Transcription
2022Formulary(List of Covered Drugs)FHCP Medicare Rx Plus (HMO-POS)FHCP Medicare Rx (HMO)FHCP Medicare Rx Savings (HMO)FHCP Medicare Premier Plus (HMO)FHCP Medicare Flagler Advantage (HMO)FHCP Medicare Premier Advantage (HMO)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLANThis formulary was updated on 06/21/2022. For more recent information or other questions, please contactFHCP Medicare Member Services at 1-833-866-6559 (TTY users should call 1-800-955-8770). Hours are 8:00a.m. to 8:00 p.m. local time, seven days a week from October 1 through March 31, except for Thanksgiving andChristmas. From April 1 through September 30, our hours are 8:00 a.m. to 8:00 p.m. local time, Mondaythrough Friday, except for major holidays, or visit www.fhcpmedicare.com.HMO coverage is offered by Florida Blue Medicare, Inc., DBA FHCP Medicare, an Independent Licensee of the BlueCross and Blue Shield Association.HPMS Approved Formulary File Submission ID 00022581, Version 16Y0011 FHCP0040 2021 C
Note to existing members: This formulary has changed since last year. Please review this document tomake sure that it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us”, or “our,” it means FHCP Medicare. When it refers to“plan” or “our plan,” it means FHCP Medicare Rx, FHCP Medicare Rx Plus, FHCP Medicare RxSavings, FHCP Medicare Premier Plus, FHCP Medicare Flagler Advantage, and FHCP Medicare PremierAdvantageThis document includes a list of the drugs (formulary) for our plan which is current as of 06/21/2022 Foran updated formulary, please contact us. Our contact information, along with the date we last updated theformulary, 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, 2022, and from time to timeduring the year.What is the FHCP Medicare Rx, FHCP Medicare Rx Plus, FHCP Medicare Rx Savings,FHCP Medicare Premier Plus, FHCP Medicare Flagler Advantage, and FHCPMedicare Premier Advantage Formulary?A formulary is a list of covered drugs selected by us 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, theprescription is filled at a plan network pharmacy, and other plan rules are followed. For more informationon 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 on the Drug Listduring the year, move them to different cost-sharing tiers, or add new restrictions. We must follow theMedicare rules in making these changes.Changes that can affect you this year: In the below cases, you will be affected by coverage changesduring the year: New generic drugs. We may immediately remove a brand name drug on our Drug List if we arereplacing it with a new generic drug that will appear on the same or lower cost sharing tier and withthe same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep thebrand name drug on our Drug List, but immediately move it to a different cost-sharing tier or addnew restrictions. If you are currently taking that brand name drug, we may not tell you in advancebefore we make that change, but we will later provide you with information about the specificchange(s) we have made.o If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can find information in the sectionbelow titled “How do I request an exception to the FHCP Medicare Rx, FHCP Medicare RxPlus, FHCP Medicare Rx Savings, FHCP Medicare Premier Plus, FHCP Medicare FlaglerAdvantage, and FHCP Medicare Premier Advantage’s Formulary?”06/21/2022i
Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. Forinstance, we may add a generic drug that is not new to market to replace a brand name drug currentlyon the formulary; or add new restrictions to the brand name drug or move it to a different cost sharingtier or both. Or we may make changes based on new clinical guidelines. If we remove drugs fromour formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug ormove a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30days before the change becomes effective, or at the time the member requests a refill of the drug, atwhich time the member will receive a 31-day supply of the drug.o If we make these other changes, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled “How do I request an exception to the FHCP Medicare Rx, FHCP Medicare RxPlus, FHCP Medicare Rx Savings, FHCP Medicare Premier Plus, FHCP Medicare FlaglerAdvantage, and FHCP Medicare Premier Advantage’s Formulary?”Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drugon our 2022 formulary that was covered at the beginning of the year, we will not discontinue or reducecoverage of the drug during the 2022 coverage year except as described above. This means these drugs willremain available at the same cost sharing and with no new restrictions for those members taking them for theremainder of the coverage year. You will not get direct notice this year about changes that do not affect you.However, on January 1 of the next year, such changes would affect you, and it is important to check the DrugList for the new benefit year for any changes to drugs.The enclosed formulary is current as of 06/21/2022. To get updated information about the drugs coveredby our plan please contact us. Our contact information appears on the front and back cover pages. Ourplan issues monthly formulary updates to our website (www.fhcpmedicare.com) and in print by request.06/21/2022ii
