Questions about the PriorityMedicare approved drug listClick any question to find the answer below.Do PriorityMedicareSM plans cover all prescription drugs? What is an approved drug list or formulary? Can an approved drug list change? How do I use an approved drug list? What are generic drugs? Are there any other restrictions on coverage? What do I do if my drug is not on the approved drug list? How do I request an exception to the approved drug list? Do PriorityMedicare plans cover the same drugs as Medicare Part B or Part D? What types of drugs might be covered under Medicare Part B? What is a Medication Therapy Management (MTM) program? Q: Do PriorityMedicare plans cover all prescription drugs? No. PriorityMedicare plans use a formulary, which is a list of approved drugs. Some drugs included on our approved drug list may have additional requirements for or limits on their coverage, such as prior authorization, step therapy (steps you must take before we approve the drug for you), or limits on quantities. Our committee of doctors and pharmacists reviews all drugs for how effective they are, and periodically makes changes to the approved drug list. If our approved drug list changes and a drug you're taking is removed, you'll be notified in writing before the change is made.
See the list of drugs not covered by Medicare plans, including PriorityMedicare Rx. Q: What is an approved drug list or formulary? An approved drug list, also known as a formulary, is a complete list of all the prescription drugs that are approved for coverage by a member's plan. All PriorityMedicare plans - PriorityMedicare Value, PriorityMedicare, PriorityMedicare Plus and PriorityMedicare Rx - use one approved drug list for individuals who purchase these plans. There's another, slightly different list used by employer groups who purchase any PriorityMedicare plan for their employees and retirees. We'll generally cover the drugs listed on our approved drug lists as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, see the FAQs on filling prescriptions. Q: Can the approved drug list change? Yes. Priority Health may add or remove drugs from the PriorityMedicare approved drug lists during the year. The approved drug lists on this website are current. To get updated information about what drugs are covered, see the Pending Changes notice on this website or contact us. If we remove drugs during the year, we must notify you of the change at least 60 days before the change becomes effective. Q: How do I use an approved drug list? There are two ways to find your drug on our approved drug lists:
Q: What are generic drugs? A generic drug has the same active ingredient formula as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as their brand-name counterparts. Q: Are there any other restrictions on coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
You can ask your PriorityMedicare plan to make an exception to these restrictions or limits. See the question, "How do I request an exception to the approved drug list?" below. Q: What do I do if my drug is not on the approved drug list? If you join PriorityMedicare Value, PriorityMedicare, PriorityMedicare Plus or PriorityMedicare Rx and find that your drug is not included on your plan's approved drug list, you should first call us and verify that your drug is not covered. If it's not covered, talk to your doctor to decide if you should switch to an appropriate drug that we cover or to request an approved drug list 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're a member of our plan. One 31-day transition supply may not give you sufficient time to talk to your doctor and review alternatives when you join one of our plans. Therefore, we may cover up to a maximum of one 90-day supply OR three 31-day transition supplies per non-approved drug list medication or approved drug list medication requiring step therapy during a single transition event in your first 90 days covered by our plan. After that, we will no longer pay for your non-approved drug list medication. More help:
Q: How do I request an exception to the approved drug list? You can ask us to make an exception to our coverage rules. You can ask us to:
You should contact us to ask for an initial coverage decision for any drug exception. Send us a statement from your doctor supporting your request. Generally, we must make our decision within 72 hours of your request. Q: Do PriorityMedicare plans cover the same drugs as Medicare Part B or Part D? Our medical plans, PriorityMedicare Value, PriorityMedicare and PriorityMedicarePlus, cover both Medicare Part B prescription drugs and Part D prescription drugs. Copay and limits may apply. The PriorityMedicare Rx plan does not cover drugs covered under Medicare Part B. Generally, it only covers drugs that are covered under the Medicare prescription drug benefit (Part D) and that are on our approved drug lists. Copays and limit may apply. Q: What types of drugs might be covered under Medicare Part B? The following prescription drugs may be covered under Medicare Part B.
Q: What is a Medication Therapy Management (MTM) Program? A Medication Therapy Management (MTM) Program helps us ensure that our members with multiple chronic conditions, such as asthma and heart disease, and who are taking multiple covered drugs, use them in ways that get the best results. You may be asked to participate in an MTM program designed for your specific health and pharmacy needs. We recommend that you take full advantage of this program if you are selected. Read more about the MTM program. H2320_4000_4006_64 F&U (05/08) S5857_4000_4006_64 F&U (05/08)
Last modified
05/12/08
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