Rocky Mountain Health Plans (RMHP) Good Health Formulary

364 Pages·2016·1.79 MB·English

Rocky Mountain Health Plans (RMHP)
Good Health Formulary

The RMHP family of health plans includes these entities:
Rocky Mountain Health Maintenance Organization
Rocky Mountain HealthCare Options

www.rmhp.org

Revised 12/01/2017 Discard all previous copies of formulary

Beneficiaries must use network pharmacies to access their prescription drug benefit.

What is the Formulary?

A formulary is a list of covered drugs selected by Rocky Mountain Health Plans (RMHP) 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. RMHP will generally cover the drugs listed in our formulary as long as the drug is
medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For
more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary change?

Yes. The Formulary is not a static list but continues to be reviewed and modified as appropriate to remain in
step with current drug therapies. RMHP reserves the right to include or exclude any drug at any time from the
Formulary or any of its parameters. If we remove drugs from our formulary or add prior authorization or quantity
limits or move a drug to a higher cost-sharing tier, we will notify affected Members of the change. The generic
or branded status of any drug is subject to change at any time and is not subject to Member
notification. 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 December 1, 2017. The
formulary is constantly being updated. To get updated information about the drugs covered by RMHP, please
call Customer Service.
Individual Members and Group Plan Members call: 970-243-7050 or 800-346-4643
Medicaid Members call: 970-244-7860 or 888-282-8801

I FORM-Good Health-December 2017
How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition
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 Agents”. Then look under the category name for your drug.

Alphabetical Listing
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.

The formulary provides coverage information about some of the drugs covered by the Health Plan. If you have
trouble finding your drug in the list, turn to the Index.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., DEXILANT) and
generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the Coverage column tells you if the Health Plan has any special requirements for coverage
of your drug. See the key below for formulary abbreviations. See the section “Are there restrictions on my
coverage?” below for information on obtaining a preauthorization.

What are generic drugs?

A generic drug has the same active-ingredient as the brand name drug. Generic drugs usually cost less than
brand name drugs and are approved by the Food and Drug Administration (FDA), which assures that the
following conditions are met.

 The generic drug must contain the same active ingredients, be the same strength, and the same dosage
form as the brand name counterpart.
 The FDA has given an “A” rating compared to the branded counterpart and thus the generic is
determined to be therapeutically bioequivalent.
 When the above two criteria are met, a generic can be substituted with the full expectation that the
substituted product will produce the same clinical effect and safety profile as the prescribed product.

What is Generic Substitution?

Some drugs are available as a cost saving generic version. Drugs available as generic will usually be filled at
the pharmacy with the generic version rather than brand unless your doctor or you request the brand.

Generic medications are generally included in Tier 1. If a generic medication does not offer financial savings
over the brand version, it may be placed in a higher tier. Medications with a generic equivalent are noted in
lower case. When a brand-name medication becomes available as a generic, that brand-name product may
move to a higher tier. Members may be required to pay more for a prescription when a higher-tier brand-name
product is dispensed. The member’s payment is determined by the pharmacy benefit plan. When generic
substitution conflicts with state regulations or restrictions; the pharmacist must obtain approval from the
prescribing physician or other health care professional to substitute the generic equivalent.

II FORM-Good Health-December 2017
What is Therapeutic Interchange?

Rocky Mountain Health Plans supports, but does not require, the use of therapeutic interchange as a part of a
comprehensive approach to quality, cost-effective patient care. Therapeutic interchange is the practice of
replacing, with the prescribing physician’s approval, a prescription medication originally prescribed for a patient
with a chemically different medication. Medications used in therapeutic interchange programs are expected to
produce similar levels of clinical effectiveness and sound medical outcomes, based on available scientific
evidence.

The Academy of Managed Care Pharmacy describes therapeutic interchange as programs developed by a
team of physicians, pharmacists, and other medical practitioners who are experts in the diagnosis and treatment
of disease. The programs are designed to work in conjunction with other tools that health care professionals use
to promote quality medical results.

