P.O. Box 52424, Phoenix, AZ 85072-2424 SilverScript Employer PDP sponsored by Dartmouth College (SilverScript) 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/23/2017. For more recent information or other questions, please contact SilverScript Customer Care at 1-866-693-4621, 24 hours a day, 7 days a week. TTY users should call 711. 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. When this drug list (formulary) refers to “we,” “us,” or “our,” it means SilverScript(cid:1) Insurance Company. When it refers to “plan” or “our plan,” it means SilverScript. This document includes a list of the drugs (formulary) for our plan, which is current as of January 1, 2018. For an 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, 2019, and from time to time during the year. Y0080_62001_FORM_COMP_CLT_2018_9428_2432_801 What is the SilverScript Formulary? A formulary is a list of covered drugs selected by SilverScript 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. SilverScript will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SilverScript network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Please note: Dartmouth College provides additional coverage that may cover prescription drugs not included in your Medicare Part D benefit. For more information about your share of the cost or which prescription drugs may or may not be covered, please call SilverScript Customer Care. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 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 amount 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 quantity limits and prior authorization 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 January 1, 2018. To get updated information about the drugs covered by SilverScript, please contact SilverScript Customer Care. Our contact information appears on the front and back cover pages. If we have other types of midyear non-maintenance formulary changes unrelated to the reasons stated above (e.g., remove drugs from our formulary; add prior authorization requirements, quantity limits, and/or step therapy restrictions on a drug; or move a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the new information. The updated formulary may be obtained by calling us. II 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 “Cardiovascular.” 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 at the back of this document. 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? SilverScript 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 (PA): SilverScript requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SilverScript before you fill your prescriptions. If you don’t get approval, SilverScript may not cover the drug. · Quantity Limits (QL): For certain drugs, SilverScript limits the amount of the drug that SilverScript will cover. For example, SilverScript provides up to 30 tablets per prescription for doxazosin. This may be in addition to a standard one-month or three-month supply. There may be additional drugs that are not available at mail and not marked NM, including some Hepatitis B medications, post-transplant medications, and oral medications used to treat HIV. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You may 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. You can ask SilverScript 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 SilverScript Formulary?” for information about how to request an exception. III 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 SilverScript Customer Care and ask if your drug is covered. If you learn that SilverScript does not cover your drug, you have two options: § You can ask SilverScript Customer Care for a list of similar drugs that are covered by our 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 our plan. § You can ask us to make an exception and cover your drug. See below for information about how to request an exception. Dartmouth College offers additional coverage on some prescription drugs not normally covered under a Medicare Part D prescription drug plan benefit. Payments made for these drugs will not count toward your initial coverage limit or total out-of-pocket costs. Please contact SilverScript Customer Care for any questions regarding your additional benefit. How do I request an exception to the SilverScript Formulary? You can ask us 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 High Cost 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 our 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. Generally, SilverScript will only approve your