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Formularies (Lists of Covered Drugs)

A formulary is a list of covered drugs selected by Samaritan Advantage Health Plan 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. 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, 2020, and from time to time during the year. See drug list limits and requirements for definitions of terms found in your formulary.

Premier Plan and Premier Plan Plus Formulary

Special Needs Plan Formulary

Understanding Your Drug Coverage

Samaritan Advantage’s Premier Plan HMO and Samaritan Advantage Premier Plan Plus HMO combine a prescription drug plan with a medical benefits package that covers more than original Medicare with less out-of-pocket expenses for you. Members with Low Income Subsidy are subject to different cost shares.

  Premier Plan HMO Premier Plan Plus HMO
Part D Prescription Drugs

Tier 1: Maximum $3 for 7 drugs:

  • High blood pressure (Enalapril, Lisinopril)
  • High cholesterol (Lovastatin, Simvastatin)

Tier 2: Maximum $9 for generic formulary drugs
Tier 3: Maximum $47 for preferred brand drugs
Tier 4: 48% of the cost for non-preferred brand drugs
Tier 5: 33% of the cost for specialty drugs
Tier 6: $0 Select Care Drugs (Some diabetic drugs including: Glipizide, Metformin, Glyburide)

Tier 1: Maximum $3 for 7 drugs:

  • High blood pressure (Enalapril, Lisinopril)
  • High cholesterol (Lovastatin, Simvastatin)

Tier 2: Maximum $9 for generic formulary drugs
Tier 3: Maximum $47 for preferred brand drugs
Tier 4: 50% of the cost for non-preferred brand drugs
Tier 5: 33% of the cost for specialty drugs
Tier 6: $0 Select Care Drugs (Some diabetic drugs including: Glipizide, Metformin, Glyburide)

Gap Coverage

NO ADDITIONAL COVERAGE
Once your total drug spend reaches $3,820, you receive Medicare’s discount for generics and brand drugs. During this payment stage, you (or others on your behalf) receive a 70% manufacturer’s discount on covered brand name drugs and the plan will cover at least another 5%, so you will pay 25% of the negotiated price on brand-name drugs. In addition, you pay 37% of the costs of generic drugs.

EXTRA COVERAGE FOR GENERICS
Once your total drug spend reaches $3,820, you will pay whichever is less for generics: a maximum $9 co-pay for generics or Medicare’s discounted cost (37%) of the costs of generic drugs. During this payment stage, you (or others on your behalf) receive a 70% manufacturer’s discount on covered brand name drugs and the plan will cover at least another 5%, so you will pay 25% of the negotiated price on brand-name drugs.

Catastrophic Coverage

After you have spent $5,100 out-of-pocket, you will pay the greater of: $3.40 and $8.50 or 5% of the cost.

After you have spent $5,100 out-of-pocket, you will pay the greater of: $3.40 and $8.50 or 5% of the cost.

Important Notice Regarding Discounts

A change in the law requires companies that make brand-name prescription drugs to give a discount on those drugs to Medicare. Beginning January 1, 2011, prescription drugs made and sold by companies that have not agreed to give a discount to Medicare can no longer be covered (paid for) by Medicare Prescription Drug Plans.

For additional help, visit the Medicare Prescription Drug Plan Finder at www.medicare.gov.

Low Income Subsidy

If you qualify for the Low Income Subsidy (also called “Extra Help") with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join one of our plans, Medicare will tell us how much Extra Help you are getting. Then we will let you know the amount you will pay. See the table below for the monthly premiums for the current year.

How to Inquire About Low Income Subsidy

If you are not getting Extra Help, you can see if you qualify by calling Social Security at 1-800-772-1213 (TTY users should call 1-800-325-0778) or visit www.socialsecurity.gov.

2019 Monthly Premiums

The following chart outlines the premium amounts based on the various Low Income Subsidy levels.

