Upcoming Changes to the Central Health Plan Formulary
Coverage Determination, Grievances, and Appeals
HPMS Approved Formulary File Submission ID, Version Number 0021042 Version: 8
This formulary was updated on 12/21/2020. For more recent information or other questions, please contact Central Health Medicare Plan Member Services, at 1-866-314-2427 or, for TTY users, 711, 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 D-SNP), Central Health Premier Plan (HMO), Central Health Focus Plan (HMO C-SNP), Central Health Ventura Medicare Plan (HMO), or Central Health Ventura Medi-Medi Plan (HMO D-SNP).
This document includes list of the drugs (formulary) for our plan which is current as of 12/21/2020. 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, 2021, and from time to time during the year.
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.
Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes.
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.
The enclosed formulary is current as of 12/21/2020. To get updated information about the drugs covered by Central Health Medicare 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.
There are two ways to find your drug within the formulary:
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.
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.
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.
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
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.
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 our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
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.
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:
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 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.
The formulary that begins on the next page provides coverage information about some of 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.
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 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 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 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 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.
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:
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