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2009 Formularies
 Medicare Preferred Drug Formulary
Medicare Non-Preferred Drug Formulary
Earlier Formularies
2008 Medicare Preferred Drug Formulary
2008 Medicare Non-Preferred Drug Formulary
This section describes your prescription drug coverage as a member of our Plan. We will explain what a formulary is and how to use it, our drug management programs, how much you will pay when you fill a prescription for a covered drug, and what an Explanation of Benefits is and how to get copies.
What is a Formulary?
We have a formulary that lists all drugs that we cover. For 2009, we have included ALL covered Medicare Part D drugs in our formulary. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary; the prescription is filled through our preferred UPREHS Depot Drug Pharmacies or at a nonpreferred network retail pharmacy (30-day supply only), it is a covered Medicare Part D drug, and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on certain drugs. These requirements and limits are described in Section 4.
The drugs on the formulary are selected by Medicare and our Plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program and both brand name drugs and generic drugs are included on the formulary. 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 rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand name drugs.
We have included all Medicare Part D covered drugs on our formulary. In some cases, the law prohibits coverage of certain types of drugs. See Drug Exclusions, later in this section, for more information about the types of drugs that cannot be covered under a Medicare Prescription Drug Plan.
In certain situations, prescriptions filled at an out of network pharmacy may also be covered. See Section 1 for more information about filling prescription at out of network pharmacies.
The UPREHS Prime Medicare Plan includes some prescription drugs on our formulary that are not a Medicare Part D benefit. Our Formulary Book identifies those drugs for you. Those drugs must be obtained through the DEPOT DRUG MAIL. If you need your prescription filled urgently, you may have a one-time-only fill at a nonpreferred network retail pharmacy. Any additional refills must go through the DEPOT DRUG MAIL with the exception of certain specialty drugs obtained through the Ascend Specialty Drug Pharmacy. Ask your physician to write 2 prescriptions for you: a one-month supply to be filled at a nonpreferred network retail pharmacy and a long-term prescription to send to the DEPOT DRUG MAIL.
We offer some prescription drugs not covered by Medicare Part D. The copayment you pay when you fill a prescription for these drugs does not count towards the deductible that UPREHS pays for you, the Medicare portion of your initial coverage limit, or your total out of pocket costs (that is, the amount you pay does not help you with your $4,350 out of pocket costs or to qualify for catastrophic coverage). The portion of drug costs we pay for these drugs is applied to the extra benefit that we give you to enhance your initial coverage limit. Once that amount is used by you for either Medicare Part D covered drugs, or the additional drugs we offer to you, 100% of the cost for those drugs will be paid out of pocket by you.
HOW TO USE THE UPREHS PRIME MEDICARE PLAN FORMULARY BOOK
You have been sent a 2009 UPREHS Prime Medicare Plan Preferred Drug Formulary Book with all tier 1, 2 and 4 preferred formulary drugs listed. If the Part D drug is not in those tiers, it is in tier 3, nonpreferred formulary drugs. All covered Medicare Part D drugs are on your formulary including some drugs not covered by Medicare. Since a formulary can change at any time, if there is any question about drug coverage, you must call Customer Services for clarification at 1-800-547-0421. You can also get updated information about the drugs covered by us by visiting our Website at www.uphealth.com.
WHAT ARE DRUG TIERS?
Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your copayment depends on which drug tier your drug is in. The table below shows the copayment amount you pay for each tier when you are in your initial coverage period and when you obtain your prescription from the DEPOT DRUG MAIL, DEPOT DRUG Walk-In Pharmacies, Ascend Specialty Drug Pharmacy, or a nonpreferred network retail pharmacy. As you can see, your benefits are stretched through lower copayments and lower drug prices when you obtain your prescriptions from the DEPOT DRUG MAIL Pharmacy. We are able to pass our quantity discounts back to you in the form of expanded benefits, lower copayments, and lower charges for your drugs.
| 2009 30-Day Coinsurance/Copayment Amounts for Part D Drugs |
Tier 1
30-Day |
Tier 2
30-Day |
Tier 3
30-Day |
Tier 4
30-Day |
UPREHS Mail Order Pharmacy (DEPOT DRUG MAIL) - Preferred Pharmacy
$$$ Your Best Money Saver
30, 60, or 90-Day Supplies Available |
$5 |
$10 |
$40 |
Higher of $50 or 33% of drug cost |
Ascend Specialty Drug Mail Order Pharmacy - Preferred Pharmacy for self-injectable medications, and those for oncology (cancer) or transplant (not insulin)
$$$ Your Best Money Saver
30-Day Supply Available |
$5 |
$10 |
$40 |
Higher of $50 or 33% of drug cost |
UPREHS Depot Drug Walk-In Pharmacies - Preferred Pharmacies
$$$ Your Best Money Saver |
$10 |
$20 |
Higher of $50 or 33% of drug cost |
Higher of $100 or 33% of drug cost |
National Retail Pharmacy Network
Non-Preferred Pharmacies
30-day or less Supply Only |
$15 |
$30 |
Higher of $50 or 33% of drug cost |
Higher of $100 or 33% of drug cost |
Out-of-Network Pharmacy - Emergency Only
We pay you the UPREHS cost for the Part D drug minus your tier copay amount. You pay any charges above UPREHS cost. Non-Part D drugs are not covered. |
$15 |
$30 |
Higher of $50 or 33% of drug cost |
Higher of $100 or 33% of drug cost |
ALPHABETICAL DRUG LIST (ALPHABETICAL DRUG INDEX)
If you are not sure what Therapeutic category to look under, you should look for your drug in the Alphabetical Drug List. This is an alphabetical index providing a list of all of the drugs included in the Formulary. Both brand-name drugs and generic drugs are listed in the Alphabetical Drug List. Look in this list and find your drug alphabetically.
THERAPEUTIC DRUG LIST (MEDICAL CONDITION)
The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. This list is most often used by physicians to identify your formulary drugs. For example, drugs used to treat pain are listed under the category, Analgesics. Another example are 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 therapeutic drug category. Then look under the Drug Name for your drug.
| Last Updated: 01/21/2009 |
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