2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

PharmacyCatastrophic coverage: Coverage begins afterthe beneficiary expends the CMS set amount(specified yearly) of their own money. Thebeneficiary will then pay reduced co-pays orco-insurance until the end of the contract year.Additional assistance is available for qualifyingbeneficiaries with low incomes and limited assets.Assistance is based on income limits. Beneficiariesmay contact the Presbyterian Customer ServiceCenter at 505-923-6060 or 1-800797-5343 forinformation and forms.Presbyterian Senior Care (HMO) andPresbyterian MediCare (PPO)The following is Presbyterian’s Medicareprescription co-pay structure:Tier 1: Preferred Generic DrugsTier 2: Non-Preferred GenericsTier 3: Preferred Brand-Name DrugsTier 4: Non-Preferred Brand/Generic DrugsTier 5: Specialty PharmaceuticalsThe beneficiary’s out-of-pocket expenses arelowest when filling prescriptions for preferredgeneric drugs (Tier 1) and preferred brand namedrugs (Tier 3). They are highest when prescriptionsfor non-preferred (Tier 2 and Tier 4) drugs areobtained. Specialty pharmaceuticals (Tier 5) arespecialized medications and may be required to beobtained through our designated specialtypharmacy vendor. Some medications may requireprior authorization. The complete Formulary,Pharmacy Prior Authorization forms, SpecialtyPharmaceutical Listing, and Specialty DrugRequest forms are available on the pharmacy pageat https://www.phs.org/providers/cliniciansresources/Pages/pharmacy-resources.aspx.Specialty pharmaceuticals are not available throughmail order and must be obtained through ourspecialty pharmaceutical vendor.Mandatory Generic Substitution RequirementSubstitution of generic products is mandatory whenan FDA-AB rated generic is available.Specific Limitations and ExclusionsQuantity limitations as well as specific exclusionsapply. Examples of exclusions are medicationsused for cosmetic purposes. Please refer tomember-specific materials for a listing of limitationsand exclusions.Medicare Formulary RequirementsFormularies must be approved by the CMS.Formularies must be developed by the Pharmacyand Therapeutics (P&T) Committee.Drugs may be added to or deleted from theformulary at any time during the plan year.Members and practitioners are notified if drugs areremoved from the formulary, if tier placementchanges, or if the criteria change.Beneficiaries are allowed to obtain a transitionsupply of their current non-formulary drug whenthey enroll in a Part D plan or move from one PartD plan to another. This transition fill allows newbeneficiaries sufficient time to establish with thenew practitioner to switch to a formulary alternativeor initiate the prior authorization process.8-62014 Practitioner and Provider Manual - Ver. 3