Revised October 2015
`
`How Medicare Prescription Drug Plans & Medicare
`Advantage Plans with Prescription Drug Coverage
`(MA-PDs) Use Pharmacies, Formularies, & Common
`Coverage Rules
`
`Each Medicare Prescription Drug Plan and Medicare Advantage Plan with
`prescription drug coverage (MA-PD) must give at least a standard level of
`coverage set by Medicare. Plans can vary on which pharmacies they use, which
`prescription drugs they cover, and how much they charge. Plans design their
`prescription drug coverage using different methods, like:
`• Network pharmacies
`• List of covered prescription drugs (formulary)
`• Coverage rules
`In this fact sheet, the term “Medicare drug plans” includes both Medicare
`Prescription Drug Plans and MA-PDs.
`
`Network pharmacies
`Medicare drug plans have contracts with pharmacies that are part of the plan’s
`“network.” If you go to a pharmacy that isn’t in your plan’s network, your plan
`may not cover your drugs. Along with retail pharmacies, your plan’s network
`may include preferred pharmacies, a mail-order program, and a 60- or 90-day
`retail pharmacy program.
`• Preferred pharmacies
`If your plan has preferred pharmacies, you may save money by using them.
`Your prescription drug costs (like a copayment or coinsurance) may be less at a
`preferred pharmacy because it has agreed with your plan to charge less.
`• Mail-order programs
`Some plans may offer a mail-order program that allows you to get up to a
`90-day supply of your covered prescription drugs sent directly to your home.
`This may be a cost-effective and convenient way to fill prescriptions you take
`every day.
`• 60- or 90-day retail pharmacy programs
`Some retail pharmacies may also offer a 60- or 90-day supply of covered
`prescription drugs.
`
`Medac Exhibit 2076
`Frontier Therapeutics v. Medac
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`List of covered prescription drugs (formulary)
`Each Medicare drug plan has a list of prescription drugs (called a formulary)
`that it covers. Plans cover both generic and brand-name prescription drugs.
`The formulary must include a range of drugs in the most commonly prescribed
`categories and classes. This helps make sure that people with different medical
`conditions can get the prescription drugs they need. The formulary might not
`include your specific drug. However, in most cases, a similar drug should be
`available. If you or your prescriber (your doctor or other health care provider who’s
`legally allowed to write prescriptions) believes none of the drugs on your plan’s
`formulary will work for your condition, you can ask for an exception. See page 5
`for more information on filing for an exception.
`If your plan removes a drug you’re taking from its formulary, in most cases, it
`must notify you at least 60 days in advance. You may have to change to another
`drug (that’s similar to the one you’re taking) on the plan’s formulary or pay more
`to keep taking the drug. You can ask for an exception to continue using the drug
`that’s being removed from your plan’s drug list if none of the other drugs on the
`list will work for your condition. In some cases, if you’re actively taking a drug on
`the formulary during the calendar year, you can continue taking that drug until the
`end of the year without paying more.
`Note: A plan isn’t required to tell you in advance when it removes a drug from
`its formulary if the Food and Drug Administration (FDA) takes the drug off the
`market for safety reasons, but your plan will let you know afterward.
`Generally, using drugs on your plan’s formulary will save you money. Using
`generics instead of brand-name drugs can also save you money.
`
`• Generic drugs
`According to the FDA, generic drugs are the same as brand-name drugs in
`safety, strength, quality, the way they work, how they’re taken, and the way they
`should be used. Generic prescription drugs use the same active ingredients as
`brand-name prescription drugs and work the same way. Generic prescription
`drug makers must prove to the FDA that their product works the same way as
`the brand-name prescription drug. Today, almost half of all prescriptions are
`filled with generics. In some cases, there may not be a generic prescription drug
`available for the brand-name prescription drug you take. Talk to your prescriber.
`
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`List of covered prescription drugs (formulary) (continued)
`• Tiers
`Many Medicare drug plans place drugs into different “tiers.” Drugs in each tier
`have a different cost. Some plans may have more tiers and some may have less.
`
`Example of drug plan tiers
`
`Tier
`1
`
`2
`
`3
`
`You pay
`Lowest copayment
`
`What’s covered?
`Most generic prescription drugs
`
`Medium copayment
`
`Preferred, brand-name prescription
`drugs
`
`Higher copayment
`
`Non-preferred, brand-name
`prescription drugs
`
`Specialty
`tier
`
`Highest copayment
`or coinsurance
`
`Unique, very high cost
`prescription drugs
`
`In some cases, if your drug is in a higher (more expensive) tier and your prescriber
`thinks you need that drug instead of a similar drug on a lower tier, you can file
`an exception and ask your plan for a lower copayment. See page 5 for more
`information on filing for an exception.
`Remember, the table above is only an example—your plan’s tier structure may be
`different.
`
`Coverage rules
`Plans may have coverage rules to make sure certain drugs are used correctly and
`only when medically necessary. These rules may include prior authorization, step
`therapy, and quantity limits as described below and on page 4.
