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Download EM00042.07RX Plan B
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Prescription Plan B: Managed Formulary with Prior Authorization Your Prescription Drug Benefit HERE’S HOW TO USE YOUR PRESCRIPTION DRUG BENEFIT: • Your physician will use PacifiCare’s formulary when prescribing a drug for you. • If your doctor determines that a non-formulary drug is necessary, he or she will contact PacifiCare to seek authorization for coverage. Pharmacy services staff review each request to determine whether criteria are met and whether coverage of the non-formulary drug is appropriate. If so, PacifiCare covers the non-formulary drug. If coverage of the drug is not approved, you still have the option to purchase the prescription at full retail price. (Some examples of non-formulary drugs are Relafen, Ortho Novum, Prozac, Lipitor, Norvasc.) • A copayment is applied each time you have a prescription filled. The Colorado Health Plan Description Form for your specific benefits package includes information on the copayments required under your prescription drug benefit. Please refer to your Evidence of Coverage (EOC) Manual for specific exclusions and limitations to your benefit. (For example, drugs used for weight loss, such as, Meridia and drugs used for hair growth, such as, Propecia are benefit exclusions.) • NEW - NATIONAL PHARMACY NETWORK This new benefit allows you to obtain covered medications outside of Colorado. PacifiCare has contracted with some independent pharmacies and several national chains, such as Kmart, Rite Aid, Safeway, Target, Walgreen and Wal-Mart. For help in locating a participating pharmacy, call PacifiCare Customer Service at 800-877-9777 or search by city and state within the www.rxsolutions.com website. PacifiCare of Colorado members who have a pharmacy benefit have access to this National Pharmacy Network to fill prescriptions while outside of Colorado, but within the United States. Maintenance medications filled outside of Colorado will only be covered when processed online by a pharmacy in the National Pharmacy Network for up to a 30-day supply. Always present your ID card to the pharmacist so that you will pay the applicable copayment as designated on your ID card. All provisions of your pharmacy benefit will apply to prescriptions filled at these pharmacies. HOW DOES YOUR PRESCRIPTION DRUG BENEFIT WORK? Under your prescription drug benefit option, PacifiCare uses a managed formulary, meaning that any drug on the formulary prescribed by your physician is covered by PacifiCare. Drugs not on the formulary are not automatically covered. However, if your doctor believes a non-formulary drug is necessary, he or she can contact PacifiCare to obtain authorization. Pharmacy services staff review each request to determine whether criteria are met and whether coverage of the non-formulary drug is appropriate. Doctors can phone or fax a request. Requests are processed in an average of 10 minutes and always within two working days. We approve about 70 percent of our prior authorization requests. • Many of our plans require that a generic drug be dispensed when available. If you or your physician prefer a brand-name product rather than generic, you will pay the generic copayment amount plus the difference between the cost of the generic and brandname drugs. If your plan does not require payment of the cost difference between the generic and brandname drugs, you pay only the brand-name copayment. • Your prescription can be filled at any of our participating Colorado pharmacies. (Please see reverse side for further information.) The medications are listed alphabetically under common drug class groupings. In each group, the products that are available and dispensed as generic are listed first, followed by products that are only available and dispensed as brand name. Please keep the Prescription Medication Pocket Guide with you for future reference. Keep in mind that PacifiCare’s formulary is updated regularly and is subject to change. Medications will be added or deleted periodically. For a copy of the complete formulary, contact PacifiCare Customer Service at 1-800-877-9777, or go to the PacifiCare website at www .pacificare.com. SECOND FOLD (FOLD GUIDE IN HALF AGAIN) This Prescription Medication Pocket Guide lists the medications on PacifiCare’s formulary that are most commonly prescribed. It does not represent all medications available on the formulary. FIRST FOLD (FOLD GUIDE IN HALF) Please detach and fold the Prescription Medication Pocket Guide. For your convenience, carry the guide with you when you visit your physician or pharmacist. Prescription Medication Pocket Guide Effective Effective6/1/98 1/1/2001 Prescription Plan B: Managed Formulary with Prior Authorization Your Prescription Drug Benefit HOW DOES YOUR PRESCRIPTION DRUG BENEFIT WORK? (continued) Copayment amounts for your benefit plan can be found on your PacifiCare I.D. card. For more information about your