Peoples Health Online Formulary

A formulary is a list of covered drugs selected by Peoples Health 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Peoples Health network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review the Evidence of Coverage.

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 or step therapy restrictions on a drug, 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. We must also provide such notice to affected members of Peoples Health Choices 65 #14, Peoples Health Choices Gold and Peoples Health Group Medicare if we move a drug to a higher cost-sharing tier.

The online formulary is updated each month.

In the event of a mid-year, nonmaintenance formulary change, we will notify you in writing of certain changes that may affect you.

The online formulary is current as of:

You can use the online formulary to search for covered drugs by name or by therapeutic category (the type of medical conditions that they are used to treat). For example, drugs used to treat a heart condition are in the “Cardiovascular” therapeutic category.  You can type in at least three letters of a drug’s name or choose a therapeutic category from the drop-down menu.

Peoples Health 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:

• Prior Authorization: Peoples Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

• Quantity Limits: For certain drugs, Peoples Health limits the amount of the drug that we will cover.  For example, we provide 12 tablets per prescription for 30 days of naratriptan. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Peoples Health 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking at the details for the drug in our online formulary. We also have posted documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information is here.

 You can ask us 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 Peoples Health formulary?” below for information about how to request an exception.

If your drug is not included in our formulary (list of covered drugs), you should first contact member services and ask if your drug is covered.

If you learn that Peoples Health 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 plans. 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 plans.
• You can ask us to make an exception and cover your drug. See below for information about how to request an exception.

You can ask us 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.
• If you are a member of Peoples Health Choices 65 #14, Peoples Health Choices Gold and Peoples Health Group Medicare, 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, we limit 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, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug (for eligible plan members, as named above), 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 (for eligible plan members, as named above) 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 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 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.

Peoples Health provides a transition process for members who experience a level-of-care change and are currently on a medication regimen that contains non-formulary drugs or formulary drugs with restrictions. This transition process will occur when the coverage determination processing time frames could interrupt the prescribed drug regimen. We will cover up to a 31-day temporary supply of these non-formulary drugs or formulary drugs with restrictions. Level-of-care changes include discharges from hospitals or psychiatric facilities; admissions to or discharges from long-term care facilities; giving up hospice status; or exceeding the limit for days covered during a skilled nursing facility stay.

For more detailed information about your plan’s prescription drug coverage, please review the Evidence of Coverage and other plan materials.

If you have questions about Peoples Health, please contact us. Our contact information is here.

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 medicare.gov.

The online formulary provides coverage information about the drugs covered by Peoples Health.