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A "List of Covered Drugs" is also known as a Formulary or a Drug List. The prescription drugs on this list are selected by the plan in consultation with a team of physicians and pharmacists who represent the prescription therapies believed to be part of a quality treatment program. The Formulary or Drug List is updated regularly with updates posted monthly. New medicines are added as needed, and medicines that are deemed unsafe by the Food and Drug Administration (FDA) or a drug's manufacturer are immediately removed. The Formulary includes both brand-name and generic drugs, and must meet the requirements set by Medicare. Medicare has approved the plan's drug list. For more information about your drug coverage, please review your Evidence of Coverage.
The Formulary or drug list includes both brand-name and generic drugs. A generic drug is a prescription drug that has the same active ingredients as the brand-name drug. Generally it works just as well as the brand-name drug, but costs less. There are generic drug substitutes available for many brand-name drugs.
To find out or search if your prescription drug is covered, you have the following options.
You may locate drugs by name in the Online Formulary Search Tool. You can search for your prescribed medications by the name of the drug, therapeutic category, or drug class.
A complete list of covered prescription drugs is available. Memorial Hermann Advantage HMO members may now request to receive a printed Formulary in the mail. Please click here to complete the request form:
You may also select from the options below.
The preferred Diabetic Brands (Vendors) are Abbott and Roche. Abbott and Roche have a 0% coinsurance as the preferred/exclusive brands of glucometer & test strips. A 20% coinsurance is charged for all other Medicare-covered diabetic supplies. Please refer to your Evidence of Coverage for more information.
|Preferred Diabetic Brands (Vendors):||Part B Copay/Coinsurance|
|Abbott & Roche||0% coinsurance|
|All other Continuous Glucose Monitor brands/products of diabetic supplies||20% coinsurance|
Continuous Glucose Monitors (CGMs) are covered through your pharmacy benefit. Members are required to obtain a valid prescription from their provider. CGMs do not require a Prior Authorization. Preferred CGM brands are DexCom G6 and Freestyle Libre. All other CGMs are excluded. Please refer to your Evidence of Coverage for more information.
|Continuous Glucose Monitor Brands||Part B Copay/Coinsurance||Quantity Limit (QL) Restrictions|
|DexCom G6 Sensor||20% coinsurance||QL= 3 sensors/28 days|
|Dexcom G6 Transmitter||20% coinsurance||QL= 1 transmitter/90 days|
|DexCom G6 Sensor||20% coinsurance||QL= 1 receiver/year|
|Freestyle Libre 14 Day Sensor||20% coinsurance||QL= 2 sensors/28 days|
|Freestyle Libre Receiver||20% coinsurance||QL= 1 receiver/year|
|All other CGM brands/products||Member will pay Full Price||EXCLUDED - Not Covered|
The plan does not cover all prescription drugs. In some cases, Medicare does not allow any Medicare plan to cover certain types of drugs (for more information about this, refer to your Evidence of Coverage, in Chapter 5). In other cases, we have decided not to include a particular drug on the drug list if another comparable drug is available on our Formulary.
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these requirements to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which makes your drug coverage more affordable.
In general, our rules encourage you to get a drug that is safe and works for your medical condition. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.
Memorial Hermann Advantage requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescription(s). If you don't get approval, Memorial Hermann Advantage may not cover the drug.
In some cases, Memorial Hermann Advantage 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, Memorial Hermann Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.
You can also view the documents that explain our prior authorization and step therapy restrictions below.
If you like to get more information or assistance with any drugs on the formulary, a drug with any limitations or coverage rules, or would like to get a drug that is not listed on the formulary, please call Customer Service.
Generally, if you are taking a drug on our Formulary that was covered at the beginning of the year, we will not discontinue the drug or add new restrictions during the covered year except when a new, less-expensive generic drug becomes available, or if new information about the safety or effectiveness of a drug is released. Most of the changes in drug coverage happen at the beginning of each year (January 1). The Formulary may change during the year for the following reasons:
These changes to our Formulary are updated monthly. If your drug has these additional restrictions or limits, you can ask Memorial Hermann Advantage to make an exception to our coverage rules.
If a change impacts your current drug regimen, we will notify you of the Formulary change at least 30 days before the date that the change becomes effective. Your doctor will also be informed about this change, and we can work with you to find another drug for your condition. However, if the Food and Drug Administration (FDA) deems a drug on our Formulary to be unsafe, if the drug's manufacturer removes the drug from the market, or if a new generic drug replaces a brand name drug on the Drug List, we will immediately remove the drug from the Formulary and provide notice to members who take the drug. In nearly all cases, we must get Medicare approval for changes made to the Formulary.