Citrus :: Part D

Citrus Part D - FAQs

WHAT IS THE CITRUS HEALTH CARE FORMULARY?

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A formulary is a list of covered drugs selected by Citrus Health Care 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. Citrus Health Care will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Citrus Health Care network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

WHAT ARE DRUG TIERS?

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Drugs on our formulary are organized into different drug tiers, or groups of different drug types. The amount you pay for each prescription depends on which drug tier your medication is in. The higher the tier the higher the cost-sharing will be.

CAN THE FORMULARY CHANGE?

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Generally, if you are taking a drug on our 2009 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2009 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 we can ensure your safety. 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 01/01/2009. To get updated information about the drugs covered by Citrus Health Care, please visit our Web site at www.citrushc.com or call Member Services at 1 -800-546-5677, 24 hours a day, seven days a week. TTY/TDD users should call 1-866-706-4757.

HOW CAN I REQUEST AN EXCEPTION TO THE FORMULARY?

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You can ask Citrus Health Care 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, Citrus Health Care limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limits and cover more.
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier subject to the tiering exceptions process instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.

Generally, Citrus Health Care will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug 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, tiering or utilization restriction exception. When you are requesting a formulary, tiering 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.

ARE THERE ANY RESTRICTIONS ON MY COVERAGE?

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Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: Citrus Health Care requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Citrus Health Care before you fill your prescriptions. If you don’t get approval, Citrus Health Care may not cover the drug.
Quantity Limits: For certain drugs, Citrus Health Care limits the amount of the drug that Citrus Health Care will cover. For example, Citrus Health Care provides six tablets per month per prescription for Zomig. This may be in addition to a standard one month or three month supply.
Step Therapy:In some cases, Citrus Health Care requires you to first try certaindrugs 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, Citrus Health Care may not cover drug B unless you try Drug A first. If Drug A does not work for you, Citrus Health Care will then cover Drug B.

Citrus Health Care requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Citrus Health Care before you fill your prescriptions. If you don’t get approval, Citrus Health Care may not cover the drug.

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 Citrus Health Care to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Citrus Health Care formulary?” on page 4 for information about how to request an exception.

HOW DO I USE THE FORMULARY?

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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 AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page number 72. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 72. 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?

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Citrus Health Care covers both brand -name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

HOW DO I USE THE FORMULARY?

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If your drug is not included in this formulary, you should first contact Member Services and ask if your drug is covered. If you learn that Citrus Health Care does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Citrus Health Care. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Citrus Health Care.
You can ask Citrus Health Care to make an exception and cover your drug. See below for information about how to request an exception.

WHAT IF MY DRUG IS NOT ON THE FORMULARY?

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The charts in this booklet list some important drug benefits. You can use this Summary of Benefits to compare the benefits offered by Citrus Part D and Citrus Part D Plus to the benefits offered by other Medicare Prescription Drug Plans or Medicare Advantage Plans with prescription drug coverage.

WHERE IS CITRUS Part D AND CITRS PART D PLUS AVAILABLE?

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The service area for this plan includes: All counties in the State of Florida. You must live in one of these areas to join this plan.

WHO IS ELIGIBLE TO JOIN?

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You can join this plan if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and live in the service area. Eligible individuals may only enroll in one Medicare Prescription Drug Plan at a time and may not be enrolled in a Medicare Advantage Plan (HMO, PPO), unless they are a member of Medicare Private-Fee-For-Services plan or are enrolled in an 1876 Cost Plan.

DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?

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Citrus Part D and Citrus Part D Plus does not cover drugs that are covered under Medicare Part B as prescribed and dispensed. Generally, we only cover drugs, vaccines, biological products and medical supplies that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our formulary.

WHERE CAN I GET MY PRESCRIPTIONS?

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Citrus Part D and Citrus Part D Plus has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We will not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases.The pharmacies in our network can change at any time. You can ask for a Pharmacy Directory or call Customer Service for an up-todate list.

WHAT IS A PRESCRIPTION DRUG FORMULARY?

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Citrus Part D and Citrus Part D Plus uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at www. citrushc.com. If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

WHAT SHOULD I DO IF I HAVE OTHER INSURANCE IN ADDITION TO MEDICARE?

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If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage, you must contact your Medigap Issuer to let them know that you have joined a Medicare Prescription Drug Plan. If you decide to keep your current Medigap supplement policy, your Medigap Issuer will remove the prescription drug coverage portion of your policy. This will occur as of the effective date of your coverage in the Medicare Prescription Drug Plan and they will adjust your premium. Call your Medigap Issuer for details.If you or your spouse has, or is able to get, employer group coverage, you should talk to your employer to find out how your benefits will be affected if you join Citrus Part D and Citrus Part D Plus. Get this information before you decide to enroll in this plan.

HOW CAN I GET HELP WITH MY DRUG PLAN COSTS?

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If you qualify for extra help with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join Citrus Part D and Citrus Part D Plus, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you are not getting this extra help you can see if you qualify by calling 1-800-MEDICARE (1-800-633-4227). TTY/TTD users should call 1-877-486-2048.

WHAT ARE MY PROTECTIONS IN THIS PLAN?

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All Medicare Prescription Drug Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare prescription drug coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

As a member of Citrus Part D and Citrus Part D Plus, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.

WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM?

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A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected.

3/17/2010