PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID 00025122, Version Number 7

This formulary was updated on 10/01/2024. We have made no changes to this formulary since 10/01/2024. For more recent information or other questions, please contact Simpra Advantage Dual Care (PPO D-SNP) Member Services, at 1-844-637-4770 (TTY/TDD users should call 1-833-312-0044).

Hours of Operation: 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, and Monday to Friday from April 1 through September 30 (closed Memorial Day, Independence Day, Labor Day, Thanksgiving, and Christmas) or visit Simpra.com.

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 Member 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 Message About Certain Drugs – Due to the Inflation Reduction Act of 2022, there may be some Medicare Part B drugs covered by our plan that will have a coinsurance lower than 20%. If you purchase one of these Part B drugs, you will be eligible for a refund for any overpayment made at the point of service.

Important Message About Paxlovid – Beginning February 12, 2024, Paxlovid will be included on this Drug List with a $0 copay. Paxlovid is a prescription medicine used to treat mild-to-moderate COVID-19. For more information contact Member Services.

Note to existing members:  This formulary has changed since last year.  Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Simpra Advantage, Inc.

When it refers to “plan” or “our plan,” it means Simpra Advantage Dual Care (PPO D-SNP). 

This document includes the Drug List (formulary) for our plan which is current as of 10/01/2024. For an updated Drug List (formulary), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. 

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2025, and from time to time during the year.

What is the Simpra Advantage Premier (PPO I-SNP) Formulary?

In this document, we use the terms Drug List and formulary to mean the same thing. A formulary is a list of covered drugs selected by Simpra Advantage, Inc. 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at our network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. For a complete listing of all prescription drugs covered by the Simpra Advantage Dual Care (PPO D-SNP), please visit our website or call us. Our contact
information, along with the date we last updated the formulary, appears on the front and back cover pages.

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but we may add or remove drugs on the formulary during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes. Updates to the formulary are posted monthly to our website here: https://formulary.simpra.com

Changes that can affect you this year:  In the below cases, you will be affected by coverage changes during the year:

• Immediate substitutions of certain new versions of brand name drugs and original
  biological products. We may immediately remove a drug on our formulary if we are replacing it with a certain new version of that drug that will appear with the same or fewer restrictions. When we add a new version of a drug to our formulary, we may decide to keep the brand name drug or original biological product on our formulary or a add new restrictions.

We can make these immediate changes only if we are adding a new generic version of a brand name drug or adding certain new biosimilar versions of an original biological product, that was already on the formulary (for example, adding an interchangeable biosimilar that can be substituted for an original biological product by a pharmacy without a new prescription).

If you are currently taking the brand name drug or original biological product, we may not tell you in advance before we make an immediate change, but we will later provide you with information about the specific change(s) we have made.

If we make such a change, you or your prescriber can ask us to make an exception and continue to cover for you the drug that is being changed. For more information, see the section below titled “How do I request an exception to the Simpra Advantage Dual Care (PPO D-SNP) Formulary?”

Some of these drug types may be new to you. For more information, see the section below titled “What are original biological products and how are they related to biosimilars?”

• Drugs removed from the market. If a drug is withdrawn from sale by the manufacturer or the Food and Drug Administration (FDA) determines to be withdrawn for safety or effectiveness reasons, we may immediately remove the drug from our formulary and later provide notice to members who take the drug.
• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may remove a brand name drug from the formulary when adding a generic equivalent or remove an original biological product when adding a biosimilar. We may also apply new restrictions to the brand name drug or original biological product, or move it to a different cost-sharing tier, or both. We may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective. Alternatively, when a member requests a refill of the drug, they may receive 30-day supply of the drug and notice of the change.

If we make these other changes, you or your prescriber can ask us to make an exception for you and continue to cover the drug you have been taking. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Simpra Advantage Dual Care (PPO D-SNP) Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2025 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2025 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the formulary for the new benefit year for any changes to drugs.

The enclosed formulary is current as of 10/01/2024. To get updated information about the drugs covered by Simpra Advantage Dual Care (PPO D-SNP), please contact us. Our contact information appears on the front and back cover pages.

 

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 9. 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 93. 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 93. 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?

Simpra Advantage Dual Care (PPO D-SNP) 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 work just as well as and usually cost less than brand name drugs. There are generic drug substitutes available for many brand name drugs. Generic drugs usually can be substituted for the brand name drug at the pharmacy without needing a new prescription, depending on state laws.

What are original biological products and how are they related to biosimilars?

On the formulary, when we refer to drugs, this could mean a drug or a biological product. Biological products are drugs that are more complex than typical drugs. Since biological products are more complex than typical drugs, instead of having a generic form, they have alternatives that are called biosimilars. Generally, biosimilars work just as well as the original biological product and may cost less. There are biosimilar alternatives for some original biological products. Some biosimilars are interchangeable biosimilars and, depending on state laws, may be substituted for the original biological product at the pharmacy without needing a new prescription, just like generic drugs can be substituted for brand name drugs.

For discussion of drug types, please see the Evidence of Coverage, Chapter 5, Section 3.1, “The ‘Drug List’ tells which Part D drugs are covered.”

Are there any restrictions on my coverage?