Using therapeutic interchange offers several advantages:

Value to Patients: When therapeutic interchange occurs, physicians and other health care experts have
determined that patients will experience similar or improved clinical outcomes with the replacement
medications. The replacement medication may be more convenient for the patient to take. For example, a
patient is more likely to take medication as prescribed if he or she is moved to a therapeutically equivalent
product that only needs to be taken twice a day rather than four times a day. A medication that has a high
likelihood to cause side effects may be replaced with one that is less likely to do so. A new medication that
offers improved therapeutic outcomes may replace an older remedy. A patient is generally less likely to miss
doses, and thereby gets the full clinical benefit of their prescription, if the medication is convenient to use,
causes fewer side effects, or provides improved control or relief of their condition.

Affordability: A replacement medication that is therapeutically equivalent might simply cost less. Once two
medications are determined to result in the same positive outcomes for the patient, it makes sense for the
hospital, health plan, or pharmacy network to use the less expensive alternative. Additionally, this may result in
lower out-of-pocket expenses for the patient because of reductions in copayments. In instances where two
medications are therapeutically equivalent, AMCP does not support therapeutic interchange programs that
result in higher costs for patients and/or plan sponsors.

Therapeutic interchange, however, is not always about lower medication costs. Therapeutic interchange often
occurs when overall health care savings can be achieved. Replacing one medication with a more expensive one
may result in fewer treatment failures, better patient adherence to the treatment plan, fewer side effects and
improved clinical outcomes. Such efficient use of medical resources helps keep medical costs down, improves
the patient’s access to more affordable health care, and enhances the patient’s quality of life.

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: RMHP requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval from RMHP before you fill your prescriptions. If you don’t
get approval, the Health Plan may not cover the drug. Drugs that are subject to a prior authorization will
have a “PA” symbol next to the drug.

o Physicians & Pharmacies call 970-248-5031 or 800-641-8921
FAX: [phone]

III FORM-Good Health-December 2017
 Quantity Limits: For certain drugs, the Health Plan limits the amount of the drug that the Health Plan
will cover. For example, the Health Plan provides 12 doses per prescription for Imitrex tablets. This may
be in addition to a standard one month or three month supply. Drugs that are subject to a quantity limit
will have a “QL” symbol next to the drug.

o Refill Limitations: Prescriptions may be refilled when 75% or more of the day’s supply has been
used.

 Step Therapy: In some cases, the Health Plan requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does
not work for you, we will then cover Drug B. Drugs that are subject to Step Therapy will have a “ST”
symbol next to the drug.

 Age Limit: In some cases, drugs are only available to Member in a select age category. Drugs that are
subject to an Age Limit will have an “AGE” symbol next to the drug.

 Gender Limit: Some drugs are only available to Members of a certain gender. Drugs that are available
to only a certain gender will have a “GM” (male) or “GF” (female) symbol next to the drug.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on
page 3.

Specialty Drugs

Certain chronic or difficult health conditions require the use of specialty drugs. Here’s what you need to know
about these medications:

What makes specialty drugs different?
Specialty drugs usually require special handling, administration or monitoring. They are usually very expensive
and often are prescribed by specialists and may require prior approval by RMHP before you can fill your
prescription. You may have to order them through a specialty pharmacy.

How do I know if my medication is a specialty drug?
Specialty drugs are listed in Tiers 4 and 5 on the formulary. Tier 6 also includes some specialty drugs.

Where do I get specialty drugs?
You can get some specialty drugs at a retail pharmacy. Not all pharmacies fill prescriptions for specialty drugs,
so check first. Some specialty drugs are Limited Distribution and can only be obtained from an RMHP specialty
pharmacy. These include Kroger Specialty Pharmacy, Diplomat, CVS, Accredo, and others. Check the Specialty
Drug List to see if a specialty drug is Limited Distribution.

Can I get a 90-day supply of specialty drugs like my other medication?
Because these drugs can be fragile and may require specialty handling or monitoring, you can only order a 30-
day supply of specialty drugs. Some specialty drugs are injections that last 3 months or 6 months per injection.
These are approved for those durations.

For questions regarding specialty drugs and our specialty pharmacies, please contact the RMHP Pharmacy
Help Desk at 970-248-5031 (1-800-640-8921).