request for an exception if the alternative drug is included on the plan’s formulary or if 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 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. IV 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 a 102-day transition supply, consistent with the 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 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you experience a change in your level of care, such as a move from a long-term care to a home setting, and you need a drug that is not on our formulary (or if your ability to get your drugs is limited), we may cover a one-time temporary supply from a network pharmacy for up to 30 days (or 34 days if you move to a long-term care facility) unless you have a prescription for fewer days. You should use the plan's exception process if you wish to have continued coverage of the drug after the temporary supply is finished. Initial Coverage Stage Copayment/Coinsurance Levels The plan has three Cost-Sharing Tiers Every drug on the plan’s drug list is in one of three cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug. · Cost-Sharing Tier 1: Generics · Cost-Sharing Tier 2: Preferred Brands · Cost-Sharing Tier 3: Non-Preferred Brands To find out which cost-sharing tier your drug is in, look it up in the plan’s drug list that begins on page 1. V Your share of the cost when you get a one-month supply of a covered Part D prescription drug from: Before your Individual Maximum Out-of-Pocket is met, your cost-sharing amounts will be: Network Long-Term Care (LTC) Retail Pharmacy Pharmacy (Up to a 30-day supply) (Up to a 34-day supply) Generics $5.00 $5.00 Preferred Brands $25.00 $25.00 Non-Preferred Brands $40.00 $40.00 Costs shown in the table above reflect the additional coverage that may be provided by Dartmouth College. Drugs that are part of your standard Medicare plan but do not have additional coverage from Dartmouth College would be covered under the 2018 Medicare Part D Defined Standard Benefit. Please visit https://q1medicare.com/PartD-The-2018-Medicare-Part-D-Outlook.php for more information about the 2018 Medicare Part D Defined Standard Benefit drug costs. For more information For more detailed information about your SilverScript prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our 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 Part D prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or visit https://www.medicare.gov. SilverScript's Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index at the back of this book. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine). VI The information in the Requirements/Limits column tells you if SilverScript has any special requirements for coverage of your drug. PA Prior Authorization. QL Drug has Quantity Limits. NM Not available at our mail-order pharmacies. NDS Non-extended day supply. Not available for an extended (long-term) supply. LA Limited Access. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call SilverScript Customer Care at 1-866-693-4621, 24 hours a day, 7 days a week. TTY users should call 711. B/D This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. GC 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. VII 2018 631 3T Copper Comm BvD Plus eff 01/01/2018 Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ANALGESICS ibuprofen TABS 400mg, 1 GOUT 600mg, 800mg allopurinol (generic of 1 ketoprofen CAPS; CP24 1 ZYLOPRIM) TABS meloxicam (generic of 1 allopurinol sodium (generic of 1 MOBIC) TABS ALOPRIM) MOBIC 2 ALOPRIM 3 nabumetone TABS 1 colchicine w/ probenecid 1 NALFON 3 COLCRYS 2 NAPRELAN 375mg, 500mg 3 NDS KRYSTEXXA 3 NDS NM LA NAPRELAN 750mg 3 MITIGARE 3 naproxen (generic of 1 probenecid 1 NAPROSYN) SUSP ULORIC 2 naproxen (generic of 1 ZURAMPIC 3 NAPROSYN) TABS 250mg, ZYLOPRIM 3 500mg naproxen TABS 375mg 1 NSAIDS naproxen dr (generic of 1 ARTHROTEC 50 3 EC-NAPROSYN) ARTHROTEC 75 3 naproxen sodium TABS 1 CELEBREX 3 275mg celecoxib (generic of 1 naproxen sodium (generic of 1 CELEBREX) CAPS ANAPROX DS) TABS DAYPRO 2 550mg diclofenac potassium 1 naproxen sodium (generic of 3 NDS diclofenac sodium TB24; 1 NAPRELAN) TB24 TBEC oxaprozin (generic of 1 diclofenac w/ misoprostol 1 DAYPRO) (generic of ARTHROTEC 50) piroxicam (generic of 1 diclofenac w/ misoprostol 1 FELDENE) CAPS (generic of ARTHROTEC 75) sulindac TABS 1 diflunisal 1 tolmetin sodium 1 DUEXIS 3 NDS VIMOVO 3 NDS EC-NAPROSYN 375mg 3 VIVLODEX 3 etodolac CAPS 1 ZIPSOR 3 NDS etodolac (generic of LODINE) 1 ZORVOLEX 3 TABS 400mg OPIOID ANALGESICS etodolac