A formulary is a list of covered drugs selected by us 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. We 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.
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 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 for those members taking it for the remainder of the coverage year.
The formulary may change during the year. Listed below are the changes which may affect the coverage of the drugs you are taking.
- We may immediately remove a brand name drug on our Drug List if we are replacing it with a newly approved generic version of the same drug. This newly approved generic drug will be on the same or lower cost sharing tier and have the same or fewer restrictions as the brand name drug. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a higher cost-sharing tier or add new restrictions. We may not give you notice in advance before we make this change—even if you are currently taking the brand name drug.
- We might add a generic drug that is not new to the market to replace a brand name drug or change the cost-sharing tier or add new restrictions to the brand name drug. We also might make changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare. We must give you at least 30 days’ advance notice of the change or give you notice of the change and a 30-day refill of the drug you are taking at a network pharmacy.
Our Medicare plans cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
Our formulary uses a tiered structure. Drugs in each tier cost different amounts.
- Tier 1 Preferred Generic - Select generic drugs that are used for maintenance of health for chronic conditions and offer clinical and cost savings advantages. Includes many of the preventive vaccines recommended for adult immunization.
- Tier 2 Generic - Most other generic drugs in our formulary.
- Tier 3 Preferred Brand - Preferred brand-name drugs that have unique significant clinical advantages and offer overall greater value over the other products in the same drug class. Certain generic drugs may appear in Tier 3 due to the high cost of the drug or the potential safety concerns for our Part D members.
- Tier 4 Non-Preferred Drug - All other brand-name drugs on our formulary. Certain generic drugs may appear in Tier 4 due to the high cost of the drug or the potential safety concerns for our Part D members.
- Tier 5 Specialty - High cost specialty generic and brand-name drugs that exceed $950 per month. For drugs in Tier 5, you pay a percentage of the cost through coinsurance.
If your drug is not on our formulary call our Customer Care Department for a list of similar drugs that are covered on our formulary. Show the list to your doctor and ask him or her to prescribe a similar drug that is covered.
For updated information about the drugs we cover, call Customer Care toll-free at 1-877-883-9577 (TTY 711) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Mar. 31, representatives also are available weekends from 8 a.m. to 8 p.m.
If you want to request coverage of a drug not on our formulary, a waiver of our utilization management requirements or your cost-sharing amount, you can request an exception
- What is an exception?
An exception is a type of initial determination (also called a "coverage determination") involving a Part D drug. You, your doctor, or other prescriber may ask us to make an exception to our Part D coverage rules in a number of situations including:- Asking us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
- Asking us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- Asking us to pay a lower price for a covered Part D drug on a higher cost sharing tier through the tiering exception process.
- If our drug list contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost sharing amount that applies to the alternative drug(s). This would lower your share of the cost for the drug.
- If we approve your request for a tiering exception and there is more than one lower cost-sharing tier with alternative drugs you can’t take, you will usually pay the lowest amount.
- You cannot ask us to change the cost sharing tier of any drug in the Specialty tier (Tier 5)
Generally, we will only approve your request for an exception if the alternative Part D drugs included on our formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.
If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you, and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.
Note: If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the co-payment or coinsurance amount we require you to pay for the drug.
You can request a Part D Prescription Drug Coverage Determination by:
- PHONE 1-877-883-9577 (TTY 711). Calls to this number are free.
- FAX 1-800-956-2397
- WRITE Pharmacy Management Department, P.O. Box 40320, Rochester, NY 14604
- Send a Coverage Determination Request (via Secure eForm) to begin the determination process
For information on the status of your exception request call Customer Care toll-free at 1-877-883-9577 (TTY 711) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Mar. 31, representatives also are available weekends from 8 a.m. to 8 p.m.
Your doctor can request and submit an exception for you using these forms.
Elderly Pharmaceutical Insurance Coverage (EPIC) is a New York State program* for seniors that helps with out-of-pocket Medicare Part D drug plan costs. It works together with Medicare Advantage plans, and over 320,000 New Yorkers have already joined EPIC to save on their prescription drug coverage. EPIC helps pay Medicare Part D drug plan premiums or provides assistance by lowering the EPIC deductible. There are two plans based on income:
- The Fee Plan is for members with incomes up to $20,000 if single or $26,000 if married.
- The Deductible Plan is for members with incomes ranging from $20,001 to $75,000 if single or $26,001 to $100,000 if married.