IV FORM-Good Health-December 2017
Formulary Exclusions

RMHP reserves the right to exclude any drug at any time from the RMHP Formulary for health and safety
concerns or other reasons as determined by RMHP in its discretion. The following drugs are excluded from the
RMHP Formulary:

 Any drug labeled by the FDA, “Caution — limited by federal law to investigational use”.
 Drugs not available, marketed or sold in the United States.
 Drugs obtained from a pharmacy or provider located outside the United States, except drugs obtained in
connection with a medical emergency.
 Any drug that is not FDA approved.
 Any drug that is used in connection with a service or supply that is not a benefit (for example, drugs used
for dental health are not covered).
 Lost or Stolen Medications: RMHP will not cover prescription refills for lost, stolen or damaged
medication.

Additionally, all drugs in the following categories are excluded from coverage under the RMHP Formulary:

Generic Drug Name or Category Example
Anorexiants/weight loss drugs
Compounded drugs used for an indication or route of administration topical Neurontin and
not approved by the FDA topical calcium channel
blockers
Compounded drugs for which an FDA approved drug is available in
the prescribed strength and dosage form
Compounded hormones not approved by the FDA* Tri-est, Bi-est
Compounded injectable erectile dysfunction drugs Trimix, prostaglandins
Compounded prescriptions utilizing powders. [Exceptions:
polystyrene sulfonate (Kayexalate), salicylic acid, nystatin, caffeine]
Cosmetic drugs Propecia, Renova, Vaniqa,
Lustra, Botox Cosmetic
DHEA
Dental drugs Monodox, Periostat
Dietary supplements Deplin, Metanx, Limbrel,
Vayarin, Hypertensa,
Theramine
Nebulized solutions compounded from powder triamcinolone
Prescription drugs for which an equivalent is available over the Claritin, lac-hydrin
counter. Certain Over the Counter drugs are covered under the
Patient Protection and Affordable Care Act for Commercial Group
and Inividual Members only. See discussion of Over the Counter
Drugs below.

* Progesterone in oil injection is not within these exclusions.

V FORM-Good Health-December 2017
Over The Counter Medications: Over-the-counter (OTC) drugs, with the exception of insulin, are not covered.
For renal dialysis patients: antacids, all multi-vitamins, calcium replacement, Proferrin and Proferrin Forte are
covered with prior authorization. OTC smoking cessation drugs are covered for Medicaid with prior
authorization, examples include Nicoderm patch and Nicorette gum.

Over The Counter Medications covered under the Patient Protection and Affordable Care Act (PPACA):
PPACA requires health plans to cover the cost of certain over-the-counter (OTC) products for commercial group
and individual members only. A prescription for these OTC products from your doctor is required for
reimbursement. These products include:

OTC Folic Acid Supplements: The cost of OTC folic acid supplements containing 0.4mg to 0.8mg of folic
acid will be reimbursed for females age 18 and older who are planning or are capable of pregnancy.
Members will be reimbursed up to a 90-day supply per request.

OTC Aspirin: The cost of OTC aspirin used in an aspirin therapy regimen for cardiovascular health will be
reimbursed for female members ages 55-79 and male members ages 45-79. Members will be reimbursed
up to a 90-day supply per request.

OTC Iron Supplements: The cost of OTC iron supplements will be reimbursed for children 6-12 months of
age who are at increased risk for iron deficiency anemia. Members will be reimbursed up to a 90-day supply
per request.

OTC Contraception: The cost of OTC sponges, spermicide and female condoms will be reimbursed for
females (does not apply to women who are participants or beneficiaries in group health plans sponsored by
religious employers) capable of pregnancy but wanting to prevent pregnancy. Members will be reimbursed
up to a 90-day supply per request.

OTC Vitamin D: The cost of OTC vitamin D supplements will be reimbursed in community-dwelling adults
age 65 years and older who are at increased risk for falls. Members will be reimbursed up to a 90-day
supply per request.

To request reimbursement for any of these OTC items, contact Customer Service and confirm that you are
eligible for reimbursement. If eligible, you must complete a Direct to Member Reimbursement form.

What if my drug is not on the Formulary?

Members: If your drug is not included in this formulary, you should first contact Customer Service and confirm
that your drug is not covered. If you learn that RMHP does not cover your drug, you can ask us to make an
exception to our coverage rules, restrictions or limits. You may call customer service to request a Formulary
Exception review or a Formulary Exception request form is available at https://www.rmhp.org/members/rx-
info/formulary-exceptions-requests-commercial.

There are two types of exceptions that you can ask us to make.
 You can ask us to cover your drug even if it is not on our formulary.
 You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs;
RMHP 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 more.

