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HealthPlus Drug Formularies

The HealthPlus Pharmacy Center provides valuable information related to drug formularies .

HealthPlus Commercial/MedicarePlus Drug Formulary 

This formulary applies to Commercial employer groups, Third Party Administrator (TPA) plans, Point of Service (POS), Preferred Provider Organization (PPO), supplemental Medicare, and Medicare Retiree Drug Subsidy (RDS) members.

This is an open formulary with restrictions, where formulary and non-formulary medications are covered, but some medications may require administration of restrictions, through the standard step therapy or prior authorization  process. A generic mandate applies, where HealthPlus covers the generic product when a drug is available in generic form.

A HealthPlus member has the option to receive a brand name medication instead of the generic, but is responsible for the difference in cost between the brand name and generic drug, plus the usual copay.

To ensure that members never go without medication, pharmacies may dispense a starter dose, for up to a seven-day supply, for any medication that requires prior authorization.

HealthPlus Three Tier Drug Formulary 

This formulary applies to specific Commercial/PPO/Medicare RDS groups who have opted for a three-tier copay benefit. The three-tier drug formulary is identical to the Commercial drug formulary (an open formulary with restrictions and a generic mandate), but the copay tiers are customized to incentivize the use of generic or formulary brand drugs, as described below:

DRUG TYPE

COPAY TIER

COPAY

Generic medications

Tier 1

Lowest copay

Formulary brand medications

Tier 2

Medium copay

Non-formulary brand medications

Tier 3

Highest copay


 HealthPlus MedicarePlus Advantage Part D Formulary  

The HealthPlus MedicarePlus Part D drug formulary is an open formulary with restrictions administered through step therapy or prior authorization.

The Part D drug formulary is structured according to Centers for Medicare and Medicaid Services  (CMS) guidelines. CMS dictates the categories that must be included or excluded from the formulary.

Based upon CMS guidelines, a member may choose to receive a brand drug when a generic drug is available. However, if the member chooses to receive the brand drug, the member is not responsible for the difference in cost, although the brand drug may fall into a higher copay tier.

Formulary tiers are described below:

DRUG TYPE

COPAY TIER

COPAY

Generic medications

Tier 1

Lowest copay

Preferred brand medications

Tier 2

Medium copay

Non-preferred brand medications

Tier 3

Highest copay

Specialty

Tier 4

25% coinsurance

Medicare Part D Program – Vaccine Administration 

Because covered Part D vaccines must be reported to CMS as part of the member’s drug benefit, Medicare members may obtain Part D vaccines from their local pharmacy. Many pharmacies are licensed to administer vaccines and can bill for both the vaccine and the administration fee associated with the injection provided. True Out- of-Pocket  (TrOOP) and Total Drug Spend (TDS) amounts are updated on-line ,in real time, when vaccines are dispensed and administered through the pharmacy.

As an option, at the physician’s discretion, members may also obtain Part D vaccines from their physician’s office. In this case, the provider must charge the member for the vaccine and the administration fee. The member is then responsible for submitting a request for reimbursement to HealthPlus.

Reimbursement to the member is at a standard amount, established by HealthPlus, for the specific vaccine and administration fee. Reimbursement is not based upon the provider’s charges.

NOTE:   Updates to the member’s TrOOP and TDS accumulators may be significantly delayed if vaccines are delivered and/or administered through the physician’s office (due to a potential delay in the billing process, on the medical side).

NOTE:   There are no changes to rules or reimbursement for Part B covered vaccines. An abridged list of Part D and Part B vaccines is available on the HealthPlus website.  

HealthPlus Signature PPO Closed Formulary 

This is a closed formulary that applies to HealthPlus Signature Plan  members who have purchased the associated prescription drug rider. A generic mandate applies, when HealthPlus covers a generic product and the drug is available in the generic.

A member may receive a brand name medication instead of a generic, but is responsible for the difference in cost between the brand and generic drug, plus the usual copay. Medications that are not on the formulary are not covered. Step therapy and prior authorization  also apply. Providers may request non-formulary medications through the HealthPlus Exceptions Process.

For more information about the HealthPlus drug formularies, please contact the HealthPlus Pharmacy Department at (810) 230-2118 or at rx@healthplus.org.

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