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Drug Formulary


2018 Central Health Medicare Plan Online Formulary Search

Coverage Determination, Grievances, and Appeals


2019 Prior Authorization Criteria - English
2019 Step Therapy Criteria - English



PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN (BEGINNING 2019)

HPMS Approved Formulary File Submission ID, Version Number 00019585 Version: 6

This formulary was updated on 10/09/2018. For more recent information or other questions, please contact Central Health Medicare Plan Member Services, at 1-866-314-2427 or, for TTY/TDD users, 1-888-205-7671, 7 days a week, 8:00 A.M. to 8:00 P.M. (P.T.), or visit www.centralhealthplan.com.

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 Central Health Medicare Plan. When it refers to “plan” or “our plan,” it means Central Health Medicare Plan (HMO), Central Health Medi-Medi Plan (HMO SNP), Central Health Premier Plan (HMO), Central Health Focus Plan (HMO SNP), Central Health Ventura Medicare Plan (HMO), Central Health Ventura Medi-Medi Plan (HMO SNP), Central Health Inspire HMO, Central Health Elite HMO SNP, or Central Health Prestige HMO.

This document includes a list of the drugs (formulary) for our plan which is current as of 10/09/2018. 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 1, 2020, and from time to time during the year.

What is the Central Health Medicare Plan 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.

For a complete listing of all prescription drugs covered by our plan, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug:

  • Drugs removed from the market. 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.
  • Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. 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 30 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 30-day supply of the drug.

The enclosed formulary is current as of 09/04/2018. 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. In the event of non-maintenance changes to the formulary throughout the plan year, Central Health Medicare Plan may make changes via errata sheets mailed to you. Additionally, you may visit our website for a link to the errata sheets.

How do I use the Formulary?

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

Medical Condition

The formulary begins on page 1. 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”. If you know what your drug is used for, look for the category name in the list that begins on page number 1. 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 I-1. 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.
  • Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 60 capsules per prescription for PRADAXA. 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 Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan 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 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line 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 Central Health Medicare Plan’s formulary?” on page v 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 Member Services 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 Member Services 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 Central Health Medicare Plan’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 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, 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, or utilization restriction exception. When you request a formulary 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. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. 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 and 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 31-day emergency supply of that drug while you pursue a formulary exception.

Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows:

  1. Beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital;
  2. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary;
  3. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits;
  4. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized.

All of these situations would warrant a temporary one-time fill exception irrespective of whether the beneficiary is in the first 90 days of program enrollment.

For more information

For more detailed information about your 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 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Our plan’s Formulary

The formulary that begins on page 1 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 I-1.

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

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

Covered Medications by Therapeutic Category

Legend

Generic drugs are shown in lower-case italic (e.g., lisinopril).

Brand-name drugs are shown in capital letters (e.g., HUMIRA).

QL – Quantity Limits: There is a quantity limitation that 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).

AGE – Age Restrictions: The drug is restricted by age.

GC – Gap Coverage: We provide coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Please Note: Gap Coverage may vary by plan.

LA – Limited Access: This prescription may be available only at certain pharmacies. For more information please call 1-888-728-5048, 24 hours a day- seven days a week. TTY/TDD users should call 711.

NDS – Non Extended Day Supply: Non-extended Day Supply drugs that are dispensed up to a month supply to monitor for possible adverse effects and to avoid medication waste.

PA – Prior Authorization: This medication requires prior authorization. To obtain an exception please call 1-888-728-5048, 24 hours a day- seven days a week. TTY/TDD users should call 711. You, your doctor or other network provider will need to request prior authorization before filling the prescription.

PA NSO – Prior Authorization-New Starts: This medication requires prior authorization for new starts only. To obtain an exception please call 1-888-728-5048, 24 hours a day- seven days a week. TTY/TDD users should call 711.

PA BvD – Prior Authorization – Part B vs Part D: This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make the determination.

PA HRM– Prior Authorization- High Risk Meds: This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. This medication requires prior authorization. To obtain an exception please call 1-888-728-5048- 24 hours a day- seven days a week. TTY/TDD users should call 711. Without prior approval, the Plan may not cover this drug.

ST – Step Therapy: Step therapy protocols apply. 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.

EX - Excluded Drugs: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is the amount you pay does not help you qualify for catastrophic coverage). In addition if you are receiving extra help to pay for your prescriptions you will not get any extra help to pay for this drug.

NM - Retail Only: Drugs not available via your mail order benefit are noted with “NM” in the Requirements/Limits column of your formulary.

How much will I pay for Central Health Medicare Plan covered drugs?

