacy Network is a list of pharmacies that apply yourstandard cost-share or co-pay. If you choose to f ill a prescription outside this Pref erredPharmacy network, you may have higher cost-share or co-pay amounts. To f ind apharmacy in the Pref erred Pharmacy Network, please log in to Florida Blue account,scroll to Know Bef ore You Go section and click Find, Doctors, Pharmacies, and More.o Specialty Pharmacy Network – We have identif ied certain drugs as specialty drugs due torequirements such as special handling, storage, training, distribution, and management of thetherapy. These drugs are listed as a ‘Specialty Drug’ in this Medication Guide. To be covered underyour pharmacy program at the in-network cost share, they must be purchased at a pref erredSpecialty Pharmacy. These pharmacies are different than the retail pharmacies and are identif ied inboth the Provider Directory and this Medication Guide. Using an in-network Specialty Pharmacy toprovide these Specialty Drugs lowers the amount you pay f or these medications. Limited Distribution (LD) Pharmacy – Drug manuf acturers will choose one or a limitednumber of specialty pharmacies to handle and dispense certain specialty drugs. Typically,these drugs are costly and require special monitoring and prior authorization (pre-approval).The pharmacy that dispenses your limited distribution drug can be f ound here: LimitedDistribution DrugsNon-Participating PharmacyoIf your plan of f ers out-of -network pharmacy coverage, choosing a non-participating pharmacywill cost you more money. You may have to pay the f ull cost of the medication and then f ile aclaim f or benef it determination. Our payment will be based on our Non-Participating PharmacyAllowance minus your cost share. You will be responsible f or your cost share and the dif ferenc ebetween our Allowance and the cost of the medication.oIf your plan doesn’t offer out-of-network pharmacy coverage, choosing a non-participatingpharmacy may risk your ability to be reimbursed. You may have to pay the f ull cost of themedication.Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of HealthOptions, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross BlueShield Association.Florida Blue November 2021 Care Choices MedicationVII

Participating Specialty Pharmacy ProvidersYour network f or Specialty Pharmacies is limited to the f ollowing participating Specialty Pharmac y p ro v ider.Unless indicated below, any other pharmacy is considered a non-participating Specialty Pharmac y ev en if itparticipates in Florida Blue’s networks f or non-Specialty Pharmacy medications. You may pay more out ofpocket if you use adif f erent specialty pharmacy.CVS/Caremark Specialty PharmacyServices Provider-Administered and Self Administered Products; excludingHemophiliaPhone: (866) 278-5108Fax: (800) 323-2445CVS/Caremark Specialty PharmacyAccredoSelf -administered Products; excluding HemophiliaPhone: (888) 425-5970Fax: (888) 302-1028AccredoCVS/Caremark Hemophilia ServicesHemophilia ProductsPhone: (866)7922731Fax: (866) 811-7450(Mon-Fri., 9:00 a.m. to 7:30 p.m. EST)CVS/Caremark Hemophilia Specialty PharmacyNOTE: Specialty Pharmacy medications are not covered when purchased through the mail order pharmacy.Self -administered specialty medications as classified by Florida Blue outside of the state of Florida may be obtainedby a member with a written prescription through the p ref erred specialty pharmacy providers Accredo orCVS/Caremark Specialty.If a member resides or is traveling outsides the state of Florida and needs to receive a provider-administeredspecialty medication, the prescribing physician should coordinate with the participating specialty pharmacyprovider f or their area or contact the local BlueCross and BlueShield Plan. This coordination can help ensuremembers receive their medications at the in-network cost share.Members that receive a written prescription directly from their provider f or a provider-administered specialtymedication should contact customer service f or f urther assistance.Mail Order Pharmacy also known as home deliveryObtaining prescription medications through a mail order pharmacy, also known as a home delivery service, mayreduce the cost you pay f or your prescription medications.Check your plan documents to determine if your plan provides a mail order pharmacy benef it.Members who have pharmacy benef its through Florida Blue can access and print out the Prescription Formf or Home Delivery on our website, www.f loridablue.com.NOTE: If the original prescription was f illed at a pharmacy other than the home delivery pharmacy, you mustsubmit a new, original three-month supply prescription with a quantity of up to a three-month supply and not lessFlorida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of HealthOptions, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross BlueShield Association.Florida Blue November 2021 Care Choices MedicationVIII

than a two-month supply along with the Registration and Prescription Form f or Home Delivery . Prescriptions maynot be transf erred f rom a retail pharmacy to the home delivery pharmacy.Three-month supply at Retail PharmacyIn addition to being able to obtain up to a three-month supply of medication through our home delivery pharmac y ,you may be able to receive up to a three-month supply of your medication through a participating retail pharmac y .Please ref er to your Benef it Booklet, Certif icate of Coverage, Contract, Member Handbook or prescription drugendorsement f or complete coverage details.Utilization Management ProgramsPrior Authorization ProgramThe Prior Authorization Program encourages the appropriate, saf e and cost -effective use of medications. If youare currently taking or are prescribed a medication that is included in the Prior Aut horization Program, yourphysician will need to submit a request f orm in order f or your prescription to be considered for coverage. If you donot request and/or receive prior approval, the medication will not be covered. Medications that require priorauthorization f or coverage are indicated in the prior authorization column f ollowing the product name in themedication list.NOTE: Some groups may customize their pharmacy plan to exclude prior authorization requirements, so it isimportant to check your plan documents to determine if prior authorization requirements apply to your plan.Coverage details are also available to you by logging into the member section of www.f loridablue.com.NOTE: Prior Authorizations expire on the earlier of , but not to exceed 12 months f or most medications:1.The termination date of your policy or2.The period authorized by us, as indicated in the letter you receive f rom us.Obtaining Prior AuthorizationInf ormation about prior authorization and f orms f or how to obtain a prior authorization approval can be f ound here:Prior Authorization Program Inf ormation and Forms.NOTE: Your provider is required to complete and submit the Prior Authorization f orm in order f or a coveragedetermination to be made.1.Once a decision is made, you and/or your doctor will be inf ormed of the decision.2.If the decision is made to authorize coverage, the medication(s) and/or supplies may be obtained f ro ma participating pharmacy or at the appropriate location if the medication(s) will be administered b y ahealth prof essional. Prior authorization approval does not waive your cost share.3.If a decision is made to deny authorization, you are f ree to purchase the prescription medication,supplies or Over-the-Counter (OTC) medication, but you will have to pay the f ull cost of the

Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc.

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