Community Health Choice (HMO D-SNP) 2020 FORMULARY
Community Health Choice (HMO D-SNP)2020 FORMULARY(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLANThis formulary was updated on 07/01/2020. For more recent information or other questions, please contactCommunity Health Choice Member Services, at 1-833-276-8306 or, for TTY users, 711, we are open October1 through March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Mondaythrough Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phonesystem, or visit www.communityhealthchoice.org.This formulary is for our service area in the following Texas counties:Austin, Brazoria, Chambers, Fort Bend, Galveston, Hardin, Harris, Jasper, Jefferson, Liberty, Matagorda,Montgomery, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller and 8306 or 713.295.5007 (TTY 711)October 1 through March 31, 8:00 am to 8:00 pm,7 days a week and April 1 through September 30,Monday through Friday, 8:00 am to 8:00 pmH9826 BD 10051 XXXXXX C
Note to existing members: This formulary has changed since last year. Please review thisdocument to make sure that it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us”, or “our,” it means Community Health Choice.When it refers to “plan” or “our plan,” it means Community Health Choice.This document includes a list of the drugs (formulary) for our plan which is current as of07/01/2020. For an updated formulary, please contact us. Our contact information, along withthe date we last updated the formulary, appears on the front and back cover pages.You must generally use network pharmacies to use your prescription drug benefit. Benefits,formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020,and from time to time during the year.What is the Community Health Choice Formulary?A formulary is a list of covered drugs selected by Community Health Choice in consultation with ateam of health care providers, which represents the prescription therapies believed to be anecessary part of a quality treatment program. Community Health Choice will generally cover thedrugs listed in our formulary as long as the drug is medically necessary, the prescription is filled ata Community Health Choice network pharmacy, and other plan rules are followed. For moreinformation on how to fill your prescriptions, please review your Evidence of Coverage.Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs onthe Drug List during the year, move them to different cost-sharing tiers, or add newrestrictions. We must follow Medicare rules in making these changes.Changes that can affect you this year: In the below cases, you will be affected by coveragechanges during the year: New generic drugs. We may immediately remove a brand name drug on our Drug List ifwe are replacing it with a new generic drug that will appear on the same or lower costsharing tier and with the same or fewer restrictions. Also, when adding the new genericdrug, we may decide to keep the brand name drug on our Drug List, but immediately move itto a different cost-sharing tier or add new restrictions. If you are currently taking that brandname drug, we may not tell you in advance before we make that change, but we will laterprovide you with information about the specific change(s) we have made.o If we make such a change, you or your prescriber can ask us to make an exceptionand continue to cover the brand name drug for you. The notice we provide you willalso include information on how to request an exception, and you can also findinformation in the section below entitled “How do I request an exception to theCommunity Health Choice Formulary?” Drugs removed from the market. If the Food and Drug Administration deems a drug onour formulary to be unsafe or the drug’s manufacturer removes the drug from the market,1
we will immediately remove the drug from our formulary and provide notice to members whotake the drug. Other changes. We may make other changes that affect members currently taking a drug.For instance, we may add a new generic drug to replace a brand name drug currently onthe formulary or add new restrictions to the brand name drug or move it to a different costsharing tier. Or we may make changes based on new clinical guidelines. If we removedrugs from our formulary, or add prior authorization, quantity limits and/or step therapyrestrictions on a drug we must notify affected members of the change at least 30 daysbefore the change becomes effective, or at the time the member requests a refill of the drug,at which time the member will receive a 30-day supply of the drug.o If we make these other changes, you or your prescriber can ask us to make anexception and continue to cover the brand name drug for you. The notice we provideyou will also include information on how to request an exception, and you can alsofind information in the section below entitled “How do I request an exception to theCommunity Health Choice’s Formulary?Changes that will not affect you if you are currently taking the drug. Generally, if you aretaking a drug on our 2020 formulary that was covered at the beginning of the year, we will notdiscontinue or reduce coverage of the drug during the 2020 coverage year except as describedabove. This means these drugs will remain available at the same cost-sharing and with no newrestrictions for those members taking them for the remainder of the coverage year.The enclosed formulary is current as of 07/01/2020. To get updated information about the drugscovered by Community Health Plan, please contact us. Our contact information appears on thefront and back cover pages.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 8. The drugs in this formulary are grouped into categoriesdepending on the type of medical conditions that they are used to treat. For example, drugsused to treat a heart condition are listed under the category, Cardiovascular Agents. If youknow what your drug is used for, look for the category name in the list that begins 8. Then lookunder the category name for your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index thatbegins on page 112. The Index provides an alphabetical list of all of the drugs included in thisdocument. Both brand name drugs and generic drugs are listed in the Index. Look in the Indexand find your drug. Next to your drug, you will see the page number where you can findcoverage information. Turn to the page listed in the Index and find the name of your drug in thefirst column of the list.2
