Elevate Medicare Advantage Pharmacy

Formulary

The Denver Health Medical Plan (DHMP) formulary is a preferred list of drugs selected to meet the needs of Medicare members.

DHMP may add or remove drugs from the formulary during the year. If we remove drugs from our formulary, or add prior authorization, quantity limits and /or move a drug at a higher cost sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. 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. Please refer to the transition process for more information.

DHMP Medicare covers both name brand 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.

Utilization Management

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 our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. For more information about these requirements and limits, please consult your copy of our formulary or the formulary on our website.

These requirements and limits may include:

• Prior Authorization: DHMP requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from DHMP before you fill your prescriptions. If you don’t get approval, DHMP may not cover the drug.
• Quantity Limits: For certain drugs, DHMP limits the amount of the drug that will be covered. For example, DHMP provides 90 capsules per 30-day prescription for Pregabalin (Lyrica). This may be in addition to a standard one month or three month supply.
• Step Therapy: In some cases, DHMP 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, DHMP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, DHMP, will then cover Drug B.
• Generic Substitution: Generally, a “generic” drug works the same as a brand name drug and usually costs less. In most cases, when a generic version of a brand name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that the generic drug will not work for you and we have approved this request, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)

Drug Utilization Review

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs. We do a review each time you fill a prescription. We also review our records on a regular basis.

During these reviews, we look for potential problems such as:

• Possible medication errors
• Drugs that may not be necessary because you are taking another drug to treat the same medical condition
• Drugs that may not be safe or appropriate because of your age or gender
• Certain combinations of drugs that could harm you if taken at the same time
• Prescriptions written for drugs that have ingredients you are allergic to
• Possible errors in the amount (dosage) of a drug you are taking
• If we see a possible problem in your use of medications, we will work with your provider to correct the problem.

Out-of-Network Coverage

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy.

Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• Prescriptions you get in connection with covered emergency care up to a 10-day supply.
• Prescriptions you get in connection with covered urgently needed care when network providers are not available up to a 10-day supply.

The pharmacy network may change at any time. You will receive notice when necessary.

In these situations, please check first with Health Plan Services to see if there is a network pharmacy nearby. How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 7, Section 2.1 in your Evidence of Coverage explains how to ask the plan to pay you back.)

Medication Therapy management (MTM) program

The Medication Therapy Management Programs can help individuals with special situations, such as individuals who:

• have complex medical conditions
• need to take many drugs at the same time
• have very high drug costs

These programs are voluntary and free to members. A team of pharmacists and doctors developed the programs for us. The MTM programs can help make sure that our members are using the drugs that work best to treat their medical conditions and help us identify possible medication errors.

If we have a program that fits your needs, we will automatically enroll you in the program and send you information. If you decide not to participate, please notify us and we will withdraw you from the program. If you have any questions about these programs, please contact Health Plan Services.