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

• Prior Authorization: Simpra Advantage, Inc. requires you or your prescriber to get prior authorization for certain drugs. This means that you will need to get approval from Simpra
  Advantage, Inc. before you fill your prescriptions. If you don’t get approval, Simpra Advantage, Inc. may not cover the drug.
• Quantity Limits: For certain drugs, Simpra Advantage, Inc. limits the amount of the drug that Simpra Advantage, Inc. will cover. For example, Simpra Advantage, Inc. provides 30 tablets per prescription for Januvia. This may be in addition to a standard one-month or three-month supply. .
• Step Therapy: In some cases, Simpra Advantage, Inc. 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, Simpra Advantage, Inc. may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Simpra Advantage, Inc. will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Simpra Advantage, Inc. to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Simpra Advantage Dual Care (PPO D-SNP) Formulary?” on page 5 for information about how to request an exception.

What are over-the-counter (OTC) drugs?

OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. The plan pays for certain OTC drugs. The plan will provide these OTC drugs at no cost to you. The cost to the plan of these OTC drugs will not count toward your total Part D drug costs.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that Simpra Advantage does not cover your drug, you have two options:

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

How do I request an exception to the Simpra Advantage Dual Care (PPO D-SNP) Formulary?

You can ask Simpra Advantage, Inc. 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 a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
• You can ask us to waive a coverage restriction including prior authorization, step therapy, or a quantity limit on your drug. For example, for certain drugs, Simpra Advantage, Inc. limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Simpra Advantage, Inc. will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or applying the restriction would not be as effective for you and/or would cause you to have adverse effects.

You or your prescriber should contact us to ask for a formulary exception, including an exception to a coverage restriction. When you request an exception, your prescriber will need to explain the medical reasons why you need the exception. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can ask for an expedited (fast) decision if you believe, and we agree, that your health could be seriously harmed by waiting up to 72 hours for a decision. If we agree, or if your prescriber asks for a fast decision, we must give you a decision no later than 24 hours after we get your prescriber’s supporting statement.

What can I do if my drug is not on the formulary or has a restriction?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but has a coverage restriction, such as prior authorization. You should talk to your prescriber about requesting a coverage decision to show that you meet the criteria for approval, switching to an alternative drug that we cover, or requesting a formulary exception so that we will cover the drug you take. While you and your doctor determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or has a coverage restriction, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. If coverage is not approved, after your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

We will provide a one-time 30-day supply of medication in the retail setting and up to a 31-day supply of medication in the long-term care setting, which will cover a temporary supply if you have a change in your medications due to a level-of-care change. A level-of-care change may include:

• Entering or leaving an LTC facility
• Discharged from a hospital or home
• End a Medicare Part A skilled nursing facility stay
• Give up Hospice status and revert back to standard Medicare benefits
• End an LTC Facility stay and return to their home
• Discharged from psychiatric hospital with drug regimen that is highly individualized

For more information

For more detailed information about your Simpra Advantage Dual Care (PPO D-SNP) prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Simpra Advantage Dual Care (PPO D-SNP), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Simpra Advantage Dual Care (PPO D-SNP) Formulary

The formulary that begins on page 9 provides coverage information about the drugs covered by Simpra Advantage Dual Care (PPO D-SNP). If you have trouble finding your drug in the list, turn to the Index that begins on page 93.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., TIVICAY) and generic drugs are listed in lower-case italics (e.g., zidovudine).

The information in the Requirements/Limits column tells you if Simpra Advantage Premier (PPO I-SNP) has any special requirements for coverage of your drug.

GUIDE TO ABBREVIATIONS 

• Insulin (INS): Drugs noted with INS indicates insulin products with a maximum copay of $35 per month.
• Insulin (INS PA BvD): Drugs noted with INS PA BvD indicate a PA is needed for Part B coverage vs Part D coverage.
  
• Non-Extended Day Supply (NDS): Drugs noted with “NDS” are limited to a 1-month supply for both Retail and Mail Order.
• Prior Authorization (PA): The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from The Plan before you fill your prescriptions. If you don’t get approval, The Plan may not cover the drug.
• Prior Authorization Restriction for New Starts Only (PA_NSO): If this drug is new to you, you (or your physician) are required to get prior authorization from The Plan before you fill your prescription for this drug. Without prior approval, The Plan may not cover this drug.
• Prior Authorization Restriction for Part B vs Part D Determination (PA_BvD): This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from The Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, The Plan may not cover this drug.
• Quantity Limits (QL): For certain drugs, The Plan limits the amount of the drug that The Plan will cover. This could include a: per fill, daily, monthly, or yearly limitation.
• Step Therapy (ST): In some cases, The Plan 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, The Plan 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.
• Step Therapy for New Starts Only (ST_NSO): If this drug is new to you, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
• Vaccine (VAC): Drugs noted with VAC indicate Medicare Part D Vaccines are covered at $0.

Simpra Advantage is a PPO I-SNP with a Medicare contract. Enrollment in Simpra Advantage Dual Care (PPO D-SNP) depends on contract renewal. Simpra Advantage, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

This formulary was updated on 10/01/2024. For more recent information or other questions, please contact Member Services, at 1-844-637-4770 (TTY/TDD users should call 1-833-312-0044) from 8 a.m. to 8 p.m., local time, seven days a week from October 1 through March 31 and Monday to Friday from April 1 through September 30 (closed for Memorial Day, Independence Day, Labor Day, Thanksgiving and Christmas) or visit Simpra.com.

Revised 10/15/2024