How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 2. The drugs in this formulary are grouped into categories depending onthe type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition 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 number 1. Then look under the category namefor your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that beginson page 68. 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 yourdrug. 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.What are generic drugs?Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA ashaving the same active ingredient as the brand name drug. Generally, generic drugs cost less than brandname drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limitsmay include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certaindrugs. This means that you will need to get approval from us before you fill your prescriptions. Ifyou don’t get approval, we may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. Forexample, our plan provides 31 tablets per prescription for Januvia 50MG. This may be in addition toa standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug Adoes not work for you, we will then cover Drug B.06/21/2022iii
You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 2. You can also get more information about the restrictions applied to specific covered drugsby visiting our Web site. We have posted online documents that explain our prior authorization and steptherapy restrictions. You may also ask us to send you a copy. Our contact information, along with the datewe last updated the formulary, appears on the front and back cover pages.You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs thatmay treat your health condition. See the section, “How do I request an exception to the FHCP Medicare Rx,FHCP Medicare Rx Plus, FHCP Medicare Rx Savings, FHCP Medicare Premier Plus, FHCP MedicareFlagler Advantage, and FHCP Medicare Premier Advantage’s formulary?” below for information abouthow to request an exception.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.If you learn that we do not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by us. When you receivethe list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by us. You can ask us to make an exception and cover your drug. See below for information about how torequest an exception.How do I request an exception to the FHCP Medicare Rx, FHCP Medicare Rx Plus,FHCP Medicare Rx Savings, FHCP Medicare Premier Plus, FHCP Medicare FlaglerAdvantage, and FHCP Medicare Premier Advantage’s Formulary?You can ask our plan to make an exception to our coverage rules. There are several types of exceptions thatyou 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 will becovered at a pre-determined cost-sharing level, and you would not be able to ask us to provide thedrug at a lower cost-sharing level. You can ask us to cover a formulary drug at lower cost-sharing level, unless the drug is on thespecialty tier. If approved, this would lower the amount you must pay for your drug. You can 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 usto waive the limit and cover a greater amount.06/21/2022iv
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’sformulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective intreating 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, tier, or utilization restrictionexception. When you request a formulary, tier, or utilization restriction exception you should submit astatement from your prescriber or physician supporting your request. Generally, we must make ourdecision within 72 hours of getting your prescriber’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 72hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24hours after we get a supporting statement from your doctor or other prescriber.What do I do before I can talk to my doctor about changing my drugs or requesting anexception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, youmay be taking a drug that is on our formulary but your ability to get it is limited. For example, you may needa prior authorization from us before you can fill your prescription. You should talk to your doctor to decideif you should switch to an appropriate drug that we cover or request a formulary exception so that we willcover the drug you take. While you talk to your doctor to determine the right course of action for you, wemay 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 willcover a temporary 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provideup to a maximum 31 day supply of medication. After your first 31-day supply, we will not pay for thesedrugs, 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 or if yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we willcover a 31-day emergency supply of that drug while you pursue a formulary exception.Note: Circumstances exist in which unplanned transitions for current members could arise and in whichprescribed drug