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EnvisionRxPlus (PDP)2017 Comprehensive Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLANHPMS Approved Formulary File Submission 17453, Version 9This formulary was updated on 08/23/2016. For more recent information or other questions, please contactEnvisionRxPlus Member Services, at 1-866-250-2005 or, for TTY users, 711, 24 hours a day, 7 days aweek, or visit www.envisionrxplus.com.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 Envision Insurance Company. Whenit refers to “plan” or “our plan,” it means EnvisionRxPlus.This document includes a list of the drugs (formulary) for our plan which is current as of August 23, 2016.For an 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, 2017, and from time to timeduring the year.This information is available for free in other languages. Please call our customer service number at 1-866250-2005. TTY/TDD users call 711. We are available 24 hours a day, 7 days a week.Esta información está disponible gratis en otras idiomas. Por favor llame nuestro servicio al cliente alnúmero 1-866-250-2005. Los usuarios de TTY/TDD llama al 711. Estamos disponible 24 horas al día, 7 díasde la semana.EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.S7694 2017 CF H Accepted 9/26/16i
What is the EnvisionRxPlus Comprehensive Formulary?A formulary is a list of covered drugs selected by EnvisionRxPlus in consultation with a team of health careproviders, which represents the prescription therapies believed to be a necessary part of a quality treatmentprogram. EnvisionRxPlus will generally cover the drugs listed in our formulary as long as the drug ismedically necessary, the prescription is filled at an EnvisionRxPlus network pharmacy, and other plan rulesare followed. For more information on how to fill your prescriptions, please review your Evidence ofCoverage.Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, wewill not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, lessexpensive generic drug becomes available or when new adverse information about the safety or effectivenessof a drug is released. Other types of formulary changes, such as removing a drug from our formulary, willnot affect members who are currently taking the drug. It will remain available at the same cost-sharing forthose members taking it for the remainder of the coverage year. We feel it is important that you havecontinued access for the remainder of the coverage year to the formulary drugs that were available when youchose 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, or add prior authorization, quantity limits and/or step therapyrestrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of thechange at least 60 days before the change becomes effective, or at the time the member requests a refill ofthe drug, at which time the member will receive a 60-day supply of the drug. If the Food and DrugAdministration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drugfrom the market, we will immediately remove the drug from our formulary and provide notice to memberswho take the drug. The enclosed formulary is current as of 08/23/2016. To get updated information aboutthe drugs covered by EnvisionRxPlus, please contact us. Our contact information appears on the front andback cover pages. If we make certain non-routine changes to coverage for drugs, we will send members anerrata sheet to update the formulary they received.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on thetype of medical conditions that they are used to treat. For example, drugs used to treat a heart condition arelisted under the category, “cardiovascular agents”. If you know 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 your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins onpage 36. The Index provides an alphabetical list of all of the drugs included in this document. Both brandname drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to yourdrug, you will see the page number where you can find coverage information. Turn to the page listed in theIndex and find the name of your drug in the first column of the list.EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.S7694 2017 CF H Accepted 9/26/16ii
What are generic drugs?EnvisionRxPlus covers both brand name drugs and generic drugs. A generic drug is approved by the FDAas having 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: EnvisionRxPlus requires you or your physician to get prior authorization forcertain drugs. This means that you will need to get approval from EnvisionRxPlus before you fillyour prescriptions. If you don’t get approval, EnvisionRxPlus may not cover the drug. Quantity Limits: For certain drugs, EnvisionRxPlus limits the amount of the drug thatEnvisionRxPlus will cover. For example, EnvisionRxPlus provides 240 tablets per 30-day perprescription for Tramadol. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, EnvisionRxPlus requires you to first try certain drugs to treat yourmedical condition before we will cover another drug for that condition. For example, if Drug A andDrug B both treat your medical condition, EnvisionRxPlus may not cover Drug B unless you tryDrug A first. If Drug A does not work for you, EnvisionRxPlus will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 1. You can also get more information about the restrictions applied to specific covered drugsby visiting our Web site. We have posted on-line 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 EnvisionRxPlus to make an exception to these restrictions or limits or for a list of other, similardrugs that may treat your health condition. See the section, “How do I request an exception to theEnvisionRxPlus formulary?” on page iv for information about how to request an exception.EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.S7694 2017 CF H Accepted 9/26/16iii
