SWHP ACA Compliant Formulary

191 Pages·2014·0.94 MB·English

SWHP ACA Compliant
Formulary
(Individual/Family Plans)
1stQuarter2015
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TableofContents
Whatismyprescriptiondrugcoverage?..............................................................................................3
WhatistheSWHPACACompliantformulary?......................................................................................3
Howwastheformularycreatedandhowarenewmedicationsreviewed?...........................................3
Doestheformularyeverchange?........................................................................................................4
HowamInotifiedofchangestotheformulary?...................................................................................4
Whatarebrand-nameandgenericdrugs?............................................................................................4
Whatisgenericsubstitution?..............................................................................................................4
WhatareSpecialtydrugs?...................................................................................................................5
Whatisatherapeuticinterchange?.....................................................................................................5
Whatarepharmaceuticalmanagementprocedures?............................................................................5
Arethereanyrestrictionsonmycoverage?.........................................................................................5
HowdoIrequestanexceptiontotheSWHPACACompliantFormulary?..............................................6
Whatdrugsarenotcoveredbymyprescriptiondrugbenefit?..............................................................6
Howmuchmedicationdoesmycopaymentcoveranddoesmyplancovermaintenancemedications?.7
HowcanIsavemoneyonprescriptions?..............................................................................................7
Abbreviations.....................................................................................................................................8
ContraceptiveCoverage......................................................................................................................8
PreventativeCareMedications&MedicationsCoveredUnderHealthCareReform...............................8
DiabeticSupplies.................................................................................................................................9
SmokingCessationMedicationCoverage.............................................................................................9
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Whatismyprescriptiondrugcoverage?
AspartofyourScottandWhiteHealthPlan(SWHP)coverage,youmayhavea
prescriptiondrugbenefit. Thisdocumentwillhelpyouunderstandyourprescription
drugbenefitandtheSWHPACA(AffordableCareAct)CompliantClosedformulary.
Noteveryprescriptiondrugbenefitisthesame. Thebestwaytofigureoutyour
prescriptiondrugcoverageistoreviewyourEvidenceofCoverageorcalltheSWHP
CustomerServicedepartment.
WhatistheSWHPACACompliantformulary?
AformularyisalistofcovereddrugsselectedbySWHPinconsultationwithateamof
healthcareproviders. Thelistrepresentstheprescriptiondrugsbelievedtobea
necessarypartofaqualitytreatmentprogram. SWHPwillgenerallycoverthedrugs
listedontheformularyaslongasthedrugismedicallynecessaryandplanrulesare
followed. Thelistcontainsbothbrand-nameandgenericmedicationsandisupdated
regularly.
ThisSWHPACACompliantformularyisaclosedformulary. Thismeansthatdrugslisted
ontheformularyarecoveredanddrugsnotlistedontheformularyarenotcovered.
Non-formularydrugsrequirepriorauthorizationandmaybesubjecttoclinicaledits.
Formulariescontinuallychangetoreflectthemostrecentadvancesindrugtherapy
therefore;thislistisnotinclusiveanddoesnotguaranteecoverage.
Theformularyistieredmeaningtherearedifferentcopaymentlevelsfordrugson
differentlevels.
Tier1(T1):preferredgenericmedications
Tier2(T2):preferredbrand-namemedications
Tier3(T3):non-preferredbrand-nameandgenericmedications
Tier4(T4):specialtymedications
Theformularymaychangebecausewereviewnewmedicalinformationregarding
currentdrugslistedaswellasnewdrugsrecentlyapprovedbytheFDA.
Howwastheformularycreatedandhowarenewmedicationsreviewed?
TheSWHPPharmacyandTherapeutics(P&T)Committeemeetsregularlytoreviewnew
drugsapprovedbytheFDAandnewinformationregardingdrugsthatarealreadyonthe
formulary. TheCommitteeisprimarilymadeupofphysicians,pharmacistsandnurses.
Itreviewsinformationandscientificevidenceconcerningsafety,effectivenessand
currentuseintherapy.