TABS 500mg 1 acetaminophen w/ codeine 1 QL etodolac TB24 1 SOLN FELDENE 3 QL (5000 mL / 30 days) fenoprofen calcium CAPS 1 acetaminophen w/ codeine 1 QL 400mg TABS fenoprofen calcium TABS 1 QL (400 tabs / 30 days) flurbiprofen TABS 1 ibuprofen SUSP 1 PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply 1 2018 631 3T Copper Comm BvD Plus eff 01/01/2018 Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits acetaminophen w/ codeine 1 QL ABSTRAL 3 NDS PA (generic of ACTIQ 3 NDS PA TYLENOL/CODEINE #3) codeine sulfate 1 TABS DILAUDID LIQD; TABS 3 QL (400 tabs / 30 days) DOLOPHINE 3 acetaminophen w/ codeine 1 QL DURAGESIC 12mcg/hr, 3 (generic of 25mcg/hr TYLENOL/CODEINE #4) DURAGESIC 50mcg/hr, 3 NDS TABS 75mcg/hr, 100mcg/hr QL (400 tabs / 30 days) EMBEDA CAP 20-0.8MG 3 acetaminophen-caff-dihydroco 1 QL EMBEDA CAP 30-1.2MG 3 d QL (360 caps / 30 days) EMBEDA CAP 50-2MG 3 aspirin-caffeine-dihydrocodein 1 EMBEDA CAP 60-2.4MG 3 e cap 356.4-30-16 mg EMBEDA CAP 80-3.2MG 3 BELBUCA 2 EMBEDA CAP 100-4MG 3 NDS butorphanol nasal spray 1 endocet (generic of 1 QL butorphanol tartrate SOLN 1 PERCOCET) BUTRANS 2 QL (360 tabs / 30 days) CONZIP 3 EXALGO 8mg, 12mg 3 nalbuphine hcl SOLN 1 EXALGO 16mg, 32mg 3 NDS SYNALGOS-DC 3 fentanyl citrate (generic of 3 NDS PA ACTIQ) LPOP tramadol hcl CP24 1 fentanyl patch 12 mcg/hr 1 tramadol hcl TB24 100mg, 1 (generic of DURAGESIC) 200mg, 300mg fentanyl patch 25 mcg/hr 1 tramadol hcl (generic of 1 (generic of DURAGESIC) ULTRAM ER) TB24 300mg fentanyl patch 50 mcg/hr 1 tramadol hcl er (biphasic) 1 (generic of DURAGESIC) 100mg fentanyl patch 75 mcg/hr 1 tramadol hcl er (biphasic) 1 (generic of DURAGESIC) 200mg fentanyl patch 100 mcg/hr 1 tramadol hcl tab 50 mg 1 (generic of DURAGESIC) (generic of ULTRAM) FENTORA 3 NDS PA tramadol-acetaminophen 1 QL HYCET 3 QL (generic of ULTRACET) QL (5400 mL / 30 days) QL (240 tabs / 30 days) hydrocodone-acetaminophen 1 QL trezix 1 QL 2.5-325mg QL (360 caps / 30 days) QL (360 tabs / 30 days) TYLENOL/CODEINE #3 3 QL hydrocodone-acetaminophen 1 QL QL (400 tabs / 30 days) 5-300mg (generic of XODOL) TYLENOL/CODEINE #4 3 QL QL (400 tabs / 30 days) QL (400 tabs / 30 days) hydrocodone-acetaminophen 1 QL ULTRACET 3 QL 5-325mg (generic of NORCO) QL (240 tabs / 30 days) QL (360 tabs / 30 days) ULTRAM 2 OPIOID ANALGESICS, CII PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply 2 2018 631 3T Copper Comm BvD Plus eff 01/01/2018 Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits hydrocodone-acetaminophen 1 QL levorphanol tartrate TABS 3 NDS 7.5-300mg (generic of lorcet hd tab 10-325mg 1 QL XODOL) (generic of NORCO) QL (400 tabs / 30 days) QL (360 tabs / 30 days) hydrocodone-acetaminophen 1 QL lorcet plus tab 7.5-325 1 QL 7.5-325 mg/15ml (generic of (generic of NORCO) HYCET) QL (360 tabs / 30 days) QL (5400 mL / 30 days) lortab tab 5-325mg (generic of 1 QL hydrocodone-acetaminophen 1 QL NORCO) 7.5-325mg (generic of QL (360 tabs / 30 days) NORCO) lortab tab 7.5-325 (generic of 1 QL QL (360 tabs / 30 days) NORCO) hydrocodone-acetaminophen 1 QL QL (360 tabs / 30 days) 10-300mg (generic of lortab tab 10-325mg (generic 1 QL XODOL) of NORCO) QL (400 tabs / 30 days) QL (360 tabs / 30 days) hydrocodone-acetaminophen 1 QL methadone hcl SOLN 1 10-325mg (generic of 5mg/5ml, 10mg/5ml NORCO) METHADONE HCL SOLN 3 QL (360 tabs / 30 days) 10mg/ml hydrocodone-ibuprofen 1 methadone hcl intensol 1 hydromorphone hcl (generic 1 (generic of METHADOSE) of DILAUDID) LIQD methadone tab 5mg (generic 1 hydromorphone hcl (generic 1 B/D of DOLOPHINE) of DILAUDID) SOLN methadone tab 10mg (generic 1 1mg/ml, 2mg/ml, 4mg/ml of DOLOPHINE) hydromorphone hcl SOLN 1 B/D MORPHABOND ER 15mg, 3 10mg/ml, 50mg/5ml, 30mg 500mg/50ml MORPHABOND ER 60mg, 3 NDS hydromorphone hcl (generic 1 100mg of EXALGO) T24A 8mg, morphine sul inj 1mg/ml 1 B/D 12mg morphine sulfate (generic of 1 hydromorphone hcl (generic 3 NDS KADIAN) CP24 10mg, of EXALGO) T24A 16mg, 20mg, 30mg, 50mg, 60mg, 32mg 80mg hydromorphone hcl (generic 1 morphine sulfate (generic of 3 NDS of DILAUDID) TABS KADIAN) CP24 100mg HYSINGLA ER 20mg, 30mg, 2 MORPHINE SULFATE 3 B/D 40mg, 60mg SOLN 2mg/ml, 4mg/ml, HYSINGLA ER 80mg, 3 NDS 8mg/ml, 150mg/30ml 100mg, 120mg morphine sulfate (generic of 1 B/D ibudone tab 5-200mg 1 MORPHINE SULFATE) ibudone tab 10-200mg 1 SOLN 4mg/ml, 8mg/ml, KADIAN 10mg, 20mg, 30mg 3 10mg/ml morphine sulfate SOLN 1 B/D KADIAN 40mg, 50mg, 3 NDS 15mg/ml 60mg, 80mg, 100mg, 200mg morphine sulfate TABS 1 LAZANDA 3 NDS PA PA - Prior Authorization QL - Quantity Limits NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply 3