`• Prior authorization
`Plans may require a “prior authorization” to make sure certain prescription drugs
`are used correctly and that only when medically necessary. This means before
`your plan will cover a certain drug, your prescriber must first contact your plan
`and show there’s a medically necessary reason why you must use that particular
`prescription drug.
`
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`Coverage rules (continued)
`Step therapy
`Step therapy is a type of prior authorization. With step therapy, in most cases,
`you must first try certain less expensive drugs that are also approved for use
`for your condition before you can move up a “step” to a more expensive drug.
`For example, your plan may require you to first try a generic prescription
`drug (if available), then a less expensive brand-name prescription drug on
`its formulary, before it will cover a similar, more expensive brand-name
`prescription drug.
`However, if you’ve already tried the similar, less expensive drugs and they
`didn’t work, or if your prescriber believes your medical condition makes
`it medically necessary for you to be on the more expensive step therapy
`prescription drug, he or she can contact your plan to ask for an exception.
`See page 5 for more information on filing for an exception. If your prescriber’s
`request is approved, your plan will cover the step therapy prescription drug.
`
`Example of step therapy
`Step 1—Dr. Smith wants to prescribe a new sleeping pill to treat Mr. Mason’s
`occasional insomnia. There’s more than one type of sleeping pill available.
`Some of the drugs Dr. Smith considers prescribing are brand-name only
`prescription drugs. The plan rules require Mr. Mason to try a generic
`prescription drug first. For most people, the generic sleeping pill the plan wants
`Mr. Mason to try is also approved for use for Mr. Mason’s condition as well as
`brand-name sleeping pills.
`Step 2—If Mr. Mason takes the generic sleeping pill but has side effects,
`Dr. Smith can use that information to ask the plan to approve a brand-name
`drug. If approved, Mr. Mason’s Medicare drug plan will cover the brand-name
`drug for Mr. Mason.
`
`• Quantity limits
`For safety and cost reasons, plans may limit the amount of prescription drugs
`they cover over a certain period of time. For example, most people who are
`prescribed a heartburn medication take 1 capsule per day for 4 weeks. Therefore,
`a plan may cover only an initial 30-day supply of the heartburn medication.
`If you need more, you may need your prescriber’s help to provide more
`information to the plan.
`
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`What if my plan won’t cover a prescription drug I need?
`If you belong to a Medicare drug plan, you have the right to:
`• Get a written explanation (called a “coverage determination”) from your
`Medicare drug plan if your plan won’t cover or pay for a certain prescription
`drug you need, or if you’re asked to pay a higher share of the cost.
`• Ask your Medicare drug plan for an exception (which is a type of coverage
`determination). If you ask for an exception, your doctor or other prescriber must
`give your drug plan a supporting statement that explains the medical reason for
`the request (like why similar drugs covered by your plan won’t work or may be
`harmful to you). You can ask for an exception if:
`– You or your prescriber believes you need a drug that isn’t on your drug plan’s
` formulary.
`– You or your prescriber believes that a coverage rule (like step therapy)
` should be waived.
`– You believe you should get a non-preferred drug at a lower copayment
` because you can’t take any of the alternative drugs on your drug plan’s list of
` preferred drugs.
`You or your prescriber must contact your plan to ask for a coverage determination.
`If your network pharmacy can’t fill a prescription as written, the pharmacist will
`give or show you a notice that explains how to contact your Medicare drug plan so
`you can make your request.
`A standard request for a coverage determination (including an exception) should
`be made in writing (unless your plan accepts requests by phone). You or your
`prescriber can also call or write your plan for an expedited (fast) request.
`If you disagree with your Medicare drug plan’s coverage determination or
`exception decision, you have the right to appeal the decision. Your plan’s written
`decision will explain how to file an appeal. You should read this decision carefully,
`and call your plan if you have questions.
`For more information on Medicare appeal rights, visit Medicare.gov/appeals.
`You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call
`1-877-486-2048.
`
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`Where can I go for more information?
`• Contact your Medicare drug plan. The contact information is in your member
`materials or on your membership card.
`• Read the “Medicare & You” handbook. It includes information about Medicare
`drug plans in your area. You can view or print the handbook at
`Medicare.gov/publications.
`• Visit the Medicare Plan Finder at Medicare.gov/find-a-plan. The Medicare Plan
`Finder allows you to search for and compare coverage options available in your
`area.
`• Read the “Your Guide to Medicare Prescription Drug Coverage” booklet. You can
`view or print the booklet at Medicare.gov/publications.
`• Call your State Health Insurance Assistance Program. Visit shiptacenter.org or call
`1-800-MEDICARE (1-800-633-4227) for their phone number. TTY users should
`call 1-877-486-2048.
`• Call 1-800-MEDICARE.
`
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`Notes
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`Notes
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`
` CIVIS
`
`CENTERS FOR MEDKJRE & MEDICAID SERVICES
`
`CMS Product No. 11136
`CMS Product No. 11136
`
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