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Kern Choice Plan (HMO)2014 Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLANThis formulary was updated on 10/28/2014. For more recent information or other questions,please Care1st Health Plan at 1-800-544-0088 or, for TTY users, 711, from 8:00 a.m. to 8:00p.m., seven days a week, or visit www.care1stmedicare.comNote 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 Care1st Health Plan.When it refers to “plan” or “our plan,” it means Kern Choice Plan.This document includes a list of the drugs (formulary) for our plan which is current as of10/28/2014. 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, premium and/or copayments/coinsurance may change on January1, 2015.Este formulario de medicamentos se actualizó en Agosto 2013. Para obtener información másreciente o si tiene preguntas, porfavor llame a Care1st Health Plan al 1-800-544-0088 o, parausuarios del TTY, 711, de 8:00 a.m. - 8:00 p.m., siete días de la semana o visitewww.care1stmedicare.com.H5928 14 206 KCPD Accepted
What is the Kern Choice Plan Formulary?A formulary is a list of covered drugs selected by Kern Choice Plan in consultation with a teamof health care providers, which represents the prescription therapies believed to be a necessarypart of a quality treatment program. Kern Choice Plan will generally cover the drugs listed inour formulary as long as the drug is medically necessary, the prescription is filled at a KernChoice Plan network pharmacy, and other plan rules are followed. For more information on howto fill your prescriptions, please review your Evidence of Coverage.Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning ofthe year, we will not discontinue or reduce coverage of the drug during the 2014 coverage yearexcept when a new, less expensive generic drug becomes available or when new adverseinformation about the safety or effectiveness of a drug is released. Other types of formularychanges, such as removing a drug from our formulary, will not affect members who are currentlytaking the drug. It will remain available at the same cost-sharing for those members taking it forthe remainder of the coverage year. We feel it is important that you have continued access forthe remainder of the coverage year to the formulary drugs that were available when you choseour 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 steptherapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notifyaffected members of the change at least 60 days before the change becomes effective, or at thetime the member requests a refill of the drug, at which time the member will receive a 60-daysupply of the drug. If the Food and Drug Administration deems a drug on our formulary to beunsafe or the drug’s manufacturer removes the drug from the market, we will immediatelyremove the drug from our formulary and provide notice to members who take the drug. Theenclosed formulary is current as of 10/28/2014. To get updated information about the drugscovered by Kern Choice Plan, please contact us. Our contact information appears on the frontand back cover pages. In the event of non-maintenance changes to the formulary throughout theplan year, Kern Choice Plan may make changes via errata sheets mailed to you. Additionally,you may visit our website for a link to the errata sheet.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 7. 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, CARDIOVASCULARAGENTS. If you know what your drug is used for, look for the category name in the list thatbegins on page 7. Then look under the category name for your drug.Alphabetical Listing2*We provide additional coverage of this drug in the coverage gap for MedicareMembers. Please refer to our Evidence of Coverage for more informationabout this coverage.
If you are not sure what category to look under, you should look for your drug in the Indexthat begins on page 164. The Index provides an alphabetical list of all of the drugs includedin this document. Both brand name drugs and generic drugs are listed in the Index. Look inthe Index and find your drug. Next to your drug, you will see the page number where youcan find coverage information. Turn to the page listed in the Index and find the name of yourdrug in the first column of the list.What are generic drugs?Kern Choice Plan 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. Theserequirements and limits may include:Prior Authorization: Kern Choice Plan requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from KernChoice Plan before you fill your prescriptions. If you don’t get approval, Kern ChoicePlan may not cover the drug.Quantity Limits: For certain drugs, Kern Choice Plan limits the amount of the drug thatKern Choice Plan will cover. For example, Kern Choice Plan provides 60 capsules perprescription for Celebrex. This may be in addition to a standard one-month or threemonth supply.Step Therapy: In some cases, Kern Choice Plan requires you to first try certain drugs totreat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Kern Choice Plan maynot cover Drug B unless you try Drug A first. If Drug A does not work for you, KernChoice Plan will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in theformulary that begins on page 7. You can also get more information about the restrictionsapplied to specific covered drugs by visiting our Web site. Our contact information, along withthe date we last updated the formulary, appears on the front and back cover pages.You can ask Kern Choice Plan to make an exception to these restrictions or limits or for a list ofother, similar drugs that may treat your health condition. See the section, “How do I request anexception to the Kern Choice Plan formulary?” on page 4 for information about how to requestan exception.3*We provide additional coverage of this drug in the coverage gap for MedicareMembers. Please refer to our Evidence of Coverage for more informationabout this coverage.