regimens may not be on the formulary. These circumstances usually involve level of carechanges in which a member is changing from one treatment setting to another. For these unplannedtransitions, you must use the exceptions and appeals processes. Coverage determinations andredeterminations will be processed as expeditiously as your health condition requires.In order to prevent a temporary gap in care when a member is discharged to home, members are permitted tohave a full outpatient supply available to continue therapy once their limited supply provided at discharge isexhausted. This outpatient supply is available in advance of discharge from a Medicare Part A covered stay.When a member is admitted to or discharged from an LTC facility and does not have access to the remainderof the previously dispensed prescription, a one-time override of the “refill too soon” edit will be provided foreach medication. Early refill edits are not used to limit appropriate and necessary access to a member’s PartD benefit, and such members are allowed to access a refill upon admission or discharge.06/21/2022v
For more informationFor more detailed information about your plan’s prescription drug coverage, please review your Evidence ofCoverage and other plan materials.If you have questions about our plan, please contact us. Our contact information, along with the date we lastupdated the formulary, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,visit http://www.medicare.gov.Our Plan’s FormularyThe formulary that begins on page 2 provides coverage information about the drugs covered by us. Ifyou have trouble finding your drug in the list, turn to the Index that begins on page 68.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TOVIAZ) andgeneric drugs are listed in lower-case italics (e.g., tamsulosin).The information in the Requirements/Limits column tells you if our plan has any special requirements forcoverage of your drug.Usage Rules 75% Usage Rule: Prescription refills will not be covered unless at least 75% of the previousprescription has been used by the Member (based on the dosage schedule prescribed by thephysician). 90% Usage Rule: Prescription refills for narcotics or controlled substances will not be coveredunless at least 90% of the previous prescription has been used by the Member (based on the dosageschedule prescribed by the physician).06/21/2022vi
List of AbbreviationsTier 1: Preferred GenericTier 2: GenericTier 3: Preferred BrandTier 4: Non-Preferred BrandTier 5: Specialty(DL) Dispensing Limit: Cannot be dispensed for more than a 31-day supply.(LA) Limited Access: This prescription may be available only at certain pharmacies. For more informationconsult your Pharmacy Directory or call Member Services at 1-833-866-6559, From October 1 throughMarch 31, we are open 8 a.m. – 8 p.m. local time, seven days a week. From April 1 through September 30,we are open 8 a.m. – 8 p.m. local time, Monday – Friday. TTY users should call 1-800-955-8770.(B/D) Part B vs. Part D Prior Authorization Required: Part B vs. Part D administrative priorauthorization required. This drug may be covered under Medicare Part B or Part D depending upon thecircumstances. Part B medications must be obtained from FHCP Pharmacies.(PA) Prior Authorization: Our plan requires you or your physician to get prior authorization for certaindrugs. This means that you will need to get approval from our plan before you fill your prescriptions. If youdon’t get approval, our plan may not cover the drug.(QL) Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. Forexample, our plan provides 31 tablets per prescription for Januvia 50mg. This appears on the formulary as“31 EA per 31 days” which means coverage is limited to 31 tablets every 31 days, or 1 tablet per day.(ST) Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug B bothtreat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does notwork for you, our plan will then cover Drug B.Distribution Types (RO) Retail Only: Must be filled at a retail pharmacy. Mail order delivery not available.(RM) Retail and Mail: May be filled at a retail pharmacy or the FHCP mail order pharmacy.(SP) Specialty Pharmacy Only: Certain drugs can only be filled via specialty pharmacies.06/21/2022vii
Deductible, Initial Coverage, and Coverage Gap StagesThe copayment/coinsurance amounts that you pay in each drug tier at a PreferredRetail (31-day supply), Standard Retail (31-day supply), or through FHCP’s Mail Order pharmacy (93-daysupply) are listed belowFHCP Medicare Rx Plus (HMO-POS)DeductiblePharmacy Type/Day SupplyInitial CoverageCoverage GapTier 1Tier 2Tier 3Tier 4NonePreferred Retail1 Month Supply 0 2 42 92Standard Retail1 Month Supply 17 20 47 100Mail Order3 Month Supply 0 3 123 273Tier 5We provideadditional coverage33%for prescriptiondrugs on Tiers 1 and2 while in theCoverage Gap.33%Please refer to ourEvidence ofCoverage for moreNotCovered information aboutthis coverage.FHCP Medicare Rx (HMO)Deductible 295 – Onlyapplies to drugsin Tiers 3, 4,and 506/21/2022Pharmacy Type/Day SupplyInitial CoverageCoverage GapTier 1Tier 2Tier 3Tier 4Tier 5Preferred Retail1 Month Supply 0 6 44 9526%Standard Retail1 Month Supply 17 20 47 10026%Mail Order3 Month Supply 0 15 129 282NotCoveredStandard Coverage.Please refer to ourEvidence ofCoverage for moreinformation aboutthis coverage.viii
