2008 Formulary
Information
What is the Senior Care Plus
Formulary?
A formulary is a list of drugs selected by Senior
Care Plus 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. Senior Care Plus
will generally cover the drugs listed in our formulary as long as the drug is
medically necessary, the prescription is filled at a Senior Care Plus network
pharmacy, and other plan rules are followed. For more information on how to fill
your prescriptions, please review your Evidence of Coverage.This document includes a comprehensive formulary. For an additional listing of all prescription drugs covered by Senior Care Plus, please call Senior Care Plus. During Open Enrollment, November 15, 2007 through March 1, 2008, Customer Services hours will be Monday through Sunday, 8 a.m. to 8 p.m. Pacific Time, at 775-982-3112 or 1-800-336-0123. Beginning March 2, 2008, Customer Services will continue their regular hours: Monday through Friday, 7:30 a.m. to 5:30 p.m.
Can the Formulary
change?
Yes, Senior Care Plus may add or remove drugs from our formulary during the year. The enclosed formulary is current as of January 01, 2008. To get updated information about the drugs covered by Senior Care Plus, call Customer Service at 800-336-0123. During Open Enrollment, November 15, 2007 through March 1, 2008, Customer Services hours will be Monday through Sunday, 8 a.m. to 8 p.m. Pacific Time, at 775-982-3112 or 1-800-336-0123. Beginning March 2, 2008, Customer Services will continue their regular hours: Monday through Friday, 7:30 a.m. to 5:30 p.m.
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 members who take
the drug that it will be removed at least 60 days before the date that 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.
How do I use the
Formulary?
There are two ways to find your drug within
the formulary:
Medical
Condition
The formulary begins on page 18. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For
example, drugs used to treat a heart condition are listed under the category,
“Cardiovascular Agents.” If you know what your drug is used for, look for the
category name in the list that begins on page 17. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under,
you should look for your drug in the Index that begins on page 73. The Index provides an alphabetical list of all of the
drugs included in this document. Both brand-name drugs and generic drugs are
listed in the Index. Look in the Index and find your drug. Next to your drug,
you will see the page number where you can find coverage information. Turn to
the page listed in the Index and find the name of your drug in the first column
of the list.
How much will I pay for Senior Care Plus
Covered Drugs?
If you qualified for extra help with
your drug costs, your costs for your drugs may be different than those described
below. Please refer to your Evidence of Coverage or call Customer Service to
find out what your costs are.
If you selected the Value Plus Plan, the amount you pay depends on which drug tier your drug is in under our plan and whether you fill your prescription at a preferred network pharmacy. For a 30-day supply you will pay $2.00 for generic drugs and $5.00 for a 90-day supply. For Brand name drugs there is an initial deductible of $125, meaning that you will pay 100% of the cost for Brand name drugs until you have paid $125 out of your pocket. After the initial deductible period, you will pay $40.00 for Preferred Brand, $70.00 for Non-Preferred Brand and $100.00 for Special Pharmaceuticals. For a 90-day supply you will pay $100 for Preferred Brand, $175.00 for Non-Preferred Brand, and $250.00 for Special Pharmaceuticals. You can find out which drug tier your drug is in by looking in the formulary that begins on page 18.
If you selected the Value Rx, Value Rx+, or Freedom Rx + Plan, the amount you pay depends on which drug tier your drug is in under our plan and whether you fill your prescription at a preferred network pharmacy. For a 30-day supply you will pay $4.00 for generic, $40.00 for Preferred Brand, $70.00 for Non-Preferred Brand and $100.00 for Special Pharmaceuticals. For a 90-day supply you will pay $10.00 for generic, $100 for Preferred Brand, $175.00 for Non-Preferred Brand, and $250.00 for Special Pharmaceuticals. You can find out which drug tier your drug is in by looking in the formulary that begins on page 18.
If you have the Value Plus Plan, you will pay a $125 deductible on Brand name drugs only and then a co-payment/co-insurance for your drugs until your total drugs costs (the amount you paid, plus the amount Senior Care Plus has paid) reach $2,510.00. Once your total drug costs reach $2,510.00, there is a gap in your coverage for Generic and Brand name drugs. This means you have to pay the full amount for your Generic and Brand name drugs. You pay the full amount until you have paid $4,050.00 out of pocket. After you have paid $4,050.00 out of pocket, you will pay $2.25 for generic and multi-source brand and $5.60 for all other drugs or 5%, whichever is greater.
If you have the Value Rx Plan, you will pay a co-payment/co-insurance for your drugs until your total drugs costs (the amount you paid, plus the amount Senior Care Plus has paid) reach $2,510.00. Once your total drug costs reach $2,510.00, there is a gap in your coverage for Brand name drugs only. You will be able to get Generic drugs the entire year. This means you have to pay the full amount for your Brand drugs. You pay the full amount until you have paid $4,050.00 out of pocket. After you have paid $4,050.00 out of pocket, you will pay $2.25 for generic and multi-source brand and $5.60 for all other drugs or 5%, whichever is greater.