The amount you pay depends on which drug tier your drug is in and whether you are receiving any extra help paying for your prescription drugs.

If you are a member of Central Health Medicare Plan (HMO) see below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage:

Drug Tier Network Pharmacy (30-day supply) Network Pharmacy (90-day supply) Mail Order
(90-day supply)
Tier 1 - Preferred Generic $0 $0 $0
Tier 2 - Generic $5 $15 $10
Tier 3 - Preferred Bland $35 $105 $70
Tier 4 - Non-Preferred Drug $75 $225 $150
Tier 5 - Specialty Tier Durgs $33 Not available Not available
Tier 6 - Select Care Drugs $10 $30 $20

If you are a member of Central Health Medi-Medi Plan (HMO SNP), Central Health Ventura Medi-Medi Plan (HMO SNP), Central Health Elite HMO SNP the amount you pay depends on whether you are receiving extra help from Medicare to pay for your prescription drugs. See below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage:

Extra Help Program Receiving Extra Help No Extra Help
Drug Tier Network Pharmacy (30-day supply) Network Pharmacy (90-day supply)
Tier 1 - Preferred Generic $0 $0
Tier 2 - Generic
Tier 3 - Preferred Bland $0, $1.25, $3.40, or 15% for generic drugs and $0, $3.80, $8.50, or 15% for brand drugs $25
Tier 4 - Non-Preferred Drug
Tier 5 - Specialty Tier Durgs
Tier 6 - Select Care Drugs $0, $3.80, $8.50, Or 15% $10

If you are a member of Central Health Premier Plan (HMO) see below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage:

Drug Tier Network Pharmacy (30-day supply) Network Pharmacy (90-day supply) Mail Order
(90-day supply)
Tier 1 - Preferred Generic $0 $0 $0
Tier 2 - Generic $0 $0 $0
Tier 3 - Preferred Bland 25% 25% 25%
Tier 4 - Non-Preferred Drug 25% 25% 25%
Tier 5 - Specialty Tier Durgs 25% Not available Not available
Tier 6 - Select Care Drugs $10 $30 $20

If you are a member of Central Health Focus Plan (HMO SNP), see below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage:

Drug Tier Network Pharmacy (30-day supply) Network Pharmacy (90-day supply) Mail Order
(90-day supply)
Tier 1 - Preferred Generic $0 $0 $0
Tier 2 - Generic $5 $15 $10
Tier 3 - Preferred Bland $35 $105 $70
Tier 4 - Non-Preferred Drug $75 $225 $150
Tier 5 - Specialty Tier Durgs 33% Not available Not available
Tier 6 - Select Care Drugs $0 $0 $0

If you are a member of Central Health Ventura Medicare Plan (HMO), see below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage:

Drug Tier Network Pharmacy (30-day supply) Network Pharmacy (90-day supply) Mail Order
(90-day supply)
Tier 1 - Preferred Generic $4 $12 $8
Tier 2 - Generic $9 $27 $18
Tier 3 - Preferred Bland $45 $135 $90
Tier 4 - Non-Preferred Drug $90 $270 $180
Tier 5 - Specialty Tier Durgs 33% Not available Not available
Tier 6 - Select Care Drugs $10 $30 $20

If you are a member of Central Health Inspire HMO, see below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage:

Drug Tier Network Pharmacy (30-day supply) Network Pharmacy (90-day supply) Mail Order
(90-day supply)
Tier 1 - Preferred Generic $0 $0 $0
Tier 2 - Generic $10 $30 $20
Tier 3 - Preferred Bland $40 $120 $80
Tier 4 - Non-Preferred Drug $90 $270 $180
Tier 5 - Specialty Tier Durgs 33% Not available Not available
Tier 6 - Select Care Drugs $5 $15 $10

If you are a member of Central Health Prestige HMO, see below for the copayment or coinsurance for each drug tier while you are in the Initial Coverage Stage

Drug Tier Network Pharmacy (30-day supply) Network Pharmacy (90-day supply) Mail Order
(90-day supply)
Tier 1 - Preferred Generic $0 $0 $0
Tier 2 - Generic $0 $0 $0
Tier 3 - Preferred Bland 25% 25% 25%
Tier 4 - Non-Preferred Drug 25% 25% 25%
Tier 5 - Specialty Tier Durgs 25% Not available Not available
Tier 6 - Select Care Drugs $10 $30 $30

Central Health Medicare Plan is an HMO Plan with a Medicare and Medicaid contract. Enrollment in Central Health Medicare Plan depends on contract renewal.



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