  Conventional Plan
($70/month)
Premier Plan
($100/month)
Premier Plan Plus
($129/month)
25% Low Income Subsidy (LIS) N/A You pay $91.50* You pay $120.50*
50% Low Income Subsidy (LIS) N/A You pay $83.10* You pay $112.10*
75% Low Income Subsidy (LIS) N/A You pay $74.60* You pay $103.60*
100% Low Income Subsidy (LIS) N/A You pay $66.20* You pay $95.20*

* The premiums listed above include both medical service and prescription drug benefits. These premiums do not include any Medicare Part B premium you may have to pay.

2019 Cost-Sharing

Standard Retail Cost-Sharing (in-network) - up to a 34-day supply

For generic/preferred multi-sourced drugs, you pay either a $0, $1.25, or $3.40 copay per prescription. For all other drugs, you pay either a $0, $3.80 or $8.50 copay per prescription. 

Long-term Care (LTC) Cost-Sharing - up to a 31-day supply

For generic/preferred multi-sourced drugs, you pay either a $0, $1.25, or $3.40 copay per prescription. For all other drugs, you pay either a $0, $3.80 or $8.50 copay per prescription. 

See also the Centers for Medicare and Medicaid Services (CMS) Best Available Evidence Policy.

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.

 

Our Network Pharmacies

A network pharmacy is one that we have made arrangements for them to provide prescription drugs to plan members. These pharmacies are where members can obtain prescription drug benefits provided by Samaritan Advantage Premier Plan HMO, Samaritan Advantage Premier Plan Plus HMO , and Samaritan Advantage Special Needs Plan HMO. Samaritan Health Plans has an arrangement with pharmacies across the United States, which consists of approximately 90 percent of pharmacies. This equals or exceeds Centers for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area. In most cases, your prescriptions are covered if they are filled at a network pharmacy.

ADOBE READER SEARCH TIPS for your Pharmacy Directory
Once you have opened the link to the Pharmacy Directory found below, you can search the document for a specific network pharmacy. Just hold down the Crtl + f keys on your keyboard to use the “Find” function within Adobe Reader, then type in the name of the facility or provider you are seeking. 

2019 Pharmacy Directory 

We also list pharmacies that are in our network but are outside our geographic area. Please contact Samaritan Advantage at 541-768-4550, 800-832-4580, TTY users must use 800-735-2900, from 8 a.m. to 8 p.m. daily, for additional information.

Once you go to a network pharmacy, you are not required to continue going to the same pharmacy to fill your prescription, you can go to any of our network pharmacies.

Out-of-Network Coverage

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

  • If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24 hour service.
  • If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail pharmacy (including high cost and unique drugs).
  • If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor’s office.

Before you fill your prescription in any of these situations, call Customer Service at 541-768-4550 or 800-832-4580 (TTY 800-735-2900), from 8 a.m. to 8 p.m. daily, to see if there is a network pharmacy in your area where you can fill your prescription.

If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting this form:

Prescription Reimbursement Form

For certain kinds of drugs, members can get prescription drugs shipped to their homes through an in-network mail order pharmacy. Our plan’s mail-order service requires you to order a 90-day supply. You can find a list of in-network mail order pharmacies in your pharmacy directory.

Local provider

You can order your prescriptions for rapid mail delivery from Samaritan Health Services:

Samaritan Pharmacy - Corvallis
3251 NW Samaritan Drive, Suite 202, Corvallis

Phone: 541-768-5225
Refill line: 541-768-5230

Hours: Weekdays from 7 a.m. to 6 p.m.; Saturday from 9 a.m. to 1 p.m.

