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Group Health Incorporated (GHI)
Prescription Drug Plan
2007 High Performance Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
Note to existing members
: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
This document includes GHI Medicare Prescription Drug Plan’s partial formulary as of January 1, 2007. For a complete, updated formulary, please visit our Web site at www.ghi.com or call 1-800-585-5786, 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-899-2114.
What is the GHI Medicare Prescription Drug Plan High Performance Formulary?
A formulary is a list of covered drugs selected by GHI Medicare Prescription Drug Plan 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. GHI Medicare Prescription Drug Plan will generally cover the drugs listed in our
formulary as long as the drug is medically necessary, the prescription is filled at a GHI Medicare Prescription
Drug Plan network pharmacy, and other plan rules are followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
This document is a partial formulary and includes only some of the drugs covered by GHI Medicare
Prescription Drug Plan. For a complete listing of all prescription drugs covered by GHI Medicare Prescription
Drug Plan’s formulary, please visit our Web site at www.ghi.com or call 1-800-585-5786, 24 hours a day, 7
days a week. TTY/TDD users should call 1-800-899-2114.
Can the Formulary change?
Generally, if you are taking a drug on our 2006 formulary that was covered at the beginning of the year, we will
not discontinue or reduce coverage of the drug during the 2007 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness of
a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued access
for the remainder of the coverage year to the formulary drugs that were available when you chose our plan,
except for cases in which you can save additional money or improve the safety of your drugs.
If we remove drugs from our formulary, or 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 affected members of the change at least 60 days before 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. The enclosed formulary is current as of January 1, 2007. To get updated information about the drugs covered by GHI Medicare Prescription Drug Plan, please visit our Web site at www.ghi.com or call Customer Service at 1-800-585-5786, 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-899-2114.
How do I use the Formulary?
There are two ways to find your drug within the formulary: Medical Condition
The formulary begins on page 7. 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 the list that begins on page 7. Then look under the category name for your drug.
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 35. 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 the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
GHI Medicare Prescription Drug Plan covers both brand-name drugs and generic drugs. A generic drug has the same active-ingredient as the brand name drug. Generic drugs usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
• Prior Authorization:
GHI Medicare Prescription Drug Plan requires you and/or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from GHI Medicare Prescription Drug Plan before you fill your prescriptions. If you don’t get approval, GHI Medicare Prescription Drug Plan may not cover the drug.
• Quantity Limits:
For certain drugs, GHI Medicare Prescription Drug Plan limits the amount of the drug
that GHI Medicare Prescription Drug Plan will cover. For example, GHI Medicare Prescription Drug Plan provides 90 tablets per 90-day supply prescription for Crestor® 40 mg. This may be in addition to a standard one-month or three-month supply.
• Step Therapy:
In some cases, GHI Medicare Prescription Drug Plan 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, GHI Medicare Prescription Drug Plan may not cover drug B unless you try Drug A first. If Drug A does not work for you, GHI Medicare Prescription Drug Plan will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can ask GHI Medicare Prescription Drug Plan to make an exception to these restrictions or limits. See the section, “How do I request an exception to the GHI Medicare Prescription Drug Plan formulary?” on page 4 for information about how to request an exception.
What if my drug is 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. This document includes only a partial list of covered drugs, so GHI Medicare Prescription Drug Plan
may cover your drug. You can contact Customer Service at 1-800-585-5786, 24 hours a day, 7 days a week.
TTY/TDD users should call 1-800-899-2114.
If you learn that GHI Medicare Prescription Drug Plan does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by GHI Medicare Prescription
Drug Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by GHI Medicare Prescription Drug Plan.
• You can ask GHI Medicare Prescription Drug Plan to make an exception and cover your drug. See
below for information about how to request an exception.
NOTE: Due to a change in Medicare, most Medicare Drug Plans will no longer cover erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra, and Caverject starting January 1, 2007. Call your Medicare Drug Plan for more information.
How do I request an exception to the GHI Medicare Prescription Drug
You can ask GHI Medicare Prescription Drug Plan 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,
GHI Medicare Prescription Drug Plan limits 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.
Generally, GHI Medicare Prescription Drug Plan will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, 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, or utilization restriction
exception. When you are requesting a formulary, 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 getting your prescribing physician’s supporting statement. You can request an expedited (fast)
exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for
a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we
get your prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may
be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior
authorization from us before you can fill your prescription. You should talk to your doctor to decide if you
should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the
drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your
drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a
temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will cover a
temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more
than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on
our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in
our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days)
while you pursue a formulary exception.
In addition to circumstances impacting new enrollees who may enter a plan with a medication list that contains
non-formulary Part D drugs, other circumstances exist in which unplanned transitions for current enrollees
could arise and in which prescribed drug regimens may not be on GHI Medicare Prescription Drug Plan’s
formulary. These circumstances usually involve level of care changes in which you are changing from one
treatment setting to another. The exception and appeals process takes into account these special circumstances
(i.e. level of care changes) to ensure that you have access to medications in these circumstances. An example of
this special circumstance would include when you are discharged from a hospital.
For more information
For more detailed information about your GHI Medicare Prescription Drug Plan’s prescription drug coverage,
please review your Evidence of Coverage and other plan materials.
If you have questions about GHI Medicare Prescription Drug Plan, please call Customer Service at 1-800-585-
5786, 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-899-2114.) Or visit www.ghi.com.
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,
GHI Medicare Prescription Drug Plan’s Formulary
The formulary than begins on page 7 provides coverage information about some of the drugs covered by GHI
Medicare Prescription Drug Plan. If you have trouble finding your drug in the list, turn to the Index that begins
on page 35. Remember: This is only a partial list of drugs covered by GHI Medicare Prescription Drug Plan. If
your prescription is not in this partial formulary, please visit our Web site at www.ghi.com or call Customer
Service at 1-800-585-5786, 24 hours a day, 7 days a week. TTY/TDD users should call 1-800-899-2114 for
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., PREVACID®) and
generic drugs are listed in lower-case italics (e.g., omeprazole
2007 MEDICARE HIGH PERFORMANCE (Closed)
PAR indicates that prior authorization may apply.
QLL indicates that quantities dispensed may be limited.
ST indicates that step therapy may apply.
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