The following information was taken from the Medicare Generation Rx Formulary. There appears to be questions/confusion as to how a Formulary is developed and what types of restrictions there may be in prescription drug coverages:
What is the Medicare Generation Rx Formulary?
A formulary is a list of covered drugs selected by Medicare Generation Rx 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. Medicare Generation Rx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare Generation Rx 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 2014 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2014 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. To get updated information about the drugs covered by Medicare Generation Rx, please contact us. If mid-year non-maintenance formulary changes occur, affected members will be notified of formulary changes in “Your Monthly Prescription Drug Summary”, also referred to as their Part D Explanation of Benefits (EOB).
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: Medicare Generation Rx requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Medicare Generation Rx before you fill your prescriptions. If you don’t get approval, Medicare Generation Rx may not cover the drug.
- Quantity Limits: For certain drugs, Medicare Generation Rx limits the amount of the drug that Medicare Generation Rx will cover. For example, Medicare Generation Rx provides 18 tablets in 28 days per prescription for Maxalt. This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, Medicare Generation Rx 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, Medicare Generation Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Medicare Generation Rx 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 10.You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site.
You can ask Medicare Generation Rx 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 Medicare Generation Rx formulary?” on page 4 of the formulary for information about how to request an exception.
Contact Medicare Generation Rx:
www.medicaregenerationrx.com/SOM or call: 1-877-633-7943.
MedImpact formulary questions:
www.mp.medimpact.com/som or call: 1-877-403-6034.
Editor’s note: Bob Kopasz is Chair of the Michigan SERA Council. He may be reached at P.O. Box 692, Mt. Morris, MI 48458; phone 810/240-8380.