Be Sure to Plan Ahead, Use Network Pharmacies When You Travel

If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You can call Customer Service at 541-768-4550, 800-832-4580 (TTY 800-735-2900), from 8 a.m. to 8 p.m. daily. to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

If you are traveling within the United States and territories and become ill, or lose or run out of your prescription drugs you may call Customer Service to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

You can also use our pharmacy directory to find an in-network nationwide pharmacy near you. We will cover prescriptions that are filled at an out-of-network pharmacy if you are unable to locate an in-network option. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. You can ask us to reimburse you for our share of the cost by submitting this form:  

Prescription Reimbursement Form

Additional Requirements for Prescription Drugs

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of utilization management tools are described below:

Prior Authorization

We require you to get prior authorization for certain drugs. This means that you, your authorized representative, or your provider will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug.

2019 Prior Authorization Requirements - Premier and Premier Plan Plus
2019 Prior Authorization Requirements - Special Needs Plan

Quantity Limits

For certain drugs we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, Samaritan Advantage Premier Plan provides 30 tabs per 30 days per prescription of Brintellix. This may be in addition to a standard one-month or three-month supply.

2019 Quantity Limits - Premier and Premier Plan Plus
2019 Quantity Limits - Special Needs Plan

Step Therapy

In some cases, we require you to first try one drug 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, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

2019 Step Therapy - Premier and Premier Plan Plus
2019 Step Therapy - Special Needs Plan

Part B vs. Part D

For drugs with a Part B versus D these drugs may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Morphine Equivalent Dose (MED)

For opiate medications, morphine equivalent dose (MED) limits apply. Exceeding plan limits will require an exception. MED is a tool used for a comparison of opioid doses to equate the many different opioids into one standard value. This standard value is based on morphine and its potency, referred to as morphine equivalent dose (MED). Knowing the MED helps determine if the patient’s opioid doses are excessive and is useful if converting from opioid to another.

You can find out if your drug is subject to these additional requirements or limits by searching the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules.

Requesting an Exception to Drug Coverage Rules

You, your representative, or your prescriber can submit a coverage determination or medication exception if:

  • Your drug has one or more additional requirements defined above.
  • Your drug is not on the plan formulary.
  • You would like the plan to lower the Tier for your drug.

To request an exception, you, your authorized representative, or the prescribing physician have the following options:

Mail:
Samaritan Advantage Health Plan HMO
P.O Box 1310
Corvallis, OR 97339

Fax:
541-768-9776

Deliver:
Samaritan Health Plans
2300 NW Walnut Blvd., Corvallis
Monday - Friday, 8:30 a.m. to 5 p.m.

Expedited Requests

For expedited requests, you or the prescribing physician may call Customer Service at 541-768-4550 or 800-832-4580, from 8 a.m. to 8 p.m. daily. TTY users should call 800-735-2900.

Please note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

To help us make a decision more quickly, you or your prescriber should include supporting medical information when you submit your request. If we approve your medication exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. For approval on prior authorizations please see our Prior Authorization Requirements. For further information regarding how to ask for an exception please refer to the Evidence of Coverage found with enrollment materials.

Drug Transitions for New or Continuing Members

As a new or continuing member in our plan, you may be taking drugs that are not on the formulary (drug list). You may also be taking a drug on our formulary that is restricted in some way. Under certain circumstances, you may be able to get a temporary supply.

How to Get a Temporary Supply

To be eligible for a temporary supply you must meet one of the changes listed below:

  • Be a current member whose drug is no longer on the plan’s formulary drug list.
  • Be a current member whose drug is now restricted in some way.
  • Be a current member that has an unplanned change due to change in treatment settings. Examples include moving from a hospital to long-term care/skilled nursing or leaving a skilled nursing facility.
  • Be a new member to the plan.

Long-Term Care Facility (LTC) Residents

For those members who reside in a long-term care (LTC) facility and were in the plan last year or are new to the plan:

We will cover a temporary supply of your drug during the first 90 days of the calendar year (current members) or during the first 90 days of your membership (new members). The total supply will be for a maximum of 91 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 91 days of medication. Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.