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 contactMember Services and ask if your drug is covered.If you learn that Kern Choice Plan does not cover your drug, you have two options:You can ask Member Services for a list of similar drugs that are covered by Kern ChoicePlan. When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Kern Choice Plan.You can ask Kern Choice Plan to make an exception and cover your drug. See below forinformation about how to request an exception.How do I request an exception to the Kern Choice Plan Formulary?You can ask Kern Choice Plan to make an exception to our coverage rules. There are severaltypes 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 drugwill be covered at a pre-determined cost-sharing level, and you would not be able to askus to provide the drug at a lower cost-sharing level.You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is noton the specialty tier. If approved this would lower the amount you must pay for yourdrug.You can ask us to waive coverage restrictions or limits on your drug. For example, forcertain drugs, Kern Choice Plan limits the amount of the drug that we will cover. If yourdrug has a quantity limit, you can ask us to waive the limit and cover a greater amount.Generally, Kern Choice Plan will only approve your request for an exception if the alternativedrugs included on the plan’s formulary, the lower cost-sharing drug or additional utilizationrestrictions would not be as effective in treating your condition and/or would cause you to haveadverse medical effects.You should contact us to ask us for an initial coverage decision for a formulary, tiering orutilization restriction exception. When you request a formulary, tiering or utilizationrestriction exception you should submit a statement from your prescriber or physiciansupporting your request. Generally, we must make our decision within 72 hours of gettingyour prescriber’s supporting statement. You can request an expedited (fast) exception if you oryour doctor believe that your health could be seriously harmed by waiting up to 72 hours for a4*We provide additional coverage of this drug in the coverage gap for MedicareMembers. Please refer to our Evidence of Coverage for more informationabout this coverage.
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 orrequesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on ourformulary. Or, you may be taking a drug that is on our formulary but your ability to get it islimited. For example, you may need a prior authorization from us before you can fill yourprescription. You should talk to your doctor to decide if you should switch to an appropriatedrug 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 yourdrug in certain cases during the first ninety (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 thirty (30) day supply (unless you have a prescription written forfewer days) when you go to a network pharmacy. After your first 30-day supply, we will not payfor 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 prescriptionuntil we have provided you with 91-day transition supply, consistent with dispensing increment,(unless you have a prescription written for fewer days). We will cover more than one refill ofthese drugs for the first 90 days you are a member of our plan. If you need a drug that is not onour formulary or if your ability to get your drugs is limited, but you are past the first 90 days ofmembership in our plan, we will cover a 31-day emergency supply of that drug (unless you havea prescription for fewer days) while you pursue a formulary exception.Exceptions are available for beneficiaries who have experienced a change in the level of carethey are receiving which requires them to transition from one facility or treatment center toanother. Examples of situations in which beneficiaries would be eligible for the one-timetemporary fill exception when they are outside of the three month effective date into the Part Dprogram are as follows:i. For example if a beneficiary was discharged from the hospital and was provided adischarge list of medications based upon the formulary of the hospital.ii. Beneficiaries who end their skilled nursing facility Medicare Part A stay (wherepayments include all pharmacy charges) and who need to revert back to their Part Dplan formularyiii. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part Aand B benefitsiv. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medicationregimens that are highly individualized.5*We provide additional coverage of this drug in the coverage gap for MedicareMembers. Please refer to our Evidence of Coverage for more informationabout this coverage.