How to Join the Program
Joining the program is easy and you can apply at any time of the year. Just complete the application and mail or fax it to EPIC. EPIC verifies information with the Social Security Administration and the New York State Department of Taxation and Finance.
* You must be a New York State resident 65 years of age or older and be enrolled or eligible to be enrolled in a Medicare Part D drug plan to receive EPIC benefits and maintain coverage. EPIC provides secondary coverage for Medicare Part D- and EPIC-covered drugs after any Part D deductible is met. EPIC also covers approved Part D-excluded drugs such prescription vitamins as well as prescription cough and cold preparations once a member is enrolled in a Part D drug plan. Learn more at the New York State Department of Health website.
Do you believe you have qualified for extra help and that you are paying an incorrect copayment amount?
If you believe you are paying an incorrect copayment amount when you get your prescription at the pharmacy, we can help you confirm your eligibility. We follow Medicare's Best Available Evidence Policy and if you have the appropriate documentation, we can help you sort out your eligibility issues. Call Customer Service toll-free at 1-877-883-9577 (TTY 711) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Mar. 31, representatives also are available weekends from 8 a.m. to 8 p.m.
What is Best Available Evidence?
Medicare's Best Available Evidence Policy is used to determine eligibility for extra help with prescription drug costs when information is not readily available to us through other standard sources. This policy allows a member, member's pharmacist, advocate, representative, family member or other individual acting on behalf of the member to submit certain documentation that we will use to update a member's eligibility when appropriate
Examples of Acceptable Documentation
- A copy of the beneficiary’s Medicaid card that includes the beneficiary’s name and an eligibility date during a month after June of the previous calendar year;
- A copy of a state document that confirms active Medicaid status during a month after June of the previous calendar year;
- A print out from the State electronic enrollment file showing Medicaid status during a month after June of the previous calendar year;
- A screen print from the State’s Medicaid systems showing Medicaid status during a month after June of the previous calendar year;
- Other documentation provided by the State showing Medicaid status during a month after June of the previous calendar year;
- A letter from SSA showing that the individual receives SSI; or,
- An Application Filed by Deemed Eligible confirming that the beneficiary is “…automatically eligible for extra help…” SSA publication HI 03094.605
If You are Dual Eligible
- A remittance from the facility showing Medicaid payment for a full calendar month for that individual during a month after June of the previous calendar year;
- A copy of a state document that confirms Medicaid payment on behalf of the individual to the facility for a full calendar month after June of the previous calendar year;
- A screen print from the State’s Medicaid systems showing that individual’s institutional status based on at least a full calendar month stay for Medicaid payment purposes during a month after June of the previous calendar year.
- Effective as of a date specified by the Secretary, but no earlier than January 1, 2012, a copy of:
- A State-issued Notice of Action, Notice of Determination, or Notice of Enrollment that includes the beneficiary’s name and home and community based services (HCBS) eligibility date during a month after June of the previous calendar year;
- A State-approved HCBS Service Plan that includes the beneficiary’s name and effective date beginning during a month after June of the previous calendar year;
- A State-issued prior authorization approval letter for HCBS that includes the beneficiary’s name and effective date beginning during a month after June of the previous calendar year;
- Other documentation provided by the State showing HCBS eligibility status during a month after June of the previous calendar year; or,
- A state-issued document, such as a remittance advice, confirming payment for HCBS, including the beneficiary’s name and the dates of HCBS.
For additional assistance on where to send your documents, please call Customer Service toll-free at 1-877-883-9577 (TTY 711) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Mar. 31, representatives also are available weekends from 8 a.m. to 8 p.m.
Follow this link to View Medicare's Best Available Evidence Policy. You will be taken to the Centers for Medicare and Medicaid Services (CMS) Website.
When you go to a network pharmacy, we provide a temporary or transition supply of at least a month's supply (unless the enrollee presents with a prescription written for less) of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"). We provide this temporary supply in the following situations:
New Member or Current Member- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are a new member or during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication.
Current member and a resident of a LTC Facility - For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away, we will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.
Current member with a level of care change - For members who are being admitted to or discharged from a LTC facility, the Plan will not utilize early refill edits and this will allow appropriate and necessary access to your Part D benefit. Members will be allowed to access a refill upon admission or discharge.
We will provide you and your provider with a written notice after we cover your temporary supply. This notice will explain the next steps, such as requesting a formulary exception for the drug or talking to your doctor about switching to an appropriate drug we cover. See Chapter 9 of the Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact our Customer Care for any additional questions about our transition policy.
GDPR Notification Content