Formulary Information and Search Tools

Formulary Information and Search Tools

What Is a Drug List (Formulary)?

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.

What Does the Drug List (Formulary) Include?

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.

What is new for 2023?

The following plans (Memorial Hermann Advantage HMO, Memorial Hermann Advantage Plus HMO, and Memorial Hermann Advantage Golden Triangle HMO) participate in the new Select Insulin Savings Program. Select Insulins (SI) are limited insulin products that are selected as part of the CMS Senior Savings Model program at a reduced member co-pay. To find out which drugs are Select Insulins, review the most recent Drug List we provided electronically. You can identify Select Insulins by SI in the Drug List. If you have questions about the Drug List, you can also call Customer Service at (855) 645-8448. If you receive Low-Income cost-sharing Subsidy (LIS), sometimes called Extra Help, you already have a set copayment and are not eligible for the savings on Select Insulins (SI) copayments. Only, non-LIS enrollees are eligible for the cost sharing for Select Insulins (SI). If you have questions about the copayment for Select Insulins (SI), you can also call Customer Service at (855) 645-8448.

• Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Customer Services for more information.
• Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.

Important cost sharing protections of the Inflation Reduction Act (IRA) added to Medicare Advantage Plans for contract year 2023:

• IRA Section 11101 - Part B Rebatable Drug Coinsurance Adjustment:

Effective 4/1/2023, Medicare Advantage enrollee cost sharing for Part B rebatable drugs will not exceed the coinsurance amount of the original Medicare adjusted beneficiary coinsurance for the Part B rebatable drug.

A rebatable drug may be in one of two categories: Chemotherapy administration services that include chemotherapy radiation drugs OR Other drugs covered under Part B of original Medicare as listed in §422.100(j)(1)(i).

MS (Centers for Medicare & Medicaid Services) specifies the adjusted beneficiary coinsurance amount for each Part B rebatable drug in quarterly pricing files.

The Part B Rebatable Drug Coinsurance Adjustment will be implemented at the point-of-service or through an enrollee refund. Implementation at point-of-service means that when the plan uses coinsurance, the enrollee will be charged no more than the dollar amount of the adjusted coinsurance percentage that applies to the specific Part B rebatable drugs they received, based on the date of service. 

If a MHHP Medicare Advantage member pays (or has paid before April 1, 2023) more than the adjusted coinsurance percentage for a Part B rebatable drug based on the date of service, MHHP will issue a refund to the member.

• IRA Section 11407 - Part B Insulin Cost Sharing Cap:

Effective 7/1/2023, Insulin furnished under Part B through an item of durable medical equipment covered under section 1861(n) (i.e., a medically necessary traditional insulin pump), is subject to a beneficiary coinsurance cap for a month’s supply of such insulin (that does not exceed $35, and the Medicare Part B deductible does not apply).

MHHP Medicare Advantage Plans will cover Part B insulin at or below the original Medicare coinsurance cap of $35 for a one-month’s supply of insulin without applying a service category or plan level deductible. Because original Medicare cost sharing is set at an absolute cap on cost sharing for Part B insulin, both Medicare Advantage coinsurance and copayments will not exceed that amount.

Which Drugs Are Covered?

To find out or search if your prescription drug is covered, please see the comprehensive formulary listed below.

Comprehensive Formulary

A complete electronic list of covered prescription drugs is available. Members may also request to receive a printed Formulary in the mail. Please click here to complete the request form for a printed formulary.

The online or electronic formulary list contains the most up-to-date formulary and may change monthly. You can view your formulary below:

Diabetic Testing Supplies and Glucometers:

The preferred Diabetic Brands (Vendors) are Lifescan (One Touch®) and Roche (Accu-Chek®). Lifescan (One Touch) and Roche (Accu-Chek) 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.

Continuous Glucose Monitors (CGM)

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/G7 and Freestyle Libre/Libre 2/Libre 14. All other CGMs are excluded. Please refer to your Evidence of Coverage for more information.

What if My Drug Is Not on the Drug List?

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.

Why Do Some Drugs Have Restrictions?

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.

What Is a Prior Authorization?

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.

What Is Step Therapy?

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.

Prior Authorization and Step Therapy Lists:

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.

Can the Formulary Change?

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:

• New FDA-approved drugs are added once they become available.
• A brand-name drug is replaced with an FDA-approved generic drug.
• A drug changes to a higher or lower cost-sharing tier.
• Prior authorizations are added or removed for a drug.
• Utilization management requirements are added or removed for a drug.
• The FDA recalls a drug or finds it to be ineffective.

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.

How Will I Know if a Formulary Change Impacts Me?

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.