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Advantra®Rx Premier
Formulary
(List of Covered Drugs)
This document includes AdvantraRx Premier’s partial formulary as of September 21, 2005. For a complete, updated formulary, please visit our website at www.AdvantraRx.com or call 1-800-882-3822, 8 a.m.–8 p.m., local time, and 8 a.m.–5 p.m. in Hawaii, 7 days a week. TTY/TDD users should call 1-800-508-9548. What is the AdvantraRx Premier
How do I use the formulary?
formulary?
There are two ways to fi nd your drug within the A formulary is a list of drugs selected by AdvantraRx Premier in consultation with a team of health care Medical Condition
providers, which represents the prescription therapies The formulary begins on page 34. The drugs believed to be a necessary part of a quality treatment in the formulary are grouped into categories program. AdvantraRx Premier will generally cover depending on the type of medical conditions that the drugs listed in the formulary as long as the drug they are used to treat. For example, drugs used is medically necessary, the prescription is fi lled at an to treat a heart condition are listed under the AdvantraRx Premier network pharmacy, and other category “Cardiovascular Agents.” If you know plan rules are followed. For more information on how what your drug is used for, look for the category to fi ll your prescriptions, please review your Evidence name in the list that begins on page 34. Then look This document is a partial formulary and includes Alphabetical Listing
only some of the drugs covered by AdvantraRx If you are not sure what category to look under, Premier. For a complete listing of all prescription you should look for your drug in the Index drugs covered by AdvantraRx Premier, please that begins on page 39. The Index provides an visit our website at www.AdvantraRx.com or call alphabetical list of all the drugs included in this 1-800-882-3822, 8 a.m.–8 p.m., local time, and document. Both brand name drugs and generic 8 a.m.–5 p.m. in Hawaii, 7 days a week. TTY/TDD drugs are listed in the Index. Look in the Index and fi nd your drug. Next to your drug, you will Can the formulary change?
see the page number where you can fi nd coverage information. Turn to the page listed in the Index Yes, AdvantraRx Premier may add or remove drugs and fi nd the name of your drug in the fi rst column from the formulary during the year. The enclosed formulary is current as of September 21, 2005. To get updated information about the drugs covered How much will I pay for AdvantraRx
by AdvantraRx Premier, please visit our website at Premier covered drugs?
www.AdvantraRx.com or call Customer Service at 1-800-882-3822, 8 a.m.–8 p.m., local time, and If you qualifi ed for extra help with your drug costs, 8 a.m.–5 p.m. in Hawaii, 7 days a week. TTY/TDD your costs for your drugs may be different than those users should call 1-800-508-9548. If we remove described below. Please refer to your Evidence of drugs from the formulary, or add prior authorization, Coverage or call Customer Service to fi nd out what quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, The amount you pay depends on which drug tier your we must notify members who take the drug that drug is in under our plan. (You can fi nd out which it will be removed at least 60 days before the date drug tier your drug is in by looking in the formulary that the change becomes effective, or at the time the member requests a refi ll of the drug, at which time the member will receive a 60-day supply of the The amount you pay depends on whether you fi ll drug. If the Food and Drug Administration deems your prescription at a retail pharmacy or at a mail- a drug on the formulary to be unsafe or the drug’s order pharmacy. Generally, when you go to a retail manufacturer removes the drug from the market, pharmacy you will pay for a 30-day supply. In we will immediately remove the drug from the addition, if you fi ll your prescription through the formulary and provide notice to members who take mail-order pharmacy, you can get a 90-day supply.
You will pay a copayment for your drugs until your example, if Drug A and Drug B both treat your total drug costs (the amount you paid, plus the medical condition, AdvantraRx Premier may amount AdvantraRx Premier has paid) reach $2,250. not cover Drug B unless you try Drug A fi rst. Once your total drug costs reach $2,250, there is a If Drug A does not work for you, AdvantraRx gap in your coverage. This means you have to pay the full amount for your drugs. You pay the full amount until you have paid $3,600 out of pocket. After you You can fi nd out if your drug has any additional have paid $3,600 out of pocket, you will generally requirements or limits by looking in the formulary • $2 for generic or a preferred brand drug that is a You can ask AdvantraRx Premier to make an exception multi-source drug and $5 for all other drugs, or to these restrictions or limits. See the section “How do I request an exception to AdvantraRx Premier’s formulary?” below for information about how to You can ask AdvantraRx Premier to make an exception to your drug’s tier placement. See the section “How do I request an exception to What if my drug is not on the formulary?
