What is a Formulary?
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. 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.
The formulary may change during the year. If we remove drugs from our formulary, or 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 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.
Some 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 medications that are used for maintenance of health for chronic conditions and offer clinical and cost savings advantages.
- Tier 2 Non-Preferred Generic - All other generic medications 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.
- Tier 4 Non-Preferred Brand - All other brand-name medications in our formulary.
- Tier 5 Specialty - High cost specialty generic and brand-name drugs that exceed $600 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 Service 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 Service toll-free at 1-800-499-2838 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the safest, most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Please consult your copy of our formulary or Search Our Online Formulary on our website for more information about these requirements and limits.
- Prior Authorization
Certain medications require prior authorization. This means we must give our approval before you fill your prescriptions. If you don't get approval, the drug may not be covered.
- Step Therapy
In some cases, we require 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.
- Quantity Limits
For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 30 tablets per 30-day supply for simvastatin. Drugs that have quantity limits are indicated on our formulary. Generally, the amount of drug we cover is based on Food and Drug Administration (FDA) approved dosing and usage guidelines. The same Quantity Limits requirements apply to both mail order and retail pharmacies.
Drugs that require Prior Authorization, Step Therapy or Quantity Limits are indicated on our drug list. Follow this link to Search Our Drug List to see if your medication requires Prior Authorization, or Step Therapy.
You can ask us to make an exception to our coverage rules, including waiving our prior authorization, step therapy and quantity limit restrictions on your drug. Learn more about Requesting an Exception below.
Requesting an Exception
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.
- Call our Customer Service Department to request an exception to our coverage rules.
- 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.
- You may ask 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.
- You may ask 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.
- You may ask us to pay a lower price for a covered non-preferred Part D drug through the tiering exception process. If your Part D drug is in one of our non-preferred tiers (Tier 2 - non-preferred generic or Tier 4 - non-preferred brand), you may ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tiers (Tier 1 - preferred generic or Tier 3 - preferred brand). This lowers the coinsurance / copayment amount you must pay for your Part D drug. Please note, if we grant your request to cover a Part D drug that is not on our formulary, you cannot ask for an exception on the copayment or coinsurance amount we require you to pay for the Part D drug. Also, you may not ask us to lower the cost for Part D drugs in the high cost specialty generic and brand 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 may contact us to ask for any of these requests at:
Part D Coverage Determinations (about your Part D Prescription Drugs)
- PHONE 1-800-499-2838. Calls to this number are free.
- TTY/TDD 1-800-421-1220. This number requires special telephone equipment. Calls to this number are free.
- FAX 1-800-956-2397
- WRITE Pharmacy Management Department, P.O. Box 40320, Rochester, NY 14604
For information on the status of your exception request call Customer Service toll-free at 1-800-499-2838 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
Your doctor needs to request prior authorization for you using these forms.
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
Select your plan in your location to learn more:
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/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, 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
Permissible documents are as follows:
- 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
To establish that you are a full benefit dual eligible individual, institutionalized and qualify for a zero cost-sharing level, we will accept any one of the following forms of proof:
- 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/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, 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.
As a new member in our Plan you may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. You should talk to your doctor to decide if you should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Section 5 of the Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact our Pharmacy Help Desk if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or to request a formulary exception.
During the period of time you are talking to your doctor to determine the right course of action, we may provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year.
When you go to a network pharmacy and we provide a temporary supply 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 will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
If you are a new member and a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days you are a new member enrolled in our Plan. If you are a long-term care facility resident and have been enrolled in our Plan for more than 90 days and need a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception.
Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug purchased at an out-of-network pharmacy, unless you qualify for out-of-network access. See Section 10 of the Evidence of Coverage for information about non-Part D drugs.