FORMULARY (LIST OF COVERED DRUGS)
2017FORMULARY (LIST OF COVERED DRUGS)Trillium Medicare AdvantageOregonPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THEDRUGS WE COVER IN THIS PLAN. 3, Version Number This formulary was updated on . For more recent information orother questions, please contact Trillium Medicare Advantage MemberServices, at 1-844-867-1156 or, for TTY users, 711. October 1 - February 14,seven days a week, 8 a.m. to 8 p.m.; February 15 - September 30, Monday Friday, 8 a.m. to 8 p.m., or visit http://trilliumadvantage.com.Y0020 CompForm17 FINAL 7@
Can the Formulary (drug list) change?Note to existing members: This formulary haschanged since last year. Please review thisdocument to make sure that it still contains thedrugs you take.Generally, if you are taking a drug on our 2017formulary that was covered at the beginning of theyear, we will not discontinue or reduce coverageof the drug during the 2017 coverage year exceptwhen a new, less expensive generic drug becomesavailable or when new adverse information aboutthe safety or effectiveness of a drug is released.Other types of formulary changes, such asremoving a drug from our formulary, will notaffect members who are currently taking the drug.It will remain available at the same cost-sharingfor those members taking it for the remainder ofthe coverage year. We feel it is important that youhave continued access for the remainder of thecoverage year to the formulary drugs that wereavailable when you chose our plan, except forcases in which you can save additional money orwe can ensure your safety.When this drug list (formulary) refers to “we,”“us”, or “our,” it means Trillium MedicareAdvantage. When it refers to “plan” or “ourplan,” it means Trillium Advantage Dual (HMOSNP), Trillium Advantage TLC ISNP (HMOSNP), and Trillium Advantage TLC CommunityISNP (HMO SNP).This document includes a list of the drugs(formulary) for our plan which is current as ofAugust 23, 2016 For an updatedformulary, please contact us. Our contactinformation, along with the date we last updatedthe formulary, appears on the front and backcover pages.If we remove drugs from our formulary, or addprior authorization, quantity limits and/or steptherapy restrictions on a drug or move a drug to ahigher cost-sharing tier, we must notify affectedmembers of the change at least 60 days before thechange becomes effective, or at the time themember requests a refill of the drug, at which timethe member will receive a 60-day supply of thedrug. If the Food and Drug Administration deemsa drug on our formulary to be unsafe or the drug’smanufacturer removes the drug from the market,we will immediately remove the drug from ourformulary and provide notice to members whotake the drug. The enclosed formulary is currentas of August 23, 2016. To get updatedinformation about the drugs covered by TrilliumMedicare Advantage please contact us. Ourcontact information appears on the front and backcover pages. If we make any other negativeformulary changes to a drug we will notifyeffected members by mail. The formulary isupdated monthly and posted on our website.You must generally use network pharmacies touse your prescription drug benefit. Benefits,formulary, pharmacy network, and/orcopayments/coinsurance may change on January1, 2018, and from time to time during the year.What is the Trillium MedicareAdvantage Formulary?A formulary is a list of covered drugs selected byTrillium Medicare Advantage in consultation witha team of health care providers, which representsthe prescription therapies believed to be anecessary part of a quality treatment program.Trillium Medicare Advantage will generally coverthe drugs listed in our formulary as long as thedrug is medically necessary, the prescription isfilled at a Trillium Medicare Advantage networkpharmacy, and other plan rules are followed. Formore information on how to fill yourprescriptions, please review your Evidence ofCoverage.How do I use the Formulary?There are two ways to find your drug within theformulary:i