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 EnvisionRxPlus does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by EnvisionRxPlus. Whenyou receive the list, show it to your doctor and ask him or her to prescribe a similar drug that iscovered by EnvisionRxPlus. You can ask EnvisionRxPlus to make an exception and cover your drug. See below for informationabout how to request an exception.How do I request an exception to the EnvisionRxPlus Formulary?You can ask EnvisionRxPlus to make an exception to our coverage rules. There are several types ofexceptions 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 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 a lower cost-sharing level if this drug is not 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,EnvisionRxPlus limits 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 a greater amount.Generally, EnvisionRxPlus will only approve your request for an exception if the alternative drugs includedon the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be aseffective 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 utilization restrictionexception. When you request a formulary 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.EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.S7694 2017 CF H Accepted 9/26/16iv
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 30-day supply (unless you have a prescription written for fewer days) when you go to anetwork pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been amember 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 haveprovided you with a 98-day transition supply, consistent with dispensing increment, (unless you have aprescription written for fewer days). We will cover more than one refill of these drugs for the first 90 daysyou are a member of our plan. If you need a drug that is not on our formulary or if your ability to get yourdrugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-dayemergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formularyexception.If you are outside of your transition period, and experience a level of care change from one treatment settingto another (example: hospital to long-term care facility, hospital to home, home to long-term care facility, orhospice to non-hospice), upon notification of the change, we will cover up to a 30 day supply of medicationin the retail setting and up to a 31 day supply in the long-term care facility for non-formulary Part Dcoverable medications (including those medications on the formulary but require a prior authorization, steptherapy, or are subject to quantity limit restrictions).For more informationFor more detailed information about your EnvisionRxPlus prescription drug coverage, please review yourEvidence of Coverage and other plan materials.If you have questions about EnvisionRxPlus, please contact us. Our contact information, along with the datewe 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 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.EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.S7694 2017 CF H Accepted 9/26/16v
EnvisionRxPlus FormularyThe formulary that begins on the next page provides coverage information about the drugs covered byEnvisionRxPlus. If you have trouble finding your drug in the list, turn to the Index that begins on page 36.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) andgeneric drugs are listed in lower-case italics (e.g., levothyroxine).The information in the Requirements/Limits column tells you if EnvisionRxPlus has any specialrequirements for coverage of your drug.Abbreviation tionB/DPart B vs PartDThese medications currently include oral diabetic medications, somemedications to treat high cholesterol and some medications to treathigh blood pressure.This drug may be covered under Medicare Part B or Part Ddepending upon the circumstances. Information may need to besubmitted describing the use and setting of the drug to make thedetermination.HRHigh uantityLimitQLSTStep TherapyAccording to medical experts, these drugs may cause more side effects ifyou are 65 years of age or older. If you are taking one of these drugs,ask your doctor if there are safer options available. These medicationsrequire prior authorization if you are 65 years of age or older.This prescription may be available only at certain pharmacies. For moreinformation consult your Pharmacy Directory or call Member Servicesat 1-866-250-2005, 24 hours a day, 7 days a week. TTY/TDD usersshould call 711.This medication requires that you or your provider get approval fromthe plan before we will agree to cover the drug for you.Most limits per 30-day supply. If the limit is for a day supply other than30 the entry will read quantity/day supply (i.e. REVLIMID 28/28 meansyou can only fill 28 capsules for 28 day supply)This requirement encourages you to try less costly but just as effectivedrugs before the plan covers another drug. For example, if Drug A andDrug B treat the same medical condition, the plan may require you totry Drug A first. If Drug A does not work for you, the plan will thencover Drug B.EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.S7694 2017 CF H Accepted 9/26/16vi