AdvantraRx Premier’s formulary?” for information If your drug is not included in this formulary, you should fi rst contact Customer Service and ask if your drug is covered. This document includes only a partial Are there any other restrictions on
list of covered drugs, so AdvantraRx Premier may coverage?
cover your drug. You can contact Customer Service at 1-800-882-3822, 8 a.m.–8 p.m., local time, and 8 a.m.–5 p.m. in Hawaii, 7 days a week. TTY/TDD requirements or limits on coverage. These If you learn that AdvantraRx Premier does not cover • Prior Authorization: AdvantraRx Premier
requires you to get prior authorization for certain drugs. (You may need prior authorization • You can ask Customer Service for a list of for drugs that are on the formulary or drugs that similar drugs that are covered by AdvantraRx are not on the formulary and were approved
Premier. When you receive the list, show it to for coverage through the exceptions process.) your doctor and ask him or her to prescribe This means that you will need to get approval a similar drug that is covered by AdvantraRx from AdvantraRx Premier before you fi ll your prescriptions. If you don’t get approval, • You can ask AdvantraRx Premier to make an AdvantraRx Premier may not cover the drug. exception and cover your drug. See below for • Quantity Limits: For certain drugs,
information about how to request an exception. AdvantraRx Premier limits the amount of the drug that AdvantraRx Premier will cover. For How do I request an exception to
example, AdvantraRx Premier provides 4 units AdvantraRx Premier’s formulary?
per prescription for FOSAMAX per 30 days.
This may be in addition to a standard 30- or 90-
You can ask AdvantraRx Premier to make an exception to its coverage rules. There are several types of exceptions that you can request. • Step Therapy: In some cases, AdvantraRx
Premier requires you to fi rst try certain drugs • You can ask AdvantraRx Premier to cover your to treat your medical condition before we will drug even if it is not on the formulary. cover another drug for that condition. For • You can ask AdvantraRx Premier to waive For more information
coverage restrictions or limits on your drug. For For more detailed information about your AdvantraRx example, for certain drugs, AdvantraRx Premier Premier prescription drug coverage, please review limits the amount of the drug that it will cover. your Evidence of Coverage and other plan materials. If your drug has a quantity limit, you can ask for the limit to be waived and cover more. If you have questions about AdvantraRx Premier, • You can ask AdvantraRx Premier to provide please call Customer Service at 1-800-882-3822, a higher level of coverage for your drug. For 8 a.m.–8 p.m., local time, and 8 a.m.–5 p.m. in example, if your drug is usually considered a Hawaii, 7 days a week. TTY/TDD users should call Tier 2 drug, you can ask AdvantraRx Premier 1-800-508-9548. Or visit www.AdvantraRx.com. to cover it as a Tier 1 drug instead. This would lower the amount you must pay for your drug. If you have general questions about Medicare Please note, if your request to cover a drug that prescription drug coverage, please call Medicare is not on the formulary is granted, you may not at 1-800-MEDICARE (1-800-633-4227) 24 hours ask AdvantraRx Premier to provide a higher a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or visit www.medicare.gov. Generally, AdvantraRx Premier will only approve AdvantraRx Premier’s formulary
your request for an exception if the alternative drugs The formulary that begins on page 34 provides included on the plan’s formulary, the low-tiered drug, coverage information about some of the drugs or additional utilization restrictions would not be covered by AdvantraRx Premier. If you have trouble as effective in treating your condition and/or would fi nding your drug in the list, turn to the Index that cause you to have adverse medical effects. begins on page 39. Remember: This is only a partial list of drugs covered by AdvantraRx Premier. If your You should contact Customer Service to ask for an prescription is not in this partial formulary, please initial coverage decision for a formulary, tiering, visit our website at www.AdvantraRx.com or call or utilization restriction exception. When you Customer Service at 1-800-882-3822, 8 a.m.–8 p.m., are requesting a formulary, tiering, or utilization local time, and 8 a.m.–5 p.m. in Hawaii, 7 days a restriction exception, you should submit a statement week. TTY/TDD users should call 1-800-508-9548 from your physician supporting your request. Generally, AdvantraRx Premier must make a decision within 72 hours of your request. The fi rst column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CLARINEX) What are generic drugs?