Generally, RMHP will only approve your request for an exception if the alternative drugs included on the plan’s
formulary would not be as effective in treating your condition and/or would cause you to have adverse medical
effects.

VI FORM-Good Health-December 2017
Information for providers:
FORMULARY EXCEPTION REQUESTS: To request coverage of an excluded drug, contact the RMHP
Pharmacy Help Desk at 970-248-5031 (1-800-640-8921). You will be faxed a Formulary Exception Request
Form, please fill this out completely and fax back to RMHP at 858-357-2538.

PRIOR AUTHORIZATION: Some drugs require prior authorization before RMHP will cover. You can view the
specific PA criteria for all drugs that require prior authorization on our website:
http://www.rmhp.org/providers/prior-authorization/prior-authorization-pharmacy. You can also call the RMHP
Pharmacy Help Desk at 970-248-5031 (1-800-640-8921) and they will fax you a prior authorization form.
Please complete this form, attach any relevant medical records, and fax back to the RMHP Pharmacy Help
Desk.

Formulary Policy Indicators

T1 High value drugs (lowest copay). May contain generic and brand medications
T2 Preferred drugs (low copay). Contains brand name and generic medications
T3 Non-preferred drugs (medium copay). Contains brand name and generic
medications
T4 Specialty drugs (higher copay). Contains brand name and generic high cost
specialty medications
T5 Nonpreferred specialty drugs (highest copay). Contains brand name and generic
high cost specialty medications
T6 Medical Benefit
PA Prior Authorization Required
PA NSO Prior Authorization Required – New Starts Only
QL Quantity Limits
ST Step Therapy
AGE Age Limit
GM/GF Gender Limit (Male/Female)
EX Drug Excluded
lower case italics Generic
CAPS Brand

REVISION POLICY
The RMHP formularies are revised at least quarterly. Drug coverage changes may occur between revisions.