xMedical ConditionThe formulary begins on page 1. The drugs inthis formulary are grouped into categoriesdepending on the type of medical conditionsthat they are used to treat. For example, drugsused to treat a heart condition are listed underthe category, “Cardiovascular Agents”. If youknow what your drug is used for, look for thecategory name in the list that begins on page 1.Then look under the category name for yourdrug.xAlphabetical ListingIf you are not sure what category to lookunder, you should look for your drug in theIndex that begins on page . The Indexprovides an alphabetical list of all of thedrugs included in this document. Both brandname drugs and generic drugs are listed in theIndex. Look in the Index and find your drug.Next to your drug, you will see the pagenumber where you can find coverageinformation. Turn to the page listed in theIndex and find the name of your drug in thefirst column of the list.xPrior Authorization: Trillium MedicareAdvantage requires you or your physicianto get prior authorization for certain drugs.This means that you will need to getapproval from Trillium MedicareAdvantage before you fill yourprescriptions. If you don’t get approval,Trillium Medicare Advantage may notcover the drug.Quantity Limits: For certain drugs,Trillium Medicare Advantage limits theamount of the drug that Trillium MedicareAdvantage will cover. For example,Trillium Medicare Advantage provides 30tablets per prescription for Januvia. Thismay be in addition to a standard onemonth or three-month supply.Step Therapy: In some cases, TrilliumMedicare Advantage requires you to firsttry certain drugs to treat your medicalcondition before we will cover anotherdrug for that condition. For example, ifDrug A and Drug B both treat yourmedical condition, Trillium MedicareAdvantage may not cover Drug B unlessyou try Drug A first. If Drug A does notwork for you, Trillium MedicareAdvantage will then cover Drug B.You can find out if your drug has any additionalrequirements or limits by looking in the formularythat begins on page 1. You can also get moreinformation about the restrictions applied tospecific covered drugs by visiting our Web site.We have posted online documents that explain ourprior authorization and step therapy restrictions.You may also ask us to send you a copy. Ourcontact information, along with the date we lastupdated the formulary, appears on the front andback cover pages.What are generic drugs?Trillium Medicare Advantage covers bothbrand name drugs and generic drugs. Ageneric drug is approved by the FDA ashaving the same active ingredient as the brandname drug. Generally, generic drugs cost lessthan brand name drugs.Are there any restrictions on mycoverage?You can ask Trillium Medicare Advantage tomake an exception to these restrictions or limits orfor a list of other, similar drugs that may treat yourhealth condition. See the section, “How do ISome covered drugs may have additionalrequirements or limits on coverage. Theserequirements and limits may include:ii
request an exception to the Trillium MedicareAdvantage formulary?” on page iii forinformation about how to request an exception.xWhat if my drug is not on theFormulary?If your drug is not included in this formulary (listof covered drugs), you should first contactMember Services and ask if your drug is covered.Generally, Trillium Medicare Advantage will onlyapprove your request for an exception if thealternative drugs included on the plan’s formulary,the lower cost-sharing drug or additionalutilization restrictions would not be as effective intreating your condition and/or would cause you tohave adverse medical effects.If you learn that Trillium Medicare Advantagedoes not cover your drug, you have two options:xYou can ask Member Services for a list ofsimilar drugs that are covered by TrilliumMedicare Advantage. When you receivethe list, show it to your doctor and ask himor her to prescribe a similar drug that iscovered by Trillium Medicare Advantage.x You can ask Trillium Medicare Advantageto make an exception and cover your drug.See below for information about how torequest an exception.You should contact us to ask us for an initialcoverage decision for a formulary, tiering orutilization restriction exception. When yourequest a formulary, tiering or utilizationrestriction exception you should submit astatement from your prescriber or physiciansupporting your request. Generally, we mustmake our decision within 72 hours of getting yourprescriber’s supporting statement. You canrequest an expedited (fast) exception if you oryour doctor believe that your health could beseriously harmed by waiting up