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Doestheformularyeverchange?
SincetheP&TCommitteemeetsregularlyandreviewsnewinformation,theformulary
maychange. Belowaresomepossiblereasonstheformularycouldchange:
 Genericformsofthebranddrugbecomeavailable. Thebrand-namemedication
maynolongerbecoveredwhenagenericisavailable. Thegenericmedication
maybecoveredatthelowercopayment.
 NewdrugsmaybeaddedbytheP&TCommittee.
 AdrugmaybewithdrawnfromthemarketbytheFDA.
 Adrugbecomesavailablewithoutaprescription(becomesover-the-counter),
thenthedrugmayberemovedfromtheformulary. Often,drugsavailableover-
the-counterarenotcoveredundertheprescriptionbenefit.
HowamInotifiedofchangestotheformulary?
YoucanfindtheSWHPformulariesonourwebsiteatswhp.org. Onthewebsite,
formulariesareupdatedquarterly(every3months),andtheFormularyChanges
documentisupdatedmonthly. TheFormularyChangesdocumentoutlineschanges
madetotheformularies.TheFormularyChangesdocumentismeanttonotifymembers
ofchangestotheformulariesthatoccurbetweenformularyupdates. Ifyouhaveany
questionsorwishtoobtainaprintedcopyoftheformulariesorpharmaceutical
managementprocedures,pleasecontactSWHPPrescriptionServicesat1-800-728-7947.
Whatarebrand-nameandgenericdrugs?
SWHPcoversbothbrand-nameandgenericdrugs. Abrand-namedrugisonethatis
producedundertheoriginalmanufacturer’sbrandname. Agenericdrugisapprovedby
theFDAashavingthesameactiveingredientasthebrandnamedrug. Generally,
genericdrugscostlessthanbrand-namedrugsbutthequalityandeffectivenessarethe
same. Genericdrugsmaydifferfromthebrand-namedrugincolor,shape,flavoror
inactiveingredients. Somebrand-namedrugshaveagenericequivalentandothersdo
not. Ifagenericformofabrand-namedrugbecomesavailable,thebrand-name
medicationmaynolongerbecovered. Thegenericmedicationmaybecoveredatthe
lowercopayment.
Whatisgenericsubstitution?
GenericsubstitutionoccurswhenapharmacistdispensesanFDAapprovedgenericdrug
inplaceofabrandnamedrug. GenericsubstitutionwillautomaticallyoccuratSWHP
ProviderPharmacies. Prescribersmaychoosetouseabrandnameproductandnot
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allowgenericsubstitutionbyindicatingontheprescription“brandnecessary”or"brand
medicallynecessary."Perstatelaw,thesestatementsmustbehandwrittenbythe
prescriber.
WhatareSpecialtydrugs?
Specialtydrugsarethosedrugsusedtotreatcomplexorchronicconditions,andwhich
usuallyrequireclosemonitoring,suchasmultiplesclerosis,hepatitis,rheumatoid
arthritis,cancer,andotherconditionsthataredifficulttotreatwithtraditional
therapies.Specialtydrugsmaybeself-administeredinthehomebyinjection(underthe
skinorintoamuscle),byinhalation,bymouth,orontheskin.Thesedrugsmayalso
requirespecialhandling,specialmanufacturingprocesses,andmayhavelimited
prescribingorlimitedpharmacyavailability.
Whatisatherapeuticinterchange?
Atherapeuticinterchangeinvolvesthedispensingofchemicallydifferentdrugsthatare
consideredequivalentinsafetyandeffectivenessbytheSWHPP&TCommittee. For
onemedicationtobedispensedinplaceofanother,theprescribingphysicianandthe
membermustapproveoftheinterchange. Whenatherapeuticinterchangeprogramis
putinplace,theprogramwillallowSWHPPharmaciestosubstituteanddispensetothe
planmember,theSWHP-approvedclinicallyequivalentproduct.
Whatarepharmaceuticalmanagementprocedures?
