Peoples Health Online Formulary | 2020

A drug list, or formulary, is a list of prescription drugs covered by your plan. Your plan and a team of health care providers work together in selecting drugs that are needed for well-rounded care and treatment.

Your plan will generally cover the drugs listed in our drug list as long as:

• The drug is used for a medically accepted indication,
• The prescription is filled at a network pharmacy and
• Other plan rules are

For more information about your drug coverage, please review your Evidence of Coverage.

You can use the online drug list to search for covered drugs by name or by therapeutic category (the type of medical conditions that they are used to treat). For example, if you have a heart condition, you should look in the category Cardiovascular Agents. This is where you will find drugs that treat heart conditions.

Generic drugs have the same active ingredients as brand name drugs. They usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA). Our plan covers both brand name and generic drugs.

Talk with your doctor to see if any of the brand name drugs you take have generic versions. For Peoples Health Choices 65 #14 (HMO), Peoples Health Choices Gold (HMO-POS), Peoples Health Choices Value (HMO) and Peoples Health Group Medicare (HMO-POS): Then review the drug list to make sure you are getting the drug you need for the least amount of money.

A compounded drug is created by a pharmacist by combining or mixing ingredients to create a prescription medication customized to the needs of an individual patient. Generally compounded drugs are non-formulary drugs (not covered) by your plan. You may need to ask for and receive an approved coverage determination from us to have your compounded drug covered. Compounded drugs may be Part D eligible. For more information about compounded drugs, please review your Evidence of Coverage.

The amount you pay for a covered prescription drug will depend on:

• Your drug payment stage. 
  Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you’re in.
• For Peoples Health Choices 65 #14, Peoples Health Choices Gold, Peoples Health Choices Value and Peoples Health Group Medicare: Your drug’s tier. 
  Each covered drug is in 1 of 5 drug tiers. Each tier has a copay or coinsurance amount. The chart below shows the differences between the tiers.

If you need help or have any questions about your drug costs, please review your Evidence of Coverage or call Member Services. 

• For Peoples Health Secure Health (HMO D-SNP) and Peoples Health Secure Choice #011 (HMO D-SNP): Your drug’s tier.
  Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier. The chart below shows your cost-sharing amount.

If you need help or have any questions about your drug costs, please review your Evidence of Coverage or call Member Services.

If you qualify for Extra Help paying for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to learn about your costs. You can also call Member Services.

Yes, some drugs may have coverage rules or have limits on the amount you can get. You can find out if your drug has any additional limits by looking at the details for the drug in our online drug list. The codes and what they mean are shown below.

We have posted online documents that explain our prior authorization and step therapy restrictions. If you would like a copy sent to you, please call Member Services.

Coverage Rules and Limits

PA – Prior authorization

The plan requires you or your doctor to get prior approval for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug.

QL – Quantity limits

The plan will cover only a certain amount of this drug for 1 copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

ST – Step therapy

There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try 1 or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug.

Other Special Coverage Rules

B/D – Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

HRM – High-risk medication

This drug is known as a high-risk medication (HRM) for patients 65 years and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition.

LA – Limited access

Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

MME – Morphine milligram equivalent

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

7D – 7-Day limit

An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.

DL – Dispensing limit

Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription.

You and your doctor may ask the plan for an exception to the coverage rules and/or limits for your drug. See section “How can I get an exception?” or see your Evidence of Coverage to learn more.

If you don’t get approval from the plan before you fill a prescription for a drug with coverage rules or limits, you may have to pay the full cost of the drug.

If your drug is not included in this drug list we may still cover it. Call Member Services to ask if it’s covered.

If you find out that your drug is not covered, you can do 1 of these things:

1. Ask Member Services for a list of similar drugs that are covered by the plan. When you get the list, show it to your doctor and ask him or her to prescribe a covered drug.
2. Ask the plan to make an exception and cover your drug.  Review the next section for more exception information.

The date we last updated the drug list is:

Sometimes you may need to ask for drug coverage that’s not normally provided by your plan. This is called asking for an exception. When you do, the plan will review your request and give you a coverage decision known as a coverage determination.