to 72 hours for adecision. If your request to expedite is granted,we must give you a decision no later than 24 hoursafter we get a supporting statement from yourdoctor or other prescriber.How do I request an exception to theTrillium Medicare AdvantageFormulary?You can ask Trillium Medicare Advantage tomake an exception to our coverage rules. Thereare several types of exceptions that you can ask usto make.xxYou can ask us to waive coveragerestrictions or limits on your drug. Forexample, for certain drugs, TrilliumMedicare Advantage limits the amount ofthe drug that we will cover. If your drughas a quantity limit, you can ask us towaive the limit and cover a greater amount.What do I do before I can talk to mydoctor about changing my drugs orrequesting an exception?You can ask us to cover a drug even if it isnot on our formulary. If approved, thisdrug will be covered at a pre-determinedcost-sharing level, and you would not beable to ask us to provide the drug at alower cost-sharing level.You can ask us to cover a formulary drugat a lower cost-sharing level if this drug isnot on the specialty tier. If approved thiswould lower the amount you must pay foryour drug.As a new or continuing member in our plan youmay be taking drugs that are not on our formulary.Or, you may be taking a drug that is on ourformulary but your ability to get it is limited. Forexample, you may need a prior authorization fromus before you can fill your prescription. Youshould talk to your doctor to decide if you shouldswitch to an appropriate drug that we cover oriii
request a formulary exception so that we willcover the drug you take. While you talk to yourdoctor to determine the right course of action foryou, we may cover your drug in certain casesduring the first 90 days you are a member of ourplan.xxFor each of your drugs that is not on our formularyor if your ability to get your drugs is limited, wewill cover a temporary 30-day supply (unless youhave a prescription written for fewer days) whenyou go to a network pharmacy. After your first30-day supply, we will not pay for these drugs,even if you have been a member of the plan lessthan 90 days.payments include all pharmacy charges)and who now need to use their Part D planbenefitMembers who give up Hospice Status andgo back to standard Medicare Part A and BcoverageMembers discharged from psychiatrichospitals with highly individualized drugregimensFor these changes in treatment settings, TrilliumMedicare Advantage will cover as much as a 31day temporary supply of a Part D covered drugwhen you fill your prescription at a networkpharmacy. If you change treatment settingsmultiple times within the same month, you mayhave to request an exception or prior authorizationand get approval for continued coverage of yourdrug. We will review these requests forcontinuation of therapy on a case-by-case basiswhen you are on a stabilized drug regimen that, ifchanged, is known to have risks. If you do notrequest an exception or prior authorization withus, you do not qualify for extra time for a level ofcare transition fill unless it is a life threateningemergency.If you are a resident of a long-term care facility,we will allow you to refill your prescription untilwe have provided you with a 91 to 98-daytransition supply, consistent with dispensingincrement, (unless you have a prescription writtenfor fewer days). We will cover more than onerefill of these drugs for the first 90 days you are amember of our plan. If you need a drug that is noton our formulary or if your ability to get yourdrugs is limited, but you are past the first 90 daysof membership in our plan, we will cover a 31-dayemergency supply of that drug (unless you have aprescription for fewer days) while you pursue aformulary exception.For more informationFor more detailed information about your TrilliumMedicare Advantage prescription drug coverage,please review your Evidence of Coverage andother plan materials.Level of care changesThroughout the plan year, you may have a changein your treatment setting (the place where you getand take your medicine) because of the level ofcare you require. Such transitions may include, butare not limited to:x Members who are discharged from ahospital or skilled-nursing facility to ahome settingx Members who are admitted to a hospital orskilled-nursing facility from a home settingx Members who transfer from one skillednursing facility to another and are servedby a different pharmacyx Members who end their skilled-nursingfacility Medicare Part A stay (whereIf you have questions about Trillium MedicareAdvantage please contact us. Our contactinformation, along with the date we last updatedthe formulary, appears on the front and back coverpages.If you have general questions about Medicareprescription drug coverage, please call Medicareat 1-800-MEDICARE (1-800-633-4227) 24 hoursa day/7 days a week. TTY users should call 1877-486-2048. Or, visithttp://www.medicare.gov.iv
