DRUG FORMULARY DISCLAIMER
HPMS Approved Formulary File Submission ID 00021513
This formulary was updated on 04/25/2024. For more recent information or other questions, please contact us, PruittHealth Premier Member Services, at PruittHealthPremier.com.
2021 Part D Model Formulary (Abridged and Comprehensive) Note to existing members: This formulary has changed since last year. Please review the formulary search to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means PruittHealth Premier. When it refers to “plan” or “our plan,” it means PruittHealth Premier. 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 time during the year.
FAQ
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 List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:
• New generic drugs
We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the PruittHealth Premier Formulary?”
• Drugs removed from the market
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.
• Other changes
We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary; or add new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 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 30- day supply of the drug. – If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the PruittHealth Premier Formulary? Changes that will not affect you if you are currently taking the drug.
Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder 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 Drug List for the new benefit year for any changes to drugs. The enclosed formulary is current as of today’s date. To get updated information about the drugs covered by PruittHealth Premier, please contact us. The formulary will be updated and posted at the beginning of each month with the most current information.
How do I use the Formulary
There are two ways to find your drug within the formulary:
1. Medical Condition
The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular agents. If you know what your drug is used for, look for the category name. Then look under the category name for your drug.
2. Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index. 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 your drug.
What are generic drugs?
PruittHealth Premier covers both brand name drugs and generic drugs. A generic drug is approved 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. These requirements and limits may include:
• Prior Authorization: PruittHealth Premier requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from PruittHealth Premier before you fill your prescriptions. If you don’t get approval, PruittHealth Premier may not cover the drug.
• Quantity Limits: For certain drugs, PruittHealth Premier limits the amount of the drug that PruittHealth Premier will cover. For example, PruittHealth Premier provides 120 units per prescription for morphine sulfate 15mg er tables. This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, PruittHealth Premier requires 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, PruittHealth Premier may not cover Drug B unless you try Drug A first. If Drug A does not work for you, PruittHealth Premier will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy.
You can ask PruittHealth Premier to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the PruittHealth Premier’s formulary?”
• New generic drugs
We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the PruittHealth Premier Formulary?”
• Drugs removed from the market
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.
• Other changes
We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary; or add new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 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 30- day supply of the drug. – If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the PruittHealth Premier Formulary? Changes that will not affect you if you are currently taking the drug.
Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder 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 Drug List for the new benefit year for any changes to drugs. The enclosed formulary is current as of today’s date. To get updated information about the drugs covered by PruittHealth Premier, please contact us. The formulary will be updated and posted at the beginning of each month with the most current information.
What if my drug is not in the Formulary
If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.
If you learn that PruittHealth Premier does not cover your drug, you have two options:
1. You can ask Member Services for a list of similar drugs that are covered by PruittHealth Premier. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by PruittHealth Premier.
2. You can ask PruittHealth Premier to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to PruittHealth Premier Formulary?
You can ask PruittHealth Premier to make an exception to our coverage rules. There are several types 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 drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, PruittHealth Premier 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, PruittHealth Premier will only approve your request for an exception if the alternative drugs included on the plan’s formulary, [the lower cost-sharing 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. When you request a formulary you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision 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 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 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 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 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-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 and 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 while you pursue a formulary exception.
We will provide a one-time 31-day transition supply per drug, which will cover a temporary supply if you have a change in your medications due to a level-of-care change.
A level of care change may include:
• Entering or leaving an LTC facility
• Discharged from a hospital or home
• End a Medicare Part A skilled nursing facility stay
• Give up Hospice status and revert back to standard Medicare benefits
• End an LTC Facility stay and return to their home
For More Information
For more detailed information about your PruittHealth Premier prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about PruittHealth Premier, please contact us. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- MEDICARE (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.
PruittHealth Premier’s Formulary
The formulary below provides coverage information about the drugs covered by PruittHealth Premier. If you have trouble finding your drug in the list, go to the Index
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TIVICAY 10MG TAB) and generic drugs are listed in lower-case italics (e.g., zidovudine 100mg cap).
The information in the Requirements/Limits column tells you if PruittHealth Premier has any special requirements for coverage of your drug.
• First Fill Limited to one-month supply (FF): You may be able to receive greater than a 1-month supply of most of the drugs on your Formulary. Drugs noted with “FF” are limited to a 1-monthsupply for both Retail on your first fill only. After the first fill, an extended day supply would be available.
• Limited Distribution (LD): The symbol [LD] next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. The drug scan only be obtained at specialty designated pharmacies able to appropriately handle the drugs.
Non-Extended Day Supply (NDS): You may be able to receive greater than a 1-month supply of most of the drugs on your Formulary at a reduced cost share. Drugs noted with “NDS” are limited to a 1-month supply for both Retail.
• Prior Authorization (PA): The plan requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from The Plan before you fill your prescriptions. If you don’t get approval, The Plan may not cover the drug.
• Prior Authorization Restriction for Part B vs Part D Determination (PA_BvD): This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from The Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, The Plan may not cover this drug.
• Prior Authorization Restriction for New Starts Only (PA_NSO): If this drug is new to the member, you (or your physician) are required to get prior authorization from The Plan before you fill your prescription for this drug. Without prior approval, The Plan may not cover this drug.
• Quantity Limits (QL): For certain drugs, The Plan limits the amount of the drug that The Plan will cover. This could include a: per fill, daily, monthly, or yearly limitation.
• Step Therapy (ST): In some cases, The Plan requires 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, The Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, The Plan will then cover Drug B.
• Step Therapy for New Starts Only (ST_NSO): If this drug is new to the member, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