The Tier column of the drug list that begins on page 1 tells you which tier your drug is in. The table belowtells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during theinitial coverage period) for up to a one month supply of drugs in each tier.Standardretail-costsharing (innetwork)(up to a 30day supply)Preferredretail costsharing (innetwork)(up to a 30day supply)StandardMail-ordercostsharing(up to a 30day supply)PreferredMail-ordercostsharing(up to a 30day supply)Long-termcare (LTC)cost-sharing(up to a 31day supply)Cost-SharingTier 1(PreferredGeneric Drugs) 14.90 1.00 14.90 1.00 14.90Cost-SharingTier 2(Generic Drugs) 20.00 15.00 20.00 15.00 20.00Cost-SharingTier 3(PreferredBrand Drugs)20%10%20%10%20%Cost-SharingTier 4(Non-preferredDrugs)32%-42%Please referto Exhibit 1for the exactCoinsuranceamount inyour state24%-27%Pleaserefer toExhibit 1for theexactCoinsurance amountin yourstate32%-42%Pleaserefer toExhibit 1for theexactCoinsurance amountin yourstate24%-27%Pleaserefer toExhibit 1for theexactCoinsurance amountin yourstate32%-42%Please refer toExhibit 1 forthe exactCoinsuranceamount inyour state27%27%27%27%27%TierCost-SharingTier 5(SpecialtyDrugs)EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.S7694 2017 CF H Accepted 9/26/16vii
Exhibit 1: Your share of the cost when you get a one-month supply of a covered Part Dprescription drug for Tier 4 drugs:Standardretail-costsharing(innetwork)(up to 30day supply)Preferredretail costsharing (innetwork(up to a 30day supply)StandardMail-ordercost-sharing(up to a 30-daysupply)PreferredMail-ordercost-sharing(up to a 30-daysupply)Long-termcare (LTC)cost-sharing(up to 31-daysupply)OH32%24%32%24%32%PA, A36%25%36%25%36%DC, DE, MD, %OR, WA42%25%42%25%42%ME, NH42%27%42%27%42%StateCT, MA, RI, VTIf you qualified for extra help with your drug costs, your costs may be different from those described above.You can find complete cost-sharing information in your Evidence of Coverage.EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.S7694 2017 CF H Accepted 9/26/16viii
Drug NameTierNotesDrug NameTierNotesfentanyl dis 12mcg/hr4ST, QL 10fentanyl dis 25mcg/hr4ST, QL 10Nonsteroidal Anti-inflammatory Drugsfentanyl dis 37.5mcg4ST, QL 10celecoxib cap 100mg4fentanyldis50mcg/hr4ST, QL 10celecoxib cap 200mg4fentanyl dis 62.5mcg4ST, QL 10celecoxib cap 400mg4fentanyldis75mcg/hr4ST, QL 10celecoxib cap 50mg4fentanyl dis 87.5mcg4ST, QL 10diclofen pot tab 50mg4methadonetab10mg4QL 240diclofenac tab 100mg er4methadone tab 5mg4QL 240diclofenac tab 25mg dr4morphine sul sol 100/5ml4diclofenac tab 50mg dr2morphine sul sol 10mg/5ml4diclofenac tab 75mg dr2morphine sul sol 20mg/5ml4diflunisal tab 500mg4morphine sul tab 100mg er4QL 90etodolac cap 200mg4morphine sul tab 15mg er3QL 90etodolac cap 300mg4morphinesultab200mger4QL 90etodolac tab 400mg4morphine sul tab 30mg er3QL 90etodolac tab 500mg4morphinesultab60mger4QL 90flurbiprofen tab 100mg2Opioid Analgesics, Short-actingflurbiprofen tab 50mg2apap/codeine sol 120-12/53QL 5000ibuprofen sus 100/5ml2apap/codeine tab 300-15mg3QL 400ibuprofen tab 400mg1apap/codeine tab 300-30mg3QL 400ibuprofen tab 600mg1apap/codeine tab 300-60mg3QL 400ibuprofen tab 800mg1Opioid Analgesics, short-actingketoprofen cap 50mg2CODEINE SULF TAB 15MG4QL 360ketoprofen cap 75mg2Opioid Analgesics, Short-actingmeloxicam sus 7.5/5ml4codeine sulf tab 30mg4QL 360meloxicam tab 15mg1CODEINE SULF TAB 60MG4QL 360meloxicam tab 7.5mg1endocettab10-325mg4QL 370nabumetone tab 500mg2endocet tab 5-325mg3QL 370nabumetone tab 750mg2endocet tab 7.5-3254QL 370naproxen dr tab 375mg2fentanyl ot loz 1200mcg5 PA, QL 180naproxen dr tab 500mg2fentanyl ot loz 1600mcg5 PA, QL 180naproxen sod tab 275mg2fentanyl ot loz 200mcg5 PA, QL 180naproxen sod tab 550mg2fentanyl ot loz 400mcg5 PA, QL 180naproxen sus 125/5ml2fentanylotloz600mcg5 PA, QL 180naproxen tab 250mg1fentanyl ot loz 800mcg5 PA, QL 180naproxen tab 375mg1hydroco/apapsol7.5-3254QL 5500naproxen tab 500mg1hydroco/apap tab 10-325mg3QL 370sulindac tab 150mg2hydroco/apap tab 5-325mg3QL 370sulindac tab 200mg2hydroco/apap tab 7.5-3253QL 370Opioid Analgesics, Long-ac
EnvisionRxPlus is PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. S7694_2017 CF H Accepted 9/26/16 ii What is the EnvisionRxPlus Comprehensive Formulary? A formulary is a list of covered drugs selected by EnvisionRxPlus in consultation with a team of health care providers, which represents the prescr