xTrillium Medicare AdvantageFormularyThe formulary that begins on the next pageprovides coverage information about the drugscovered by Trillium Medicare Advantage. If youhave trouble finding your drug in the list, turn tothe Index that begins on page .The first column of the chart lists the drugname. Brand name drugs are capitalized (e.g.,HUMALOG) and generic drugs are listed inlower-case italics (e.g. Amoxicillin).xThe information in the Requirements/Limitscolumn tells you if Trillium Medicare Advantagehas any special requirements for coverage of yourdrug.List of abbreviationsx B/D: This prescription drug has a Part Bversus D prior authorization requirement.This drug may be covered under MedicarePart B or D depending upon thecircumstances. Information may need to besubmitted describing the use and setting ofthe drug to make the determination.x LA: Limited Access. This drug may onlybe available at one or a certain number ofpharmacies. For more information callMember Services at 1-844-867-1156,From October 1 to February 14, you cancall us 7 days a week from 8 a.m. to 8 p.m.From February 15 to September 30, youcan call us Monday through Friday from 8a.m. to 8 p.m. On weekends and holidays,an automated system will handle your call.TTY users should call 711.x PA: Prior Authorization (Prior Approval).The plan requires you or your physician toget prior authorization for certain drugs.This means that you will need to getapproval from Trillium MedicareAdvantage before you fill yourprescriptions. If you don't get approval,Trillium Medicare Advantage may notcover the drug.xxvST: Step Therapy. In some cases, TrilliumMedicare Advantage requires you to firsttry certain drugs to treat your medicalcondition before we will cover anotherdrug for that condition. For example, ifDrug A and Drug B both treat yourmedical condition, Trillium MedicareAdvantage may not cover Drug B unlessyou try Drug A first. If Drug A does notwork for you, Trillium MedicareAdvantage will then cover Drug B.QL: Quantity Limit. For certain drugs,Trillium Medicare Advantage limits theamount of the drug that Trillium MedicareAdvantage will cover. For example,Trillium Medicare Advantage provides 30tablets per prescription for Januvia. Thismay be in addition to a standard one monthor three month supply.MO: Mail Order. This prescription drug iseligible for up to a 90-day supply throughour mail order pharmacy as well asthrough certain retail network pharmacies.Consider using mail order for your longterm (maintenance) medications (such ashigh blood pressure medications). Retailnetwork pharmacies may be moreappropriate for short-term prescriptions(such as antibiotics).NDS: Non-Extended Day Supply. Thisprescription drug is not available for anextended days' supply.
5SJMMJVN .FEJDBSF "EWBOUBHF DPWFST CPUI CSBOE OBNF ESVHT BOE HFOFSJD ESVHT (FOFSBMMZ HFOFSJD ESVHT DPTU MFTT UIBO CSBOE OBNF ESVHT Trillium Medicare Advantage is contracted withMedicare for HMO SNP and PPO plans, and withthe Oregon Medicaid program. Enrollment inTrillium Medicare Advantage depends on contractrenewal.Cost SharingThis information is available for free in otherlanguages. Please call our Member Servicesnumber at 1-844-867-1156 or, for TTY users,711, from October 1 to February 14, you can callus 7 days a week from 8 a.m. to 8 p.m. FromFebruary 15 to September 30, you can call usMonday through Friday from 8 a.m. to 8 p.m.DrugTier1TierDescriptionGeneric andBrandCopayment and/orCo-Insurance 25%- OR – 0, 1.20, 3.30 copayor 15% of the total costfor generic drugs 0, 3.70, 8.25 copayor 15% of the total costfor brand name drugs(depending upon yourlevel of Extra Help)] For more detailed information about your out ofpocket costs for prescriptions, please refer to yourEvidence of Coverage and other plan materials.Esta información está disponible gratis en otrosidiomas. Por favor llame a nuestro número deServicios para Afiliados al 1-844-867-1156 o, parausuarios de TTY, al 711 , Del 1 de octubre al 14de febrero, puede llamarnos 7 días a la semana de8 AM a 8 PM. Del 15 de febrero al 30 deseptiembre, puede llamarnos de lunes a viernesentre 8 AM y 8 PM.vi
Drug NameAnalgesicsNonsteroidal Anti-inflammatory Drugscelecoxib caps 100mgcelecoxib caps 200mgcelecoxib caps 400mgcelecoxib caps 50mgdiclofenac potassium tabs 50mgdiclofenac sodium dr tbec 25mgdiclofenac sodium dr tbec 50mgdiclofenac sodium dr tbec 75mgdiclofenac sodium er tb24 100mgdiclofenac sodium xr tb24 100mgdiclofenac sodium/misoprostol tbec 50mg; 200mcgdiclofenac sodium/misoprostol tbec 75mg; 200mcgdiflunisal tabs 500mgetodolac er tb24 400mgetodolac er tb24 500mgetodolac er tb24 600mgetodolac caps 200mgetodolac caps 300mgetodolac tabs 400mgetodolac tabs 500mgFENOPROFEN CALCIUM CAPS 400MGfenoprofen calcium tabs 600mgflurbiprofen tabs 100mgflurbiprofen tabs 50mgibuprofen susp 100mg/5mlibuprofen tabs 400mgibuprofen tabs 600mgibuprofen tabs 800mgindomethacin er cpcr 75mgindomethacin sr cpcr 75mgindomethacin caps 25mgindomethacin caps 50mgINDOMETHACIN INJ 1MGketoprofen er cp24 200mgketoprofen caps 50mgketoprofen caps 75mgketorolac tromethamine inj 15mg/mlketorolac tromethamine inj 300mg/10mlketorolac tromethamine inj 30mg/mlketorolac tromethamine inj 30mg/mlketorolac tromethamine inj 30mg/mlketorolac tromethamine tabs 10mgmeclofenamate sodium caps 100mgmeclofenamate sodium caps 50mgmefenamic acid caps 11111111Requirements/LimitsQL (60 EA per 30 days) MOQL (60 EA per 30 days) MOQL (60 EA per 30 days) MOQL (60 EA per 30 days) MOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOMOPA MOPA MOPA MOPA MOPAMOMOMOPAPAPAPAPAQL (20 EA per 30 days) PAMOMOMOPage 1 of 143You can find information on what the symbols and abbreviations in this table mean by going to page Y.
Drug Namemeloxicam susp 7.5mg/5mlmeloxicam tabs 15mgmeloxicam tabs 7.5mgnabumetone tabs 500mgnabumetone tabs 750mgnaproxen dr tbec 375mgnaproxen dr tbec 500mgnaproxen sodium cr tb24 375mgnaproxen sodium er tb24 375mgnaproxen sodium tabs 275mgnaproxen sodium tabs 550mgnaproxen susp 125mg/5mlnaproxen tabs 250mgnaproxen tabs 375mgnaproxen tabs 500mgoxaprozin tabs 600mgpiroxicam caps 10mgpiroxicam caps 20mgtolmetin sodium caps 400mgtolmetin sodium tabs 200mgtolmetin sodium tabs 600mgZIPSOR CAPS 25MGOpioid Analgesics, Long-actingbuprenorp
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.
The UCare formulary is a list of generic and brand drugs that are covered by this plan(s). To be covered, the drug must be on our formulary. The most current list of covered drugs can be found on the UCare . Express Scripts for review/copay override. Contraceptives Women u
Express Scripts Medicare (PDP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION . ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN. Formulary ID Number: 19057, v5. This formulary was updated on 08/24/2018. For more recent information or to price a medication,
Express Scripts Medicare (PDP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION . ABOUT THE DRUGS WE COVER IN THIS PLAN . Formulary ID Number: 19155, Version 5 . This formulary was updated on 09/27/2018. For more recent information or
Oct 19, 2017 · Express Scripts Medicare (PDP) 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION . ABOUT THE DRUGS WE COVER IN THIS PLAN . Formulary File Submission ID: 17070, V18. This formulary was updated on 10/19/2017. For more recent informa
UPMC for Life Dual (HMO SNP) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00016312, Version Number 17.
Pharmacy Benefit Dimensions Prescription Drug Plan . Part D Formulary . 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINSINFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN . HPMS Approved Formulary File Submission ID 00019368, Version Number 33. This formulary was updated on December 1, 2019.
MDwise Formulary Introduction – Hoosier Healthwise (HHW) HHW members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on the type of medical
WellCare Reserve (HMO D-SNP), WellCare Select (HMO D-SNP), WellCare Summit (PPO) Comprehensive Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believe