Pharmaceuticalmanagementproceduresareprocessesthathelpmanagethedrug
formularyinordertoprovidethemostcost-effectivetherapyoptions. Aspartofsuch
processes,restrictions(describedinthefollowingsection)maybeappliedtocertain
drugsontheformulary.
Arethereanyrestrictionsonmycoverage?
Somecovereddrugsmayhaveadditionalrequirementsorlimitsoncoverage. These
requirementsandlimitsmayinclude:
 PriorAuthorization:SWHPrequiresyouoryourphysiciantogetprior
authorizationbeforefillingcertaindrugs. Drugsneedingpriorauthorizationare
notedontheformularybya“PA”nexttothedrugname.
 QuantityLimits:Forcertaindrugs,SWHPlimitstheamountofmedication
covered. Quantitylimitshelpensuretheappropriateuseofmedications.
Quantitylimitsareoftenappliedforsafetyreasons(e.g.limitingproducts
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containingacetaminophentomaximumsafelimits). Drugswithquantitylimits
arenotedontheformularybya“QL”nexttothedrugname.
 StepTherapy:Insomecases,SWHPrequiresyoutofirsttrycertaindrugsto
treatyourmedicalconditionbeforeanotherdrugwillbecoveredforthat
condition. Drugswithsteptherapyarenotedontheformularybyan“ST”nextto
thedrugname.
 AgeRestriction: Therearecertainmedicationswhichmaybelimitedtoacertain
agegroup. Drugswithagerestrictionsarenotedontheformularybyan“AL”
nexttothedrugname.
 DrugException: Amedicationmayrequireadrugexceptionforavarietyof
reasons,i.e.;maybelimitedtocertainspecialtyprescribers,limitedtocertain
pharmacies,maybeamedicationthatispartofthetherapeuticinterchange
program,orvariousotherreasons. Pleasecontactourcustomerservice
departmentforquestionsregardingthesemedications. Drugswithdrug
exceptionarenotedontheformularybya“DE”nexttothedrugname.
 GenderLimit: Therearecertainmedicationswhichmaybelimitedtoacertain
genders. Drugswithgenderlimitsarenotedontheformularybyan“GL”nextto
thedrugnamewithfforfemaleandmformale.
HowdoIrequestanexceptiontotheSWHPACACompliantFormulary?
Thereareseveraltypesofexceptionsthatcanberequested:
 Exceptiontocoveradrugthatisnotlistedontheformulary
 Exceptiontowaiveacoveragerestrictionorlimitonadrug(example:waiveor
increaseaquantitylimit).
 Exceptiontoprovideahigherlevelofcoverageforadrug(example:coverthe
drugatalowercopayment).
Torequestanexception,yourphysiciancansubmitacoverageexceptionformbyfaxor
initiatearequestviatelephone(SWHPPrescriptionServices)ortheswhp.orgwebsite.
Youasamembercanalsoinitiateanexceptionrequestviatheswhp.orgwebsiteor
telephonebycontactingSWHPPrescriptionServices.Bothyouandyourphysicianwill
benotifiedoftheapprovalbymailandthedrugwillbecoveredundertheapplicable
copayment. Iftherequestisdenied,bothyouandyourphysicianwillbenotified. You
maystillpurchasethemedicationforthefullprice.
Whatdrugsarenotcoveredbymyprescriptiondrugbenefit?
PleaserefertoyourEvidenceofCoverageforcompleteplancoverage,limitationsand
exclusionsspecifictoyourprescriptiondrugbenefit.
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Often,over-the-countermedicationsandherbalproductsarenotcoveredunderSWHP
benefitplans.
Howmuchmedicationdoesmycopaymentcoveranddoesmyplancover
maintenancemedications?
Youcangetuptoa30-daysupplyofmedicationforasinglecopayment. Some
medicationsmayhaveaquantitylimit,restrictingtheamountofdrugyoucangetper
prescriptionorpercopayment.
Maintenancemedications(notedontheformularybya“MN”nexttothedrugname)
areusedtotreatchronicmedicalconditions. Theprescriptionforthedrugmustbe
writtenforathreemonthsupplyofmedication.