Types of exceptions you can ask for

• Drug list exception: Ask the plan to cover your drug even if it’s not on the drug list. If approved, this drug will be covered at a pre-determined cost-sharing level. You will not be able to ask us to provide the drug at a lower cost-sharing level.
• Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For example, if your drug has a quantity limit, you can ask the plan to change the limit and cover more.
• For Peoples Health Choices 65 #14, Peoples Health Choices Gold, Peoples Health Choices Value and Peoples Health Group Medicare: Tiering exception: Ask the plan to cover your drug on our list at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you pay out-of-pocket for your drug.
The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as effective in treating your condition or would cause adverse medical effects.

Who can ask for an exception?

You, your authorized representative or your doctor can ask for an exception by calling Member Services. Your doctor must give us a supporting statement with the reason for the exception.

How long does it take to get an exception?

After we get the statement from your doctor supporting your request for an exception, we’ll give you a decision within 72 hours. You can ask for an expedited (fast) decision if you or your doctor believes that your health could be seriously harmed by waiting 72 hours. If your request for an expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s supporting statement.

As a new or continuing member in our plan, we may cover a temporary supply of your drug if it’s not on our drug list or if it has rules or limits. For example, you may need a prior authorization from us before you can fill your prescription. During the time when you are getting a temporary supply, you should talk with your doctor to decide if there is a similar drug on the drug list you can take instead. If you and your doctor decide this is the only drug that will work for you, you will need to ask for an exception. We may cover your drug in certain cases during the first 90 days of your membership.

The following chart shows how much of your drug we may cover while you ask for an exception.

The prescription must be filled at a network pharmacy. If your prescription is written for fewer days, we’ll allow refills to provide at least the day supply listed in the chart above. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

We will not pay for more of your drug after you get this temporary or emergency supply unless you receive authorization from the plan.

Most changes in drug coverage happen on January 1. We may need to make changes during the plan year for safety or other reasons that can affect you. We must follow Medicare rules in making these changes.

The drug list may change during the year if your plan:

• Adds new drugs, including generic drugs, as they become available.
• Removes a drug that has been found to be ineffective or unsafe.
• Changes the coverage rules or limits for a drug.
• For Peoples Health Choices 65 #14, Peoples Health Choices Gold, Peoples Health Choices Value and Peoples Health Group Medicare: Moves a drug into a different cost-sharing tier.

If we add new generic drugs

We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier (for Peoples Health Choices 65 #14, Peoples Health Choices Gold, Peoples Health Choices Value and Peoples Health Group Medicare) and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier (for Peoples Health Choices 65 #14, Peoples Health Choices Gold, Peoples Health Choices Value and Peoples Health Group Medicare) or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section “How can I get an exception?”.

If we remove a drug from the list

Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we will not remove or reduce coverage during the year. If you are taking a drug that is removed because a generic version becomes available, we will tell you. If the Food and Drug Administration (FDA) says a drug you are taking is not effective or is unsafe, we will take it off the drug list right away.

If we change the coverage rules or limits

We’ll tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug. You can find out if your drug has any rules or limits by looking at the details for the drug in our online drug list.

We’ll tell you about other changes

If a drug you are taking is removed from the drug list during the plan year, we’ll include an update in your Part D Explanation of Benefits (Part D EOB) statement. We’ll tell you about other changes to our drug list at least 30 days before they go into effect or when you request a refill of the drug. If you find out when requesting a refill, you will receive at least a 30-day supply of the drug so you have time to talk with your doctor. To get updated information about the drugs covered by your plan, please call Member Services..

For Peoples Health Choices 65 #14, Peoples Health Choices Gold, Peoples Health Choices Value and Peoples Health Group Medicare: Drugs with dosages other than a 1-month supply

Drugs packaged in an extended day supply

Some drugs are packaged from the manufacturer to provide more than a 1-month supply. When you fill these drugs, you may have to pay more than 1 copay/coinsurance for a single prescription. For more information, please call Member Services.

Daily cost-sharing for oral medications filled for less than a 1-month supply

A daily cost-sharing rate may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply.

Daily cost-sharing applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than 1 month under applicable law. The daily cost-sharing requirements do not apply to either of the following:

1. Solid oral doses of antibiotics.
2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions.