Note:

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premiums, copayments, and/or coinsurance may change on January 1.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

What is a Formulary?

A formulary is a list of covered drugs selected 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Health First Health Plans network pharmacy, and other plan rules are followed.

Can the Formulary change?

Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, 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 affected members of the change at least 60 days before 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.

What are generic drugs?

Health First Health Plans covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient formula as a 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 effective as brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have requirements or limits on coverage, including:

• Prior Authorization: We require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
• Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 30 tablets per prescription for PLAVIX. This may be in addition to a standard one month or three month supply.
• Step Therapy: In some cases, we require 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

These and any other requirements or limits are listed with the search results for each drug.

You can ask us to make an exception to these restrictions or limits.

What if my drug is not on the Formulary?

If you don't see your drug in this formulary, you should first contact your Customer Service Representative and confirm that your drug is not covered. If we do not cover your drug, you have two options:

• You can contact your Customer Service Representative for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered.
• You can ask us to make an exception and cover your drug.

How do I request an exception to the Formulary?

There are several types of exceptions you can ask us to make:

• Ask us to cover your drug even if it is not on our formulary.
• Ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit 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.
• Ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier 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. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-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 requesting a formulary, tiering, or utilization restriction exception, please submit a statement from your provider supporting the request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

What do I do before I can talk to my doctor about changing my drugs or requesting 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. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary 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 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, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay 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, we will allow you to refill your prescription until we have provided you with a 31-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Additionally, we understand that if you have been enrolled in the plan for more than 90 days, there may be other situations in which you are prescribed non-formulary medications. These circumstances usually involve a change from one treatment setting to another, including but not limited to:

• Discharge from a hospital to home,
• Discharge from a skilled nursing facility to home,
• Ending a long-term care facility stay and returning to the community.

As a current member, if you have been prescribed non-formulary medications as a result of changing from one treatment setting to another, you may be eligible to receive a one-time temporary 30-day supply of your non-formulary drugs. During this transition period you can talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception so we will cover the drug(s) you take. You can contact a Customer Service Representative to ask for a temporary supply if the above circumstances apply to you.

Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.

Y0089_EL108951_M | Accepted date: 10/01/2024
Last updated: 10/01/2024