MaintenanceMedications
Thefollowingcategoriesareconsideredmaintenanceeligible:
 Anticonvulsants
 Bupropion,bupropionSR,bupropionXL
 CardiovascularMedications
 EstrogenandProgestinreplacementmedications
 Genericselectiveserotoninreuptakeinhibitors(SSRIs)medications
 Lithium
 Medicationstotreatasthma
 Medicationstotreatdiabetesanddiabeticsupplies
 Medicationstotreatglaucoma
 Medicationstotreatgout
 Medicationstotreatosteoporosis
 MedicationstotreatParkinson’s
 Potassiumsupplements
 TestosteroneCypionate
 Thyroidreplacementmedications
 Tricyclicantidepressantmedications
 Urinaryincontinencemedications
NOTE: Notalldrugswithinthecategoryarepreferredtobemaintenanceeligible.Only
thoselistedwithan“MN”onformularyaremaintenanceeligible. Pleaserefertoyour
EvidenceofCoverageforcompleteplancoverage.
HowcanIsavemoneyonprescriptions?
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MedicationsontheSWHPformularygenerallycostlessthanmedicationsnotlisted. A
genericmedicationwillusuallybethelowestcopaymentoption. Asktheprovideror
pharmacistwhethergenericmedicationsareappropriate.
Besuretotakethisformularywithyoutoeachvisitsothattheproviderknowswhat
medicationiscovered.
Abbreviations
T1,T2,T3,T4 Copaymenttiers
MN Maintenancemedication
PA Priorauthorizationrequired
QL Quantitylimit
AL Age-limit
ST Step-therapyrequired
DE DrugException
NOTE: Whenagenericformofthebranddrugbecomesavailable,thebrand-name
medicationmaynolongerbecovered. Thegenericmedicationmaybecoveredatthe
lowercopayment. Theprintformulariesmaynothavethemostup-to-datecoverageof
drugs.
ContraceptiveCoverage
Asspecifiedbyhealthcarereform,womenmusthaveaccesstoafullrangeofFDA-approved
contraceptivemethods.However,planscanusereasonablemedicalmanagementtodecide
whatbirthcontrolproductsareavailableat$0cost-share.Formostplanscoverageisasfollows:
 Allgenericcontraceptiveslistedonyourdrugformularyareavailableforyouat$0cost-
share.Thesearenotedontheformularywiththefollowingcomment:“Eligiblefora$0
copay”
 Brandedcontraceptiveagentslistedontheformularymayrequireyoutofailorhave
triedagenericcontraceptivebeforeobtainingat$0cost-share
Coveragemayvaryaccordingtoyourplan.Pleaserefertoapplicableplandocuments.
PreventativeCareMedications&MedicationsCoveredUnderHealthCareReform
PreventativecaremedicationsaswellasothermedicationscoveredunderHealthCareReform
arecoveredaccordingtoyourplanbenefits.Thesemedicationsarenotedontheformularywith
thefollowingcomment:“Eligiblefora$0copay”.Pleasenotethislistissubjecttochange.
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DiabeticSupplies
SyringesandNeedles:AllsyringesandneedlesarecoveredatTier1copay.
TestStrips/lancetsanddevices/controlsolution:Accu-chekproductsarepreferredandcovered
atTier1copay.
SmokingCessationMedicationCoverage
AllFDAapprovedtobaccocessationmedications,includingprescriptionandover-the-counter
medications,areallowedat$0cost-shareperthePatientProtectionandAffordableCareAct
(PPACA).Youarelimitedtotwosmokingcessationattemptsperyear,upto180daystotal.
Pleaserefertoyourdrugformularywithinthisdocumentforspecificmedicationsthatare
eligible.
Inordertoobtainthisbenefit,youmustfillatanetworkpharmacywithaprescription
prescribedbyahealthcareprofessional(includesprescriptionandover-the-counter
medications).
Revised11/10/2014
By Category