Deductible, Initial Coverage, and Coverage Gap Stages (Continued)FHCP Medicare Premier Plus (HMO)DeductiblePharmacy Type/Day SupplyInitial CoverageCoverage GapTier 1Tier 2Tier 3Tier 4NonePreferred Retail1 Month Supply 0 7 45 98Standard Retail1 Month Supply 17 20 47 100Mail Order3 Month Supply 0 18 132 291Tier 5We provideadditional coverage33%for prescriptiondrugs on Tiers 1 and2 while in theCoverage Gap.33%Please refer to ourEvidence ofCoverage for moreNotCovered information aboutthis coverage.FHCP Medicare Rx Savings (HMO)Deductible 395 – Onlyapplies todrugs in Tiers3, 4, and 506/21/2022Pharmacy Type/Day SupplyInitial CoverageCoverage GapTier 1Tier 2Tier 3Tier 4Tier 5Preferred Retail1 Month Supply 4 10 45 9825%Standard Retail1 Month Supply 17 20 47 10025%Mail Order3 Month Supply 9 27 132 291NotCoveredStandard Coverage.Please refer to ourEvidence ofCoverage for moreinformation aboutthis coverage.ix
Deductible, Initial Coverage, and Coverage Gap Stages (Continued)FHCP Medicare Flagler Advantage (HMO)DeductiblePharmacy Type/Day SupplyInitial CoverageCoverage GapTier 1Tier 2Tier 3Tier 4NonePreferred Retail1 Month Supply 0 5 44 95Standard Retail1 Month Supply 17 20 47 100Mail Order3 Month Supply 0 12 129 282Tier 5We provideadditional coverage33%for prescriptiondrugs on Tiers 1 and2 while in theCoverage Gap.33%Please refer to ourEvidence ofCoverage for moreNotCovered information aboutthis coverage.FHCP Medicare Premier Advantage (HMO)DeductiblePharmacy Type/Day SupplyInitial CoverageCoverage GapTier 1Tier 2Tier 3Tier 4None06/21/2022Preferred Retail1 Month Supply 0 5 44 95Standard Retail1 Month Supply 17 20 47 100Mail Order3 Month Supply 0 12 129 282Tier 5We provideadditional coverage33%for prescriptiondrugs on Tiers 1 and2 while in theCoverage Gap.33%Please refer to ourEvidence ofCoverage for moreNotCovered information aboutthis coverage.x
Table of ContentsAnalgesics. 2Anesthetics.3Anti-Addiction/ Substance Abuse Treatment Agents.3Antibacterials.4Anticonvulsants. 9Antidementia Agents.12Antidepressants.12Antiemetics. 14Antifungals. 15Antigout Agents.17Antimigraine Agents. 17Antimyasthenic Agents. 18Antimycobacterials. 18Antineoplastics.18Antiparasitics. 24Antiparkinson Agents. 25Antipsychotics.26Antispasticity Agents. 28Antivirals. 28Anxiolytics. 32Bipolar Agents. 32Blood Glucose Regulators.32Blood Products and Modifiers. 35Cardiovascular Agents. 36Central Nervous System Agents.41Dental and Oral Agents. 42Dermatological Agents.43Electrolytes/Minerals/Metals/Vitamins. 46Gastrointestinal Agents.48Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment. 49Genitourinary Agents.50Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal). 50Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary). 51Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers). 51Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid). 53Hormonal Agents, Suppressant (Adrenal). 53Hormonal Agents, Suppressant (Pituitary). 53Hormonal Agents, Suppressant (Thyroid). 54Immunological Agents. 54Inflammatory Bowel Disease Agents.59Metabolic Bone Disease Agents. 60Ophthalmic Agents. 60Otic Agents. 63Respiratory Tract/ Pulmonary Agents. 63Skeletal Muscle Relaxants.67Sleep Disorder Agents. 671
Drug -codeine #3 oral tablet 300-30 mgTier 2RMacetaminophen-codeine oral solution 120-12mg/5mlTier 2RO; DLacetaminophen-codeine oral tablet 300-15 mg,300-60 mgTier 2RMbuprenorphine hcl sublingual tablet sublingual 2mg, 8 mgTier 2RO; DLbutalbital-apap-caffeine oral tablet 50-325-40mgTier 2RMbutalbital-aspirin-caffeine oral capsule 50-32540 mgTier 2RMcelecoxib oral capsule 100 mg, 200 mg, 400 mg,50 mgTier 2RMdiclofenac sodium external gel 1 %Tier 2RO; DLdiclofenac sodium external gel 3 %Tier 2PA; RO; QL (100 GM per 30days); DLdiclofenac sodium oral tablet delayed release 25mg, 50 mg, 75 mgTier 2RMetodolac er oral tablet extended release 24 hour400 mg, 500 mg, 600 mgTier 2RMetodolac oral capsule 200 mg, 300 mgTier 2RMetodolac oral tablet 400 mg, 500 mgTier 2RMFENTANYL CITRATE BUCCALLOZENGE ON A HANDLE 1200 MCG,1600 MCG, 200 MCG, 400 MCG, 600 MCG,800 MCGTier 4PA; RO; QL (120 EA per 30days); DLfentanyl transdermal patch 72 hour 100 mcg/hr,12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hrTier 2PA; RO; DLhydrocodone-acetaminophen oral solution 7.5325 mg/15mlTier 2RO; QL (2700 ML per 30 days);DLhydrocodone-acetaminophen oral tablet 10-325mg, 5-325 mg, 7.5-325 mgTier 2RMhydromorphone hcl oral liquid 1 mg/mlTier 2RO; DLhydromorphone hcl oral tablet 2 mg, 4 mg, 8 mgTier 2RMibuprofen oral tablet 400 mg, 600 mg, 800 mgTier 1RMindomethacin er oral capsule extended release 75mgTier 2
(List of Covered Drugs) FHCP Medicare Rx Plus (HMO-POS) FHCP Medicare Rx (HMO) FHCP Medicare Rx Savings (HMO) FHCP Medicare Premier Plus (HMO) . Most changes in drug coverag e happen on January 1, bu t we may add or remove drugs on the Drug List during the year, move them to different cost-s haring tiers, or add new restrictions. We must .