All of these situations would warrant a temporary one-time fill exception irregardless of if thebeneficiary is in their first ninety (90) days of program enrollment.For more informationFor more detailed information about your Kern Choice Plan prescription drug coverage, pleasereview your Evidence of Coverage and other plan materials.If you have questions about Kern Choice Plan, please contact us. Our contact information, alongwith the date we last updated the formulary, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1877-486-2048. Or, visit www.medicare.gov.Kern Choice Plan FormularyThe formulary that begins on page 7 provides coverage information about the drugs covered byKern Choice Plan. If you have trouble finding your drug in the list, turn to the Index that beginson page 164.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,CELEBREX) and generic drugs are listed in lower-case italics (e.g., lisinopril).The information in the Requirements/Limits column tells you if Kern Choice Plan has anyspecial requirements for coverage of your drug.How much will I pay for Kern Choice Plan covered drugs?The amount you pay depends on which drug tier your drug is in and whether you arereceiving any extra help paying for your prescription drugs.Copayment/CoinsuranceTierDescription30 day supply90 day supplyTier 1Preferred GenericDrugs 0.00 0.00Tier 2Non-PreferredGeneric Drugs)Preferred BrandDrugs 3.00 9.00 25.00 75.00 40.00 120.0030% coinsurance30% coinsuranceTier 3Tier 4Non-PreferredBrand DrugsTier 5Specialty Tier Drugs6*We provide additional coverage of this drug in the coverage gap for MedicareMembers. Please refer to our Evidence of Coverage for more informationabout this coverage.
DRUG NAMEDRUG TIERREQUIREMENTS/LIMITSANALGESICSAnalgesics, Otherbutalbital-acetaminophen tab 50325 mgbutalbital-acetaminophen tab 50650 mgbutalbital-acetaminophen-caffeinecap 50-325-40 mgbutalbital-acetaminophen-caffeinetab 50-325-40 mgbutalbital-acetaminophen-caffeinetab 50-500-40 mgbutalbital-aspirin-caffeine cap 50325-40 mgbutalbital-aspirin-caffeine tab 50325-40 mgNonsteroidal Anti-Inflammatory Drugs2*Quantity limitation 180 per 30 days2*Quantity limitation 180 per 30 days2*Quantity limitation 120 per 30 days2*Quantity limitation 120 per 30 days2*Quantity limitation 120 per 30 days2*Quantity limitation 180 per 30 days2*Quantity limitation 180 per 30 daysCELEBREX CAP100MG3CELEBREX CAP200MG3CELEBREX CAP400MG3Quantity limitation 60 per 30 days;Step therapy protocols applyQuantity limitation 60 per 30 days;Step therapy protocols applyQuantity limitation 60 per 30 days;Step therapy protocols applyQuantity limitation 60 per 30 days;Step therapy protocols applyCELEBREX CAP50MG3diclofenac potassium tab 50 mg2*diclofenac sodium tab delayedrelease 25 mg2*diclofenac sodium tab delayedrelease 50 mg2*diclofenac sodium tab delayedrelease 75 mg2*diclofenac sodium tab sr 24hr 100mg2*diclofenac w/ misoprostol tabdelayed release 50-0.2 mg2*diclofenac w/ misoprostol tabdelayed release 75-0.2 mg2*diflunisal tab 500 mg2*7 *We provide additional coverage of this drug in the coverage gap for MedicareMembers. Please refer to our Evidence of Coverage for more informationabout this coverage.
