Medicare Formularies

The following Formularies list the covered medications your doctor uses when determining the most appropriate course of treatment for you. The Formulary includes many commonly prescribed medications, both brand name and generic drugs.

You will need Adobe Acrobat to open these files. Please select the Formulary that coincides with your policy:

2013 MEDICARE FORMULARIES

• Presbyterian Senior Care (HMO) Formulary   En Español
• Presbyterian MediCare PPO Formulary   En Español

FORMULARY UPDATES

• 2013 Formulary Changes (coming soon) (En Español coming soon)
• Prior Authorization Criteria for 2013 Formulary  En Español 
• Step Criteria for 2013 Formulary  En Español 
• Quantity Limits for 2013 Formulary En Español 

 SUPPLEMENT FORMULARY INFORMATION

• Drug Coverage Determination Request Form  This form may be used by an enrollee, the enrollee's representative or the enrollee's prescriber to request a coverage determination.
• Medicare Part D Transition Process Policy
• Pharmacy Prior Authorization Form (.pdf)
• Specialty Pharmaceuticals/Medical Drugs List
• Specialty Pharmacy Drug Request Form
• 2013 Presbyterian Senior Care (HMO) Provider Directory  En Español  The directory lists both the types and locations of providers and pharmacies.
• 2013 Presbyterian MediCare PPO Provider Directory  En Español The directory lists both the types and locations of providers and pharmacies. 

MEDICATION THERAPY MANAGEMENT (MTM)

• Information about  our Medication Therapy Management (MTM) program
• Personal Medication List (Blank)  En Español  These lists can be filled out to help you keep track of your medications.

Disclaimer

Please be sure a prescription drug benefit is part of your specific coverage before consulting this list. If you do not know which list is correct, please contact the Presbyterian Customer Service Center at (505) 923-6060 or 1-800-797-5343 for assistance. TTY users may call 1-888-625-8818.

Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit design determines what is covered for you and what your copayment will be. Please refer to your benefit materials for your specific coverage information.

The medications listed on this Formulary/Preferred Drug List (PDL) are subject to change pursuant to the Formulary/PDL management activities of Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian). This list is not all-inclusive nor does it imply a guarantee of coverage. In addition, coverage for some drugs listed may be limited to specific dosage forms and/or strengths. Substitution of a generic product for a brand-name drug is mandatory when a generic equivalent is available. If a member requests the brand-name drug in this situation, a pharmacy exception may be required and the member must pay the difference in cost between the generic and branded versions. Non-formulary medications are not considered for coverage unless trial and failure of Formulary alternatives are documented.

EXPLANATION OF TERMS IN YOUR FORMULARY

You will see these words next to some drug names:

1. Prior Authorization (PA) - a drug that requires prior approval before the Plan will cover it, and when the patient meets the established criteria. The doctor must submit a Prior Authorization Request Form. The doctor can submit the request by fax, phone, or regular mail.
2. Step Edit (ST) - a drug that requires a prescription history of specific drugs in the pharmacy claims or data system, and these specific drugs must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly-prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Prior Authorization.
3. Medical Exception - a drug that is not on the Plan's formulary. Non-formulary drugs require an exception to the formulary due to allergy, adverse reactions, or no response to all formulary drugs. 
4. Quantity Limit (QL) -  a coverage limit on the medication quantity covered for a defined days' supply (usually 30 or 90 days) based on safety, efficacy and/or dose optimization issues.
5. Age Limitation (AG) - a coverage limit based on minimum or maximum age of the member imposed as a result of safety, efficacy or dosage form considerations.
6. Specialty (SP) - Tier 4 medications obtained through the pharmacy benefit.  Tier 4 medications are defined as high cost (greater than $600 per 30 day supply) injectable, infused, oral or inhaled drugs that generally require complex care and supervision. These medications involve unique distribution and are usually provided by a specialty pharmacy vendor. Specialty pharmaceuticals are self-administered, meaning they are administered by the patient or to the patient by a family member or caregiver. Non-formulary medications, when approved by prior authorization, may be subject to specialty pharmacy requirements.
7. Medical Drugs (MED) - Medications obtained through the medical benefit. Medical drugs are defined as medications administered in the office or facility that require a health care professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution and may be provided by a specialty pharmacy vendor. Some Medical Drugs may require Benefit Certification before they can be obtained. Office administered applies to all outpatient settings including, but are not limited to, physician's offices, emergency rooms, urgent care facilities and outpatient surgery facilities.

WHAT IF MY DRUG IS NOT COVERED?

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Updated 04/09/2013