EDITOR
Your feedback, comments, and suggestions are encouraged as we continually improve and update the
Formulary. Please feel free to contact Zach Kareus, Pharm D (970-248-8743, 800-843-0719 ext. 8743) or Steve
Nolan, Pharm D (970-248-5182, 800-843-0719 ext. 5182), Rocky Mountain Health Plans, 2775 Crossroads
Blvd., PO Box 10600, Grand Junction, CO 81502.
VII FORM-Good Health-December 2017
Commercial Tagline for Notices
English Russian
Thereisimportantinformationaboutyourcoverageorapplicationwith В данном уведомлении содержится важная информация касательно
RockyMountainHealthPlans(RMHP)inthisnotice.Reviewit Вашего страхового покрытия или заявления в организацию Rocky Mountain
carefully.Lookforactionsyoumayneedtotakeanddeadlines.You Health Plans (RMHP). Просим Вас внимательно его изучить. Вам необходимо
havetherighttogetinformationinyourlanguageatnocost.Call наметить порядок действий и сроки. У Вас есть право на бесплатное
800-346-4643forassistance.
получение информации на родном языке. За помощью обращайтесь по
номеру телефона 800-346-4643.
Spanish
HayinformaciónimportantesobresucoberturaosolicituddeRocky SimplifiedChinese
MountainHealthPlans(RMHP)enesteaviso.Revíselo
meticulosamente.Tomelasaccionesnecesariasyconsiderelas 本通知中包含有关落矶山健康计划（RMHP）范围和应用的重要信息。请仔
fechasdevigencia.Ustedtieneelderechoaobtenerestainformación 细阅读。寻找您可能需要采取的措施和最终期限。您有权免费获得以自己的
ensuidiomasinningúncargo.Llameal800-346-4643 paraobtener
asistencia. 语言提供的信息。请致电 800-346-4643寻求帮助。
Arabic Vietnamese
ﻂﻄﺨﻟا ﻊﻣ ﻚﺑ صﺎﺨﻟا ﻖﯿﺒﻄﺘﻟا وأ ﻚﺑ ﺔﺻﺎﺨﻟا ﺔﯿﻄﻐﺘﻟا صﻮﺼﺨﺑ ﺔﻣﺎھ تﺎﻣﻮﻠﻌﻣ كﺎﻨھ ةﺮﻛﺬﻤﻟا هﺬھ ﻲﻓ Trong thông báo này có thông tin quan trọng về phạm vi bảo hiểm
ﻚﯿﻠﻋ نﻮﻜﯾﺪﻗ يﺬﻟا فﺮﺼﺘﻟا ﻦﻋ ﺚﺤﺒﻟﺎﺑ ﻢﻗو.ﺔﯾﺎﻨﻌﺑ ﺎﮭﺘﻌﺟاﺮﻣ ﻚﯿﻠﻋ.(RMHP) ﻦﺘﻧوﺎﻣ ﻲﻛوﺮﻟ ﺔﯿﺤﺼﻟا hoặc đơn xin của quý vị với Chương Trình Chăm Sóc Sức Khỏe
ﻚﯿﻠﻋ نﻮﻜﯾو.ﻞﺑﺎﻘﻣ نوﺪﺑ ﻚﺘﻐﻠﺑ تﺎﻣﻮﻠﻌﻤﻟا ﻰﻠﻋ لﻮﺼﺤﻟا ﻚﻘﺣ ﻦﻣ نإ.ﻚﻟﺬﻟ ﺔﺑﻮﻠﻄﻤﻟا ﺔﻠﮭﻤﻟا دﺪﻣو ﮫﺑ مﺎﯿﻘﻟا RockyMountainHealthPlans (RMHP). Vui lòng xem kỹ thông báo này.
.ةﺪﻋﺎﺴﻤﻠﻟ3464-643-008 ﻢﻗﺮﻟا ﻰﻠﻋ لﺎﺼﺗﻻا Hãy tìm các hành động quý vị cần thực hiện và hạn chót của các hành
động đó. Quý vị có quyền nhận thông tin bằng ngôn ngữ của quý vị
mà không bị tính phí. Hãy gọi 800-346-4643 để được hỗ trợ.
German
EsgibtwichtigeInformationenüberIhreAbsicherungoder
Yoruba
AnwendungbeiRockyMountainHealthPlans(RMHP)indieser
Mitteilung.SehenSiediesesorgfältigdurch.SchauenSie,obsie Ìfitónilétípàtàkìwànípaìdarapọ̀ rẹ àbí ìbéèrè rẹ pẹ̀lú Àwọn Èto Ìlera
MaßnahmenergreifenoderTermineeinhaltenmüssen.Siehabendas RockyMountain[RMHP]nínúàfiyèsíyìí.Fipẹ̀lépẹ̀lẹ́ gbéeyẹ̀wò.Wò
Recht,kostenlosInformationeninIhrerSprachezuerhalten.Rufen àwọn ìgbésẹ̀ tí o lè gbé àti àwọn àkókò tí ó dópin. O ní ẹ̀tọ́ látigbà
Sie800-346-4643an,wennSieHilfebenötigen. ìfitónilétí yìí ní èdè rẹ lọ́fẹ̀ẹ́.Pè800-346-4643fúnìrànlọ́wọ́.
French Ibo/Igbo
Cettenoticecomprenddesinformationsimportantessurvotre Enwere ozi dị mkpa gbasara mkpuchi ma ọ bụ akwụkwọ anamachọihe
assuranceouvotredemandeauxrégimesdeRockyMountainHealth gị na Rocky Mountain Health Plans (RMHP) n’ọkwa a. Gụgharịa ya nke
Plans(RMHP).Veuillezl’examinerattentivement.Voyezquelles ọma. Chọọ ihe ndị ị ga-eme yana nduzi. Ị nwere ikike ịnweta ozi
actionsquevousdevezprendreetleurséchéances.Vousavezledroit n’asụsụ gị na akwụghị ụgwọ ọ bụla. Kpọọ 800-346-4643 maka
d’obtenirgratuitementdesrenseignementsdansvotrelangue. enyemaka.
Appelezle800-346-4643 pourobtenirdel’aide.
Tagalog
Japanese
Maymahalagangimpormasyontungkolsaiyongcoverageo
この通知にはロッキー・マウンテン・ヘルス・プラン(RMHP)の補償範囲 aplikasyonsaRockyMountainHealthPlans(RMHP)sapaalalangito.
と申請に関する重要な情報が掲載されていますので、よくお読みください Suriinitonangmabuti.Alaminangmgapagkilosnamaaaring
kailanganmonggawinathanggangkailanmodapatmaisagawaang