If you have the Value Rx + or the Freedom Rx + Plan, you will pay a co-payment/co-insurance for your drugs until your total out-of-pocket drugs costs reach $4,050.00. After you have paid $4,050.00 out of pocket, you will pay $2.25 for generic and multi-source brand and $5.60 for all other drugs or 5%, whichever is greater. You can ask Senior Care Plus to make an exception to your drug's tier placement. See the section, "How do I request an exception to the Senior Care Plus List of Covered Drugs?" for information about how to request an exception.
Are there any other restrictions on coverage?
Some covered drugs may have additional requirements
or limits on coverage. These requirements and limits may include
Prior Authorization Senior Care Plus requires you to get prior authorization
for certain drugs. (You may need prior authorization for drugs that are on the
formulary or drugs that are not on the formulary and were approved for coverage through
our exceptions process.) This means that you will need to get approval from
Senior Care Plus before you fill your prescriptions. If you don’t get approval,
Senior Care Plus may not cover the drug.
Quantity Limits: For certain drugs, Senior Care Plus limits the amount of the drug that
Senior Care Plus will cover. For example, Senior Care Plus provides 34 tablets
per prescription for lovastatin 10mg. This may
be in addition to a standard 30- or 90-day supply.
Step Therapy: In some cases, Senior Care
Plus 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, Senior Care Plus may not cover drug B
unless you try Drug A first. If
Drug A does not work for you, Senior Care Plus 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 14.
You can ask Senior Care Plus to make an
exception to these restrictions or limits. See the section, “How do I request an
exception to the Senior Care Plus formulary?” below for information about how to request an
exception.
What if my drug is not on the
Formulary?
If your drug is not included in this formulary, you should first contact Customer Service and ask if your drug is covered. You can contact Customer Service at 800-336-0123. During Open Enrollment, November 15, 2007 through March 1, 2008, Customer Services hours will be Monday through Sunday, 8 a.m. to 8 p.m. Pacific Time, at 775-982-3112 or 1-800-336-0123. Beginning March 2, 2008, Customer Services will continue their regular hours: Monday through Friday, 7:30 a.m. to 5:30 p.m.
If you learn that Senior Care Plus does not cover
your drug, you have two options:
You can ask Customer Service for a list of similar
drugs that are covered by Senior Care Plus. When you receive the list, show it
to your doctor and ask him or her to prescribe a similar drug that is covered by
Senior Care Plus.
You can ask Senior Care Plus to make an exception
and cover your drug. See below for information about how to request an
exception.
How do I request an
exception to the Senior Care
Plus Formulary?
You can ask Senior Care Plus 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 your drug even if it is not
on our formulary.
You can ask us to waive coverage restrictions or
limits on your drug. For example, for certain drugs, Senior Care Plus limits 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 more.
You can ask us to
provide a higher level of coverage for your drug. For example, if your drug is
usually considered a Brand drug, you can ask us to cover it as a generic
instead. This would lower the amount you must pay for your drug. Please note, if
we grant your request to cover a drug that is not on our formulary, you may not
ask us to provide a higher level of coverage for the drug.
Generally, Senior Care Plus will only approve your
request for an exception if the alternative drugs included on the plan’s
formulary, the low-tiered drug 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 or utilization restriction exception.
When you are requesting a formulary, tiering or utilization restriction
exception you should submit a statement from your physician supporting your
request. Generally, we must make our decision within 72 hours of your
request.
Download Request for Exceptions Form (PDF 39KB)
What are generic drugs?
Senior
Care Plus covers both brand-name drugs and 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 approved by
the Food and Drug Administration (FDA).
Generic drugs are listed in lower-case italics (e.g., lovastatin) within the formulary. Brand-name drugs are capitalized in the formulary (e.g.,
CRESTOR).
For more detailed information about your Senior
Care Plus prescription drug coverage, please review your Senior Care Plus Evidence of Coverage and other plan
materials.
If you have questions about Senior Care Plus,
please call Customer Service at 800-336-0123.During Open Enrollment, November 15, 2007 through March 1, 2008, Customer Services hours will be Monday through Sunday, 8 a.m. to 8 p.m. Pacific Time, at 775-982-3112 or 1-800-336-0123. Beginning March 2, 2008, Customer Services will continue their regular hours: Monday through Friday, 7:30 a.m. to 5:30 p.m.
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/TDD users should call 1-877-486-2048. Or, visit
www.medicare.gov.
Click here to read the Member Rights for Prescription Drugs Coverage.
Senior Care Plus Formulary
The formulary below provides coverage information about all of the drugs covered by Senior Care Plus. If you have trouble finding your drug in the list, turn to the Index that begins on page 75. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., lovastatin). The information in the "Notes: Requirements/Limits" column tells you if Senior Care Plus has any special requirements for coverage of your drug.
Comprehensive Formulary
2008 Pharmacy Directory and Formulary (PDF 596 KB)
Revised October 2007
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