and generic drugs are listed in lower-case italics AdvantraRx Premier covers both brand name drugs and generic drugs. A generic drug has the same active-ingredient formula as the brand name drug. The information in the Requirements/Limits column Generic drugs usually cost less than brand name tells you if AdvantraRx Premier has any special drugs and are approved by the Food and Drug The following abbreviations may be used in the Generic drugs are listed in lower-case italics (e.g., digoxin) within the formulary on page 34. Brand • PA–Prior Authorization: AdvantraRx Premier
name drugs are capitalized in the formulary (e.g., 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 AdvantraRx Premier before you fi ll your prescriptions. If you don’t get approval, AdvantraRx Premier may not cover the drug. • QL–Quantity Limits: For certain drugs,
AdvantraRx Premier limits the amount of the drug that AdvantraRx Premier will cover. For example, AdvantraRx Premier provides 4 units per prescription for FOSAMAX per 30 days. This may be in addition to a standard 30- or 90-day supply.
• ST–Step Therapy: In some cases, AdvantraRx
Premier requires you to fi rst try certain drugs to treat your medical condition before it will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, AdvantraRx Premier may not cover Drug B unless you try Drug A fi rst. If Drug A does not work for you, AdvantraRx Premier will then cover Drug B. • *–Drugs marked with an asterisk “*” do not count towards your total out-of-pocket expenditure, and if you are receiving extra help to pay for your prescriptions, you will not receive any extra help to pay for these drugs.
Drug Requirements/
Drug Requirements/
Drug Name
Drug Name
ANALGESICS–PAIN
ANTIDEPRESSANTS–DEPRESSION
ANTIBACTERIALS–INFECTION
ANTIEMETICS–NAUSEA/VOMITING
ANTIFUNGALS–FUNGAL INFECTION
ANTIGOUT AGENTS–GOUT
ANTIHISTAMINES–ALLERGY
ANTI-CONVULSANTS–SEIZURE
ANTI-INFLAMMATORIES–ARTHRITIS/PAIN
ANTIDEMENTIA AGENTS–ALZHEIMER’S DISEASE
* These drugs do not count toward your total out-of-pocket expenditure, and if you are receiving extra help to pay for your prescriptions, you will not receive any extra help to pay for these drugs. Drug Requirements/
Drug Requirements/
Drug Name
Drug Name
ANTIVIRALS–VIRAL INFECTION
ANTIMALARIALS–MALARIA
ANTIMIGRAINE AGENTS–MIGRAINE
ANTINEOPLASTICS–CANCER
ANXIOLYTICS–ANXIETY
BLOOD GLUCOSE REGULATORS–DIABETES
ANTIPARKINSON AGENTS–PARKINSON’S DISEASE
BLOOD PRODUCTS/MODIFIERS/VOLUME
ANTIPSYCHOTICS–BEHAVIORAL HEALTH
EXPANDERS–BLOOD THINNERS
ANTIRHEUMATIC AGENTS–ARTHRITIS
* These drugs do not count toward your total out-of-pocket expenditure, and if you are receiving extra help to pay for your prescriptions, you will not receive any extra help to pay for these drugs. Drug Requirements/
Drug Requirements/
Drug Name
Drug Name
CARDIOVASCULAR AGENTS–HEART/BLOOD
PRESSURE
DERMATOLOGICAL AGENTS–SKIN
PREPARATIONS
* These drugs do not count toward your total out-of-pocket expenditure, and if you are receiving extra help to pay for your prescriptions, you will not receive any extra help to pay for these drugs. Drug Requirements/
Drug Requirements/
Drug Name
Drug Name
GASTROINTESTINAL AGENTS–STOMACH
IMMUNOLOGICAL AGENTS
INFLAMMATORY BOWEL DISEASE AGENTS–
GENITOURINARY AGENTS
OPHTHALMIC AGENTS–EYE
HORMONAL AGENTS–HORMONES
* These drugs do not count toward your total out-of-pocket expenditure, and if you are receiving extra help to pay for your prescriptions, you will not receive any extra help to pay for these drugs. Drug Requirements/
Drug Requirements/
Drug Name
Drug Name
RESPIRATORY AGENTS–BREATHING
SEDATIVES/HYPNOTICS–SLEEP
SKELETAL MUSCLE RELAXANTS–MUSCLE
THERAPEUTIC NUTRIENTS / MINERALS /
ELECTROLYTES–VITAMINS/MINERALS
* These drugs do not count toward your total out-of-pocket expenditure, and if you are receiving extra help to pay for your prescriptions, you will not receive any extra help to pay for these drugs.

Source: http://retirementprogram.trinity-health.org/media/pdf/trinity_en/BankersAdvantra_Rx_Premier_Formulary_List.pdf