Formulary Frequently Asked Questions (FAQs)

Q: What is the Optimum HealthCare Formulary?
A: A formulary is a list of covered drugs selected by Optimum HealthCare, Inc. 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. Optimum HealthCare, Inc. will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Optimum HealthCare, Inc. network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Q: Can the formulary change?
A: Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except as described below. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you.

• Immediate substitutions of certain new versions of brand name drugs and original biological products.
• Drugs removed from the market to ensure safety.
• Other changes: We may remove a brand name drug from the formulary when adding a generic equivalent or remove an original biological product when adding a biosimilar. We may also apply new restrictions to the brand name drug or original biological product, or move it to a different cost-sharing tier, or both. We may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective. Alternatively, when a member requests a refill of the drug, they may receive a 30-day supply of the drug and notice of the change.

Q: What are Generic Drugs?
A: Optimum HealthCare, Inc. 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 work just as well as and usually cost less than brand name drugs. There are generic drug substitutes available for many brand name drugs. Generic drugs usually can be substituted for the brand name drug at the pharmacy without needing a new prescription, depending on state laws.

Q: What if my drug is not on the formulary?
A: If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that Optimum HealthCare, Inc. does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Optimum HealthCare, Inc. When you receive the list, show it to your doctor and ask them to prescribe a similar drug that is covered by Optimum HealthCare, Inc.
• You can ask Optimum HealthCare, Inc. to make an exception and cover your drug. See below for information about how to request an exception.