Formulary (List of Covered Drugs)
The Network Health Insurance Corporation Pharmacy Formulary
A Formulary is a list of drugs selected by Network Health Insurance Corporation Pharmacy in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Network Health Insurance Corporation Pharmacy will generally cover the drugs listed in our Formulary as long as the drug is medically necessary, the prescription is filled at a Network Health Insurance Corporation Pharmacy's network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, or on any of the topics below, please review your Evidence of Coverage.
Network Health Insurance Corporation Pharmacy may add or remove drugs from our Formulary during the year. The enclosed Formulary is current as of October 1, 2006. If we remove drugs from our Formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify members who take the drug that it will be removed at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug.
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.
Keep up-to-date about the drugs covered by Network Health Insurance Corporation Pharmacy by visiting this website regularly, or call our Customer Services Department at 1-800-417-3380, 24-hours-a-day, seven-days-a-week. TTY/TDD users should call 1-800-899-2114.
How to use the Formulary
There are two ways to find your drug within the Formulary:
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 Medications.” If you know what your drug is used for, look for the category name in that list. Then look under the category name for your drug. |
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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. Next to your drug, you will see where you can find coverage information. Click on that link in the Index and find the name of your drug in the first column of the list. |
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Costs for Network Health Insurance Corporation Pharmacy Covered Drugs
If you qualified for extra help with your drug costs, your costs for your drugs may be different than those described below. Please refer to your Evidence of Coverage or call Customer Service to find out what your costs are.
The amount you pay depends on which drug tier your drug is in under our plan and whether you fill your prescription at a preferred network pharmacy. (You can find out which drug tier your drug is in by looking in the Formulary.)
As of 2007, you will no longer be responsible for the "gap" in coverage between your total drug cost of $2,250 and your total out-of-pocket expenses of $3,850. That means, you will generally pay just a $2 co-payment for generic or a preferred brand drug and $5 for all other drugs, or 5% coinsurance, whichever is greater.
You can ask Network Health Insurance Corporation Pharmacy to make an exception to your drug’s tier placement. See the section, “Requesting an exception to the Network Health Insurance Corporation Pharmacy's List of Covered Drugs,” for information about how to request an exception.
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Coverage Restrictions
Some covered drugs may have additional requirements or limits on coverage. Their requirements and limits may include:
- Prior Authorization: Network Health Insurance Corporation Pharmacy requires you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the Formulary or drugs that are not on the Formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval from Network Health Insurance Corporation Pharmacy before you fill your prescriptions. If you don’t get approval, Network Health Insurance Corporation Pharmacy may not cover the drug.
- Quantity Limits: For certain drugs, Network Health Insurance Corporation Pharmacy limits that amount of the drug that Network Health Insurance Corporation Pharmacy will cover. For example, Network Health Insurance Corporation Pharmacy provides four inhalers per prescription for albuterol. This may be in addition to a standard 30- or 90-day supply.
- Step Therapy: In some cases, Network Health Insurance Corporation Pharmacy 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, Network Health Insurance Corporation Pharmacy may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Network Health Insurance Corporation Pharmacy 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 ask Network Health Insurance Corporation Pharmacy to make an exception to these restrictions or limits. See the section, “Requesting an exception to the Network Health Insurance Corporation Pharmacy Formulary” for information about how to request an exception.
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What to do if your drugs are not on the Formulary
If your drug is not included in this Formulary, you should first contact Customer Service and ask if your drug is covered. If you learn that Network Health Insurance Corporation Pharmacy does not cover your drug, you have two options:
- You can ask Customer Service for a list of similar drugs that are covered by Network Health Insurance Corporation Pharmacy. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Network Health Insurance Corporation Pharmacy.
- You can ask Network Health Insurance Corporation Pharmacy to make an exception and cover your drug. See below for information about how to request an exception.
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Requesting an exception to the Network Health Insurance Corporation Formulary
- You can ask Network Health Insurance Corporation Pharmacy 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 your drug even if it is not on our Formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Network Health Insurance Corporation Pharmacy may limit 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 more.
- You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Non-Preferred Medication drug, you can ask us to cover it as a Formulary Preferred Brand instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our Formulary, you may not ask us to provide a higher level of coverage for the drug.
Generally, Network Health Insurance Corporation Pharmacy will only approve your request for an exception if the alternative drugs included on the plan’s Formulary, the low-tiered 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, tiering or utilization restriction exception. When you are requesting a Formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of your request.
Exception and appeals information for members
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Generic Drugs
Network Health Insurance Corporation Pharmacy covers both brand-name drugs and generic drugs. A generic drug has the same active-ingredient formula as the brand name drug. Generic drugs usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).
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Generic drugs are listed in lower-case italics (e.g., warfarin) within the
Formulary. Brand-name drugs are capitalized in the Formulary (e.g., SINGULAIR).
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Drug Utilization Management Quality Assurance and Medication Therapy Management Programs
Network Health Insurance Corporation Pharmacy utilizes a variety of programs to ensure that our beneficiaries receive the highest quality of care at an affordable price. These programs are developed and monitored by a committee of physicians and pharmacists from within our service area.
Drug Utilization Management
Our Drug Utilization Management program is designed to ensure an appropriate level of medication therapy for our beneficiaries. These methods include requiring:
- Prior Authorization to help determine if the medication is right for the beneficiary.
- Quantity limits to help ensure the medication is used in the right amount for the right length of time.
- Step Therapy to help ensure that the most cost effective medications are tried first.
Quality Assurance
Our Quality Assurance program is designed to reduce medication errors, adverse drug interactions and improve medication use. We make use of computer programs to check for potential problems such as drug interactions and allergies. We also require that our pharmacists perform a review of your medication therapy prior to dispensing your medications.
Medication Therapy Management
The Medication Therapy Management Program is designed to identify beneficiaries that may require extra help due to the complexity of their illnesses. Beneficiaries who meet certain criteria will be asked if they wish to participate in the program. Beneficiaries are not required to participate but we believe beneficiaries will find the program helpful.
Network Health Insurance Corporation Pharmacy’s Medication Therapy Management Program looks for members that meet three criteria:
- The beneficiary has three out of five of the following diseases: Diabetes, High Blood Pressure, Asthma/Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, High Cholesterol
- The beneficiary has filled seven or more maintenance medication in the last 90 days.
- The beneficiary is likely to incur an annual drug spend of at least $4,000 for all covered Part D drugs.
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For more information
For more detailed information about your Network Health Insurance Corporation Pharmacy prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Network Health Insurance Corporation Pharmacy, please call Customer Service at 1-800-378-5234, Monday, Wednesday, Thursday, and Friday, 8:00am – 5:00pm, and Tuesday, 8:00am – 4:00pm. TTY/TDD users should call 1-800-947-3529.
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/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.
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