。行う必要のある手続きおよび締め切り日にご注意ください。お客様には
mgaiyon.Maykarapatankanghumilingngimpormasyonsaiyong
、関連情報を無料で母国語で受け取る権利があります。800-346-4643 ま
wikananglibre.Tumawagsa800-346-4643parasatulong.
でご連絡いただきサポートをご依頼ください。
Amharic
Korean
በዚህ ማስታወቂያ ላይ RockyMountainHealthPlans(RMHP)ስለሚሰጥዎት ሽፋን
이안내문은로키마운틴의료보험(RockyMountainHealthPlans ወይም ማመልከቻዎን በተመለከተ ጠቃሚ መረጅ ኣይገኛል። በጥንቃቄ ይገምግሙት። መውሰድ
ሊኖርብዎት ስለሚችሉ እርምጃዎችና የግዜ ገደብ ላይ ያተኩሩ። ያለምንም ክፍያ በቋንቋዎ መረጃ የማግኘት
(RMHP))의보험적용범위또는신청서에대한중요한정보를포함하고 መብት አለዎት። እርዳታ ለማግኘት በ 800-346-4643 ይደውሉ።
있습니다.신중하게검토하시기바랍니다.취해야할조치와마감기일에
Cushite—Oromo
유의하세요.고객님의언어로된정보를무료로받으실수있습니다.서비스
관련문의는800-346-4643로 전화주시기 바랍니다. FacaatiiyokiniyyanookeeRockyMountainHealthPlans(RMHP)walin
qabiduuilalichiseeodeeffannoobaribaachisaatujiraa. Irradeebi’an
siritixiinxalii.Kanitifuxachooqabidufiguyyaaittixumramuuitti
Nepali hojachofiilaalii.Kafalitiimalleodeeffannoafaniketiinarigachofimiriga
qabidaa.Garigarisafi800-346-4643lakofisaakananiibilibili.
योसूचनामा”ȡɃ€Ȫबीमाकृतšȡͧž वाš€ȧ˜ȡ`ۊȯ“ ¡ȯ㐠ܛȡÛ  Q(RMHP)लाई
”ȡɃ›ȯपेश‚“—Ǖ[ f€Ȫआवेदनकाबारेमा˜¡×ם”ŽǗ[‡ȡ“€ȡšȣ¡Ǿ छन।् यसलाई Kru-Bassa
ڙȡ“”Ǘ€[ ¡ȯ“¡Ǖ[Ȫ ।Q”ȡɃ›ȯ…ȡ㓠] æ™€ हुन È“ȯ€‘˜¡Ǿ रसमयसीमाबारेथाहा Libihneliniligwebangabiniigana.Libihneliniligwebangabi
niigananyumammakolbahandjombiyongtolema
पाउनहु ोस।् ”ȡɃ ȱ‚ ] ݓȪभाषामाǓ“ȬžǕ〠Ǿ”˜ȡ‡ȡ“€ȡšȣ¡Ǿ Ĥȡ܏ ‚“ȶ\ ͬ’€ȡš
teedamongnguedaRockyMountainHealthPlans(RMHP).Yengma
छ।सहायताका›ȡͬ‚ 800-346-4643 माफोन‚“¡Ǖ[Ȫ @Q kelmanguimunulibihnelini.Bebegleunlamabon
nguimmannwaaleguimdilooinkwonyuItedamatedamamboo
yongtoleIbanaminsombogmimahola.Ugwee
Persian
Kundeikosnabiniiguenebininimaholaihopwongnninsaawogui
RockyMountain یﻮﺳ زا ﺎﻤﺷ ﺮﻈﻧ ﺪﻣ ﺶﺷﻮﭘ ﺎﯾﺖﺳاﻮﺧردﮫﺑﻊﺟار ﯽﻤﮭﻣتﺎﻋﻼطاﺖﺷاددﺎﯾ ﻦﯾارد wo.Sebel800-346-4643.
و ﺪﯿھدمﺎﺠﻧا ﺪﯾﺎﺑ ﮫﮐ ﯽﺗﺎﻣاﺪﻗاﮫﺑ.ﺪﯿﯾﺎﻣﺮﻓ ﮫﻌﻟﺎﻄﻣاﺮﻧآﺖﻗد ﺎﺑ .دﻮﺷ ﯽﻣ ﮫﺋاراHealthPlans(RMHP)
ﺖﻓﺎﯾرد یاﮫﻨﯾﺰھﺖﺧادﺮﭘنوﺪﺑنﺎﺗدﻮﺧنﺎﺑزﮫﺑارتﺎﻋﻼطا ﺪﯾراد ﻖﺣ ﺎﻤﺷ.ﺪﯿﯾﺎﻤﻧ ﮫﺟﻮﺗﺎﮭﻧآرﺮﻘﻣﺖﻠﮭﻣ
.ﺪﯿﻧﺰﺑ ﮓﻧز3464-643-008هرﺎﻤﺷﮫﺑ ﮏﻤﮐ ﺖﺳاﻮﺧرد یاﺮﺑ.ﺪﯿﻨﮐ
Notice of Nondiscrimination
Rocky Mountain Health Plans (RMHP) complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. RMHP does not exclude
people or treat them differently because of race, color, national origin, age, disability, or sex.
RMHP takes reasonable steps to ensure meaningful access and effective communication is provided timely
and free of charge:
 Provides free auxiliary aids and services to people with disabilities to communicate effectively with us,
such as:
 Qualified sign language interpreters (remote interpreting service or on-site appearance)
 Written information in other formats (large print, audio, accessible electronic formats, other
formats)
 Provides free language assistance services to people whose primary language is not English, such
as:
 Qualified interpreters (remote or on-site)
 Information written in other languages
If you need these services, contact the RMHP Member Concerns Coordinator at 800-346-4643, 970-243-
7050, or TTY 970-248-5019, 800-704-6370, Relay 711; para asistencia en español llame al 800-346-4643.
If you believe that RMHP has failed to provide these services or discriminated in another way on the basis of
race, color, national origin, age, disability, or sex, you can file a grievance with: the RMHP EEO Officer at
800-346-4643, 970-244-7760, ext. 7883, or TTY 970-248-5019, 800-704-6370, Relay 711; para asistencia
en español llame al 800-346-4643, or [email protected]. You can file a grievance in person or by mail,
fax, or email. If you need help filing a grievance, the RMHP EEO Officer is available to help you. You can
also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-
1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal.
H0602_MC_MLIS_09152016Accepted
Table of Contents

