2016 Formulary (List of Covered Drugs) - PDF

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Amerivantage Classic (H) 06 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on August, 0. For more
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Amerivantage Classic (H) 06 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on August, 0. For more recent information or other questions, please contact Amerivantage Classic (H) Customer Service at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0, or visit Y0_6_7_U_0 CMS Accepted 8//0 69MUSENMUB _0 H87_00 Core_69_CG6_v8_60_ 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 Amerigroup. When it refers to plan or our plan, it means Amerivantage Classic (H). This document includes a list of the drugs (formulary) for our plan which is current as of August, 0. 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, 07 and from time to time during the year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Effective Date January, 06 Core_69_CG6_v8_60_ What is the Amerivantage Classic (H) formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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 (drug list) change? Generally, if you are taking a drug on our 06 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 06 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 forumulary 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, 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 Administration (FDA) 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, 06. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (nonmaintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on 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 Medications. If you know what your drug is used for, look for the category name in the list that begins on 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 that begins on page 9. 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? Our plan 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: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Effective Date January, 06 Core_69_CG6_v8_60_ Quantity : For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per prescription for irbesartan 7 tablets. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our 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 A and B both treat your medical condition, our plan may not cover B unless you try A first. If A does not work for you, our plan will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also 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 our plan 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 Amerivantage Classic (H)'s formulary? on page for information about how to request an exception. 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 Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service 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 our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Amerivantage Classic (H)'s formulary? You can ask our plan 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 predetermined 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 specialty 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, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, 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 us 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 7 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 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. Effective Date January, 06 Core_69_CG6_v8_60_ 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 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-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 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. 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 -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan 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 prescription drug coverage, please call Medicare at -800-MEDICARE ( ), hours a day/7 days a week. TTY users should call Or, visit Our plan s formulary The formulary 8 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 9. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lowercase italics (e.g., atenolol). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B Effective Date January, 06 Core_69_CG6_v8_60_ drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0. TTY/ TDD users should call 7. INJ - Injectable: The drug is available in injectable form. - Mail Orders: Prescription drugs available through mail order. CG Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Effective Date January, 06 6 Core_69_CG6_v8_60_ Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing : Preferred Generic Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Generic Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Preferred Brand Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Nonpreferred Brand Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Specialty * Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing 6: Select Care s Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) $.00 $9.00 $.00 $7.00 $.00 $7.00 $9.00 $00.00 % % $0.00 $0.00 Please refer to our Evidence of Coverage for more information for cost sharing. Network Pharmacy with preferred cost-sharing A network pharmacy that offers covered drugs to members of our plan that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing. * A long-term supply is not available for drugs in the : Specialty ** Mail-Order Pharmacy Mail-order service allows you to order a 0 90-day supply of drugs. The drugs available through our plan s mail-order service are marked as mail-order drugs in our drug list. Effective Date January, 06 7 Core_69_CG6_v8_60_ Covered Medications by Therapeutic Category Legend Generic drugs are shown in lowercase italic (e.g., atenolol). Brand-name drugs are shown in capital letters (e.g., CRESTOR). QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0. TTY/TDD users should call 7. INJ - Injectable: The drug is available in injectable form. - Mail Orders: Prescription drugs available through mail order. CG Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Name Anti - Infectives abacavir abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 / ml acyclovir oral tablet acyclovir sodium intravenous recon soln 00 acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME ; QLL (60 per 0 ; QLL (60 per 0 ; ; ; QLL (80 per ; Name amikacin injection solution,000 / ml, 00 / ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet, chewable, 0 amoxicillin-pot clavulanate oral suspension for reconstitution / ml, 00-7 / ml, / ml amoxicillin-pot clavulanate oral suspension for reconstitution 0-6. / ml amoxicillin-pot clavulanate oral tablet 0- amoxicillin-pot clavulanate oral tablet 00-, 87- Core_69_CG6_v8_60_ 8 Effective Date January, 06 Name amoxicillin-pot clavulanate oral tablet extended release hr amoxicillin-pot clavulanate oral tablet,chewable amphotericin b ampicillin oral capsule ampicillin oral suspension for reconstitution ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln. gram, gram ampicillin-sulbactam injection recon soln gram ampicillin-sulbactam intravenous recon soln. gram ampicillin-sulbactam intravenous recon soln gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil ATRIPLA azithromycin intravenous recon soln 00 azithromycin intravenous recon soln 00 ( /ml) azithromycin oral packet azithromycin oral suspension for reconstitution 00 / ml azithromycin oral suspension for reconstitution 00 / ml azithromycin oral tablet aztreonam BARACLUDE ORAL SOLUTION ; ; QLL (0 per 0 QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; Name BICILLIN C-
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