Simpra Advantage (PPO I-SNP) 2021 Formulary Instructions (Preamble)
5 List of Covered Drugs
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary File Submission ID 00021515, Version Number 14
This formulary was updated on May 18, 2022. For more recent information or other questions, please contact us, Simpra Advantage (PPO I-SNP) Member Services, at 1-844-637-4770 or, for TTY users, 711, 8am to 8pm daily excluding major holidays, or visit Simpra.com.
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 (PPO I-SNP). When it refers to “plan” or “our plan,” it means Simpra Advantage (PPO I-SNP).
This document includes list of the drugs (formulary) for our plan which is current as of September 1, 2021. For an updated 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, 2022, and from time to time during the year.
What is the Simpra Advantage (PPO I-SNP) Formulary?
A formulary is a list of covered drugs selected by Simpra Advantage 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. Simpra Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Simpra Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:
- New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that 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 the brand name drug for you. 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 (PPO I-SNP)’s Formulary?”
- Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and 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 add a generic drug that is not new to market to replace a brand name drug currently on the formulary; or add new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] 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, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.
- If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. 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 (PPO I-SNP)’s Formulary?
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 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 Drug List for the new benefit year for any changes to drugs.
The enclosed formulary is current as of September 1,2021. To get updated information about the drugs covered by Simpra Advantage, please contact us. Our contact information appears on the front and back cover pages. The formulary will be updated and posted at the beginning of each month with the most current information.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
The formulary begins on page 8. 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 8. Then look under the category name for your drug.
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 66. 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 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 cost less than brand name drugs.
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 requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Simpra Advantage before you fill your prescriptions. If you don’t get approval, Simpra Advantage may not cover the drug.
- Quantity Limits: For certain drugs, Simpra Advantage limits the amount of the drug that Simpra Advantage will cover. For example, Simpra Advantage provides 120 units per prescription for morphine sulfate 15mg er tables. This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, Simpra 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, Simpra Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Simpra Advantage 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 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online a document 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 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 (PPO I-SNP)’s formulary?” on page 5 for information about how to request an exception.
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. 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.
- You can ask Simpra Advantage 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 (PPO I-SNP)’s Formulary?
You can ask Simpra Advantage 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 coverage restrictions or limits on your drug. For example, for certain drugs, Simpra Advantage 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 will only approve your request for an exception if the alternative drugs included on the plan’s formulary, [the lower cost-sharing drug] or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary. When you request a formulary you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
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 your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to 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 if your ability to get your drugs is limited, we will cover a temporary 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-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 31-day transition supply per drug, 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
For more information
For more detailed information about your Simpra Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Simpra Advantage, 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’s Formulary
The formulary below provides coverage information about the drugs covered by Simpra Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 102.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TIVICAY 10MG TAB) and generic drugs are listed in lower-case italics (e.g., zidovudine 100mg cap),
The information in the Requirements/Limits column tells you if Simpra Advantage has any special requirements for coverage of your drug.
- First Fill Limited to one-month supply (FF): You may be able to receive greater than a 1-monthsupply of most of the drugs on your Formulary. Drugs noted with “FF” are limited to a 1-monthsupply for both Retail and Mail Order on your first fill only. After the first fill, an extended day supply would be available
- Limited Distribution (LD): The symbol [LD] next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drug scan only be obtained at specialty designated pharmacies able to appropriately handle the drugs.
- Non-Extended Day Supply (NDS): You may be able to receive greater than a 1-month supply of most of the drugs on your Formulary via mail order at a reduced cost share. 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 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.
- Prior Authorization Restriction for New Starts Only (PA_NSO): If this drug is new to the member, 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.
- 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 the member, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
Simpra Advantage is a PPO I-SNP with a Medicare contract. Enrollment in Simpra Advantage depends on contract renewal. Simpra Advantage 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 September 1, 2021. For more recent information or other questions, please contact us, Simpra Advantage (PPO I-SNP) Member Services, at 1-844-637-4770 or, for TTY users, 711, 8am to 8pm daily excluding major holidays, or visit Simpra.com.