DRUG NAMEetotolac cap200mgetotolac cap300mgetotolac tab400mgetotolac tab500mgetotolac tab400mg eretotolac tab500mg eretotolac tab600mg erfenoprofen calcium tab 600 mgflurbiprofen tab 100 mgflurbiprofen tab 50 mgibuprofen susp 100 mg/5mlibuprofen tab 400 mgibuprofen tab 600 mgibuprofen tab 800 mgindomethacin cap 25 mgindomethacin cap 50 mgindomethacin cap cr 75 mgketoprofen cap 50 mgketoprofen cap 75 mgketoprofen cap sr 24hr 200 mgmeclofen sodcap100mgmeclofen sodcap50mgmefenamic acid cap 250 mgmeloxicam sus 7.5/5mlmeloxicam tab 15 mgmeloxicam tab 7.5 mgnabumetone tab 500 mgnabumetone tab 750 mgnaproxen sodium tab 275 mgnaproxen sodium tab 550 mgnaproxen susp 125 mg/5mlnaproxen tab 250 mgnaproxen tab 375 mgnaproxen tab 500 mgnaproxen tab ec 375 mgnaproxen tab ec 500 mgoxaprozin tab 600 mgpiroxicam cap 10 mgpiroxicam cap 20 mgsulindac tab 150 mgsulindac tab 200 mg8DRUG tity limitation 300 per 30 daysQuantity limitation 30 per 30 daysQuantity limitation 30 per 30 days*We provide additional coverage of this drug in the coverage gap for MedicareMembers. Please refer to our Evidence of Coverage for more informationabout this coverage.
DRUG NAMEtolmetin sodium cap 400 mgtolmetin sodium tab 200 mgtolmetin sodium tab 600 mgOpioid Analgesics, Long-ActingAVINZA CAP120MGAVINZA CAP30MGAVINZA CAP45MGAVINZA CAP60MGAVINZA CAP75MGAVINZA CAP90MGDRUG TIER2*2*2*REQUIREMENTS/LIMITS444444fentanyl citrate lollipop 1200 mcg2*fentanyl citrate lollipop 1600 mcg2*fentanyl citrate lollipop 200 mcg2*fentanyl citrate lollipop 400 mcg2*fentanyl citrate lollipop 600 mcg2*fentanyl citrate lollipop 800 mcg2*Quantity limitation 30 per 30 daysQuantity limitation 30 per 30 daysQuantity limitation 30 per 30 daysQuantity limitation 30 per 30 daysQuantity limitation 30 per 30 daysQuantity limitation 30 per 30 daysQuantity limitation 120 per 30 days;This medication requires priorauthorization. To obtain an exceptionplease call 1-800-546-5677 - 24 hoursa day- seven days a week. TTY/TDDusers should call 1-866-706-4757.Quantity limitation 120 per 30 days;This medication requires priorauthorization. To obtain an exceptionplease call 1-800-546-5677 - 24 hoursa day- seven days a week. TTY/TDDusers should call 1-866-706-4757.Quantity limitation 120 per 30 days;This medication requires priorauthorization. To obtain an exceptionplease call 1-800-546-5677 - 24 hoursa day- seven days a week. TTY/TDDusers should call 1-866-706-4757.Quantity limitation 120 per 30 days;This medication requires priorauthorization. To obtain an exceptionplease call 1-800-546-5677 - 24 hoursa day- seven days a week. TTY/TDDusers should call 1-866-706-4757.Quantity limitation 120 per 30 days;This medication requires priorauthorization. To obtain an exceptionplease call 1-800-546-5677 - 24 hoursa day- seven days a week. TTY/TDDusers should call 1-866-706-4757.Quantity limitation 120 per 30 days;This medication requires prior9*We provide additional coverage of this drug in the coverage gap for MedicareMembers. Please refer to our Evidence of Coverage for more informationabout this coverage.
DRUG NAMEDRUG TIERfentanyl td patch 72hr 100 mcg/hrfentanyl td patch 72hr 12 mcg/hrfentanyl td patch 72hr 25 mcg/hrfentanyl td patch 72hr 50 mcg/hrfentanyl td patch 72hr 75 mcg/hr2*2*2*2*2*LAZANDASPR100MCG5LAZANDA SPR400MCGlevorphanol tartrate tab 2 mg52*METHADONE INJ10MG/MLmethadone hcl conc 10 mg/mlmethadone hcl soln 10 mg/5mlmethadone hcl soln 5 mg/5mlmethadone hcl tab 10 mgmethadone hcl tab 5 mgmorphine sulfate (concentrate) oralsoln 20 mg/mlmorphine sulfate cap sr 24hr 100mgmorphine sulfate cap sr 24hr 20 mg
care1stmedicare.com Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refe
