2016 FORMULARY OF COVERED PRESCRIPTION DRUGS - PDF

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A Medicare Advantage Plan 206 FORMULARY OF COVERED PRESCRIPTION DRUGS Approved Formulary Submission ID Number: , Version 7 H5549_206 Formulary_085_DSB_rv_Accepted Preferred (HMO SNP) VNSNY
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A Medicare Advantage Plan 206 FORMULARY OF COVERED PRESCRIPTION DRUGS Approved Formulary Submission ID Number: , Version 7 H5549_206 Formulary_085_DSB_rv_Accepted Preferred (HMO SNP) VNSNY CHOICE Total (HMO SNP) Maximum (HMO SNP) Classic (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/29/205. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday through Friday from 8:00 AM to 8:00 PM or visit and VNSNY CHOICE Total 206 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Includes members enrolled in Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) Approved Formulary Submission ID Number: , Version: 7 This formulary was updated on August 29, 205. For more recent information or other questions, please contact Member Services at or, for TTY users, 7, Monday through Friday from 8:00 AM to 8:00 PM or visit 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 VNSNY CHOICE Medicare. When it refers to plan or our plan, it means our VNSNY CHOICE Medicare Preferred (HMO SNP), Classic (HMO), Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP). This document includes a list of the drugs (formulary) for our plan, which is current as of August 29, 205. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January, 207, and from time to time during the year. is an HMO plan with a Medicare contract. Enrollment in depends on contract renewal. H5549_206 Formulary_085_DSB Last updated: 08/29/205 What is the Formulary? A formulary is a list of covered drugs selected by 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. VNSNY CHOICE Medicare 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 (drug list) change? Generally, if you are taking a drug on our 206 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 206 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. 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. The enclosed formulary is current as of August 29, 205. To get updated information about the drugs covered by, please contact us. Our contact information appears on the front cover and back cover pages. If we update our printed formulary with non-maintenance formulary changes, we will send you a notice that includes this information. 2 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 49. 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. If you know what your drug is used for, look for the category name in the list that begins on page 49. 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 I-. 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? 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: requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from before you fill your prescriptions. If you don t get approval, may not cover the drug. Quantity Limits: For certain drugs, limits the amount of the drug that will cover. For example, provides 60 capsules per prescription for Celebrex. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, requires you to first try certain drugs to treat 3 cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, may not cover Drug B unless you try Drug A first. If Drug A does not work for you, will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 49. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. You can ask 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 s formulary? on page 5 for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. pays for certain OTC drugs. COVERED OVER-THE-COUNTER (OTC) DRUGS DRUG Generic Name cetirizine hydrochloride cetirizine hydrochloride/ pseudoephedrine hydrochloride (Reference Brand Name) (Zyrtec) (Zyrtec-D) Dosage Form Chewable Tablets, Solution, Tablets 2 Hour Tablets loratadine (Claritin) Solution, Tablets loratadine/ 2 Hour Tablets (Claritin-D) pseudoephedrine sulfate 24 Hour Tablets ketotifen fumarate (Zaditor) Drops will provide these OTC drugs at no cost to you. The cost to of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap.) 4 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 Member Services and ask if your drug is covered. If you learn that does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by. You can ask 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 Formulary? You can ask 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 pre-determined 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, 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, will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower costsharing 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. 5 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 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. 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 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-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 9-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 3-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. A transition fill is provided to current members that are in need of a one-time Emergency Fill or that are prescribed a non-formulary drug as a result of a level of care change. 6 For more information For more detailed information about your prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit This information is available for free in other languages. Please call Member Services at for additional information. (TTY users should call 7 Toll-free) Monday through Friday from 8:00 AM to 8:00 PM. Member Services also has free language interpreter services available for non-english speakers. is an HMO with a Medicare contract. Enrollment in depends on contract renewal. 7 s Formulary The formulary that begins on page 49 provides coverage information about the drugs covered by. If you have trouble finding your drug in the list, turn to the Index that begins on page I-. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., naproxen). The information in the Requirements/Limits column tells you if VNSNY CHOICE Medicare has any special requirements for coverage of your drug. The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug. PA BvD Prior Authorization Restriction for Part B vs Part D Determination This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE Medicare may not cover this drug. 8 ABBREVIATION DESCRIPTION EXPLANATION PA-HRM PA NSO QL ST Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug If you are a new member, you (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, may not cover this drug. limits the amount of this drug that is covered per prescription, or within a specific time frame. Before will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. 9 The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION DESCRIPTION EXPLANATION LA NM Limited Access Drug Non-Mail Order Drug This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services at , Monday through Friday from 8:00 am to 8:00 pm. TTY/TDD users should call 7. You may be able to receive greater than a -month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. 0 STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION DESCRIPTION adh. patch adhesive patch aer br act aerosol, breath activated aer pow aerosol, powder aer pow ba aerosol powder, breath activated aer refill aerosol refill aer w/adap aerosol with adapter ampul ampule blkbaginj bulk bag injection cap dr mp capsule, delayed release multiphasic cap ds pk capsule, dose pack cap er 2h capsule, 2 hour extended release cap er 24h capsule, 24 hour extended release cap er deg capsule, extended release degradable cap er pel capsule, extended release pellets cap mphase capsule, multiphasic cap.sa 24h capsule, 24 hour sustained action cap.sr 2h capsule, 2 hour sustained release cap.sr 24h capsule, 24 hour sustained release cap24h pct capsule, 24 hour controlled-onset pellets cap24h pel capsule, 24 hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 2hr capsule, 2 hour multiphasic cpmp 24hr capsule, 24 hour multiphasic cpmp capsule, multiphasic, 30%-70% ABBREVIATION DESCRIPTION cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(2-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator froz.piggy frozen piggyback g gram gel/pf app gel with prefilled applicator gel (gm) gel (grams) gel (ml) gel (milliliters) gel md pmp gel in metered dose pump gel w/appl gel with applicator gel w/pump gel with pump gran pack granule pack hfa aer ad hfa aerosol adapter infus. btl infusion bottle insuln pen insulin pen ip soln intraperitoneal solution irrig soln irrigating solution iv soln. intravenous solution jel jelly jelly/app jelly with applicator jel/pf app jelly with pre-filled applicator kit cl&crm kit: cleanser and cream kt crm le kit: cream, lotion emollient 2 ABBREVIATION kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 2h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon DESCRIPTION kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 2 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solut
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