plan, please refer to your Evidence of Coverage or call Customer Service at 1-800-877-9777. If you use long-term prescription drugs, such as, blood pressure medication, you can obtain extended supplies through PacifiCare’s mail order pharmacy. Most of our plans allow you to receive a 90-day supply of medication through mail order at a reduced copayment. Please see your Evidence of Coverage (EOC) Manual, Plan Brochure or call Prescription Solutions at 1-800-5626223 for more information. WHAT IS A FORMULARY? Quite simply, a formulary is a list of preferred or recommended drugs that have been carefully selected by physicians and pharmacists based on safety and effectiveness. WHAT DRUGS ARE INCLUDED ON THE FORMULARY? Approximately 95 percent of prescription drug classes are represented on PacifiCare’s formulary, including some generic and some brand-name drugs. WHO DECIDES WHAT THE FORMULARY INCLUDES? PacifiCare’s formulary is managed by a committee comprised of pharmacists and practicing doctors. The group meets quarterly to review clinical literature and information on the latest drugs on the market. This group selects drugs based on effectiveness, patient safety and cost-effectiveness. Both A-rated, brand equivalent generics and brand-name drugs are included on the formulary and all are approved by the federal Food and Drug Administration (FDA.) WHAT IS THE PURPOSE OF A FORMULARY? Prescription drug formularies are designed to help members get the prescriptions they need, affordably. In fact, hospitals, health plans and medical groups have used lists of preferred medications for more than 50 years to manage costs and to ensure that patients receive safe and effective drugs. Prescription drug costs have been rising sharply (and much faster than the rate of inflation) — about 15 percent to 20 percent per year. Using a formulary system allows us to continue to offer our members a comprehensive prescription drug benefit with affordable copayments. This information contains the major features of the outpatient prescription drug benefit and is not intended to replace the legal documents that contain the complete provisions of these benefits. Please refer to your Evidence of Coverage and Owner’s Manual for a complete description of this benefit, including applicable exclusions and limitations. CM-700-19703 EM00042.07 3/01 COMMONLY PRESCRIBED MEDICATIONS NOTE: GENERICS WILL BE DISPENSED FOR ALL MEDICATIONS LISTED IN ITALICS. ANTIBIOTICS GENERIC WILL BE DISPENSED Amoxicillin Ampicillin Bactrim Dynapen Erythromycin Keflex Pediazole Penicillin VK Tetracycline Vibramycin BRAND NAME WILL BE DISPENSED Augmentin Cefzil Cipro Zithromax ANTIDEPRESSANTS GENERIC WILL BE DISPENSED Elavil Desyrel Norpramin Pamelor BRAND NAME WILL BE DISPENSED Celexa Effexor Nardil Parnate Paxil Serzone ANTI-VIRAL GENERIC WILL BE DISPENSED Symmetrel Zovirax BRAND NAME WILL BE DISPENSED Combivir Crixivan Epivir Fortovase Hivid Invirase Norvir Rescriptor Retrovir Trizivir Videx Viracept Viramune Zerit ARTHRITIS AND PAIN MEDICATIONS GENERIC WILL BE DISPENSED Clinoril Disalcid Feldene Indocin Lodine Motrin Naprosyn Orudis Tolectin Trilisate Voltaren ASTHMA MEDICATIONS GENERIC WILL BE DISPENSED Metaprel Proventil, Ventolin BRAND NAME WILL BE DISPENSED Accolate Atrovent Maxair Serevent Vanceril, Beclovent CHOLESTEROL LOWERING MEDICATIONS GENERIC WILL BE DISPENSED Lopid Questran BRAND NAME WILL BE DISPENSED Baycol Niaspan Pravachol COUGH, COLD OR ALLERGY MEDICATIONS GENERIC WILL BE DISPENSED Atarax, Vistaril Entex LA Naldecon Phenergan Robitussin AC Rynatan Tavist Zephrex LA BRAND NAME WILL BE DISPENSED Allegra Claritin Flonase Polyhistine Rhinocort Vancenase, Beconase DIABETIC MEDICATIONS GENERIC WILL BE DISPENSED Diabinese Diabeta, Micronase Orinase Tolinase BRAND NAME WILL BE DISPENSED Glucophage Novolin, Humulin ESTROGEN REPLACEMENT MEDICATIONS GENERIC WILL BE DISPENSED Estrace Ortho-Est, Ogen BRAND NAME WILL BE DISPENSED Menest Premarin Premphase, Prempro Estraderm Vivelle HEART/BLOOD PRESSURE MEDICATIONS GENERIC WILL BE DISPENSED Aldomet Apresoline Calan, Isoptin Calan SR, Isoptin SR Cardizem Capoten Catapres Dilacor XR Hydrochlorothiazide Hytrin Inderal Lopressor Minipress Normodyne, Trandate Tenormin BRAND NAME WILL BE DISPENSED Adalat CC Cardura DynaCirc Lotensin Nitro-Dur Plendil Sular Tiazac Univasc Zestril MEDICATIONS FOR STOMACH AILMENTS GENERIC WILL BE DISPENSED Carafate Reglan Tagamet Zantac BRAND NAME WILL BE DISPENSED AcipHex(8 Wks.) Protonix(8 Wks.) MUSCLE RELAXANTS GENERIC WILL BE DISPENSED Flexeril Norflex Robaxin ORAL CONTRACEPTIVES BRAND NAME WILL BE DISPENSED Alesse Brevicon Demulen Desogen Jenest Lo/Ovral Mircette Nordette Norinyl Nor QD Ovral Tri-Norinyl Triphasil THYROID REPLACEMENTS BRAND NAME WILL BE DISPENSED Levoxyl Levothroid TRANQUILIZERS OR SLEEPING MEDICATIONS GENERIC WILL BE DISPENSED Ativan Dalmane Halcion Librium Restoril Serax Valium Xanax All oral chemotherapy agents are covered, with the exception of brand-name drugs where a generic equivalent is available.