Analgesics ................................................................................................................................................................. 3
Anesthetics ............................................................................................................................................................. 17
Anti-Addiction/Substance Abuse Treatment Agents ......................................................................................... 21
Antianxiety Agents ................................................................................................................................................ 23
Antibacterials ......................................................................................................................................................... 25
Anticancer Agents ................................................................................................................................................. 40
Anticholinergic Agents .......................................................................................................................................... 51
Anticonvulsants ..................................................................................................................................................... 52
Antidementia Agents ............................................................................................................................................. 58
Antidepressants ..................................................................................................................................................... 59
Antidiabetic Agents ............................................................................................................................................... 64
Antifungals ............................................................................................................................................................. 71
Antigout Agents ..................................................................................................................................................... 75
Antihistamines ....................................................................................................................................................... 75
Anti-Infectives (Skin And Mucous Membrane) ................................................................................................. 76
Antimigraine Agents ............................................................................................................................................. 77
Antimycobacterials ............................................................................................................................................... 80
Antinausea Agents ................................................................................................................................................. 80
Antiparasite Agents ............................................................................................................................................... 83
Antiparkinsonian Agents ...................................................................................................................................... 84
Antipsychotic Agents ............................................................................................................................................ 86
Antivirals (Systemic) ............................................................................................................................................. 90
Blood Products/Modifiers/Volume Expanders ................................................................................................... 96
Caloric Agents ..................................................................................................................................................... 105
Cardiac Function ................................................................................................................................................. 108
Cardiovascular Agents ........................................................................................................................................ 109
Central Nervous System Agents ........................................................................................................................ 130
Contraceptives ..................................................................................................................................................... 136
Cough And Cold Products .................................................................................................................................. 159
Dental And Oral Agents ..................................................................................................................................... 161
Dermatological Agents ........................................................................................................................................ 162
Devices .................................................................................................................................................................. 181
Diabetes Mellitus ................................................................................................................................................. 198
1 FORM-Good Health-December 2017