PHP, Florida

Robert Heglar
AHF Provider

Formulary

PHP (HMO SNP) uses a formulary (list of covered drugs).  The drugs that the plan covers are listed in the 2020 Comprehensive Formulary (effective November 1, 2020; last updated October 23, 2020) and the 2021 Comprehensive Formulary (effective January 1, 2021; last updated September 3, 2020).  You can also see the most current prescription drug prior authorization and step therapy criteria and any future formulary change notices on our Publications and Forms page.

The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists.  The list must meet requirements set by Medicare, which has approved our formulary.  The drugs on the formulary are only those covered under Medicare Part D.

PHP 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.  There are generic drug substitutes available for many brand name drugs.

Every drug in the formulary is in one of four cost-sharing tiers.  Look in the formulary to see in which tier your drug is in.

• Tier 1 includes preferred generic drugs
• Tier 2 includes preferred brand drugs
• Tier 3 includes non-preferred brand drugs
• Tier 4 includes specialty drugs
• Tier 5 includes select care drugs

For certain prescription drugs, special rules restrict how and when the plan covers them.  A team of doctors and pharmacists developed these rules to help members use drugs in the most effective ways.  These rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you get a drug that works for your medical condition and is safe and effective.  Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option.  We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

If there is a restriction for our drug, it usually means that you or your doctor will have to take extra steps in order for us to cover the drug.  These are the types of restrictions that may be placed on certain drugs.

• Restricting brand name drugs when a generic version is available.  When a generic version of a brand name drug is available, our network pharmacies will provide you with the generic.  We usually will not cover the brand name drug when a generic version is available.  If your provider has told us the medical reason that neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug.
• Getting plan approval in advance.  For certain drugs, you or your doctor need to get approval from the plan before we will agree to cover the drug for you.  This is called “prior authorization.”  Drugs that require prior authorization are noted as such in the formulary.
• Trying a different drug first.  This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug.  This requirement is called “step therapy.”  Drugs that have a step therapy are noted as such in the formulary.
• Quantity limits.  For certain drugs, we limit the amount of the drug that the plan will cover.  The plan may limit the number of refills you can get, or how much you can get each time you fill your prescription.  Drugs that have a quantity limit restriction are noted as such in the formulary.

If your drug is not on the formulary or is restricted, you can do one of the following:

• You may be able to get a temporary supply of the drug.  Only members in certain situations can get a temporary supply.  Read about the plan’s Transition Policy.  This will give you and your doctor time to change to another drug or to file an exception request.
• You can change to another drug.  Talk to you doctor about this.
• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

The formulary may change at any time.  You will receive notice when necessary.  For example, a drug can be added or removed from the formulary, moved to a higher or lower cost-sharing tier, have restrictions added or removed, or a brand replaced with a generic.  If you are affected by a change in the formulary, you will be notified in writing at least 60 days ahead of time so you and your provider can decide what to do.

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