What are generic drugs?Community Health Choice covers both brand name drugs and generic drugs. A generic drug isapproved by the FDA as having the same active ingredient as the brand name drug. Generally,generic drugs cost less than brand name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirementsand limits may include: Prior Authorization: Community Heath Choice requires you [or your physician] to get priorauthorization for certain drugs. This means that you will need to get approval fromCommunity Health Choice before you fill your prescriptions. If you don’t get approval,Community Health Choice may not cover the drug. Quantity Limits: For certain drugs, Community Health Choice limits the amount of the drugthat Community Health Choice will cover. For example, Community Health Choice provides60 capsules per prescription for celecoxib. This may be in addition to a standard one-monthor three-month supply. Step Therapy: In some cases, Community Health Choice requires you to first try certaindrugs 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, Community HealthChoice may not cover Drug B unless you try Drug A first. If Drug A does not work for you,Community Health Choice will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formularythat begins on page 8. You can also get more information about the restrictions applied to specificcovered drugs by visiting our Web site. We have posted on line documents that explain our priorauthorization and step therapy restrictions. You may also ask us to send you a copy. Our contactinformation, along with the date we last updated the formulary, appears on the front and backcover pages.You can ask Community Health Choice to make an exception to these restrictions or limits or for alist of other, similar drugs that may treat your health condition. See the section, “How do I requestan exception to the Community Health Choice’s formulary?” on page 4 for information about howto request an exception.3
What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact MemberServices and ask if your drug is covered. For more information, please contact us. Our contactinformation, along with the date we last updated the formulary, appears on the front and backcover pages.If you learn that Community Health Choice does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by CommunityHealth Choice. When you receive the list, show it to your doctor and ask him or her toprescribe a similar drug that is covered by Community Health Choice. You can ask Community Health Choice to make an exception and cover your drug. Seebelow for information about how to request an exception.How do I request an exception to the Community Health Choice Formulary?You can ask Community Health Choice to make an exception to our coverage rules. There areseveral types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug willbe covered at a pre-determined cost-sharing level, and you would not be able to ask us toprovide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, forcertain drugs, Community Health Choice limits the amount of the drug that we will cover. Ifyour drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.Generally, Community Health Choice will only approve your request for an exception if thealternative drugs included on the plan’s formulary, or additional utilization restrictions would not beas 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, or utilizationrestriction exception. When you request a formulary or utilization restriction exception youshould submit a statement from your prescriber or physician supporting your request.Generally, we must make our decision within 72 hours of getting your prescriber’s supportingstatement. You can request an expedited (fast) exception if you or your doctor believe that yourhealth could be seriously harmed by waiting up to 72 hours for a decision. If your request toexpedite is granted, we must give you a decision no later than 24 hours after we get a supportingstatement from your doctor or other prescriber.4
What do I do before I can talk to my doctor about changing my drugs orrequesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary.Or, you may be taking a drug that is on our formulary but your ability to get it is limited. Forexample, you may need a prior authorization from us before you can fill your prescription. Youshould talk to your doctor to decide if you should switch to an appropriate drug that we cover orrequest a formulary exception so that we will cover the drug you take. While you talk to yourdoctor to determine the right course of action for you, we may cover your drug in certain casesduring the first 90 days you are a member of our plan.For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, wewill cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refillsto provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will notpay for these drugs, even if you have been a member of the plan less than 90 days.If you are a resident of a long-term care facility and you need a drug that is not on our formulary orif your ability to get your drugs is limited, but you are past the first 90 days of membership in ourplan, we will cover a 31-day emergency supply of that drug while you pursue a formularyexception.Exceptions are available for members who have experienced a change in the level of care they arereceiving which requires them to transition from one facility or treatment center to another.Examples of situations in which members would be eligible for the one-time temporary fillexception when they are outside of the three month effective date into the Part D program are asfollows:i.ii.iii.iv.v.Members who enter LTC facilities from hospitals with a discharge list of medicationsfrom the hospital formulary with very short term planning taken into account (i.e. under 8hours).Members who are discharged from a hospital to a home with very short-term planningtaken into account.Members who end their skilled nursing facility Medicare Part a stay (where paymentsinclude all pharmacy charged) and who need to revert to their Part D plan formulary.Members who give up hospice status to revert to standard Medicare Part A and Pbenefits.Members who end an LTC facility stay and return to the community.Mem
Community Health Choice Member Services, at 1-833-276-8306 or, for TTY users, 711, we are open October 1 through March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone
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