For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility:

We will cover one 31-day supply or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

You Can Ask Your Doctor to:

  1. Switch you to a different drug that we cover, or
  2. Submit a formulary exception request for us to cover the drug you take.

Contact Us

To request a temporary supply, please call Samaritan Advantage at 800-832-4580 (TTY 800-735-2900), 8 a.m. to 8 p.m. daily.

 

When You Want Us to Reconsider a Decision About Your Covered Drugs

A drug coverage redetermination is when you want us to reconsider and change a decision we have made about what drugs are covered for you or what we will pay for a drug. For example, if we deny the request for coverage determination and you think we should cover the medication, you can request a redetermination.

There are two kinds of coverage redeterminations you can request. They are described below.

Expedited Request

You can request an expedited (fast) coverage redetermination for cases that involve coverage, if you or your doctor believes that your health could be seriously harmed by waiting for a standard decision. For expedited requests, you or the prescribing physician may call Customer Service at 541-768-4550 or 1-800-832-4580, from 8 a.m. to 8 p.m. TTY users should call 1-800-735-2900. If your request to expedite is granted, the reviewer must give you a decision no later than 72 hours after receiving your request.

Standard Request

You can request a standard coverage redetermination for a case that involves coverage or payment for prescription services. You must file a request for coverage redetermination to Samaritan Advantage Health Plan HMO no later than 60 days from the date of the denial. The plan will review your request and make a determination as expeditiously as your health requires, but no later than 7 days from the date of the request.

Please include the following information:

  • Name
  • Address
  • Member ID number
  • The reasons for your request
  • Any evidence you wish to attach

If your request relates to a decision by us to deny a drug that is not on our list of covered drugs (formulary), your prescribing physician must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health. You or your appointed representative should mail your written request to the address below:

Samaritan Advantage Health Plan HMO
Attn: Part D Pharmacy Dept.
PO Box 1310
Corvallis, OR 97339

Drug Redetermination Request Form

Authorized Representative

As a member of Samaritan Advantage Health Plan HMO, you have appeal rights to adverse organization determinations for services requested. You also have the right to appoint any individual (such as a relative, advocate, friend, attorney or any physician) to act as your representative and file an appeal on your behalf.

By appointing a representative to act on your behalf concerning your appeal, you are giving him or her the right to:

  • Obtain information about your claim to the extent consistent with Federal and State laws;
  • Submit evidence;
  • Make statements of fact and law; and
  • Make any request, or give or receive any notice about the appeal proceedings.

To appoint a representative for your Medicare benefits, both you and the representative you’ve assigned must sign, date and complete Medicare’s authorized request form. You must send a copy to Samaritan Advantage Health Plan HMO each time you want the appointed representative to head any of your appeal requests within 60 days of the initial denial for the service requested. Once the form is received by Samaritan Advantage Health Plan HMO, it is considered current for one year. After one year has passed, you must complete a new form if you would like to continue the appointment of that representative.

Special Program for Members with Multiple Prescriptions, High Drug Costs, or Chronic Diseases

If you are a member who takes many prescription drugs, or who has high drug costs or chronic diseases, you could be eligible for the Samaritan Advantage Health Plan HMO medication therapy management (MTM) program. This is a free service for eligible members.

Qualifications

To qualify for MTM, members must meet the following criteria:

  • Must be taking a minimum of eight drugs covered by Medicare Part D
  • Must have a prescription drug spend that is greater than or equal to $4,044 per calendar year
  • Must have a minimum of three chronic diseases that Samaritan Advantage has chosen to monitor, as permitted by Centers for Medicare & Medicaid Services (CMS):
    • Bone Disease-Arthritis-Osteoporosis
    • Bone Disease-Arthritis-Rheumatoid Arthritis
    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia
    • Hypertension
    • Mental Health-Depression
    • Respiratory Disease-Asthma
    • Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD)
    • HIV/AIDS

Program Details

Each eligible MTM member’s drug information is analyzed for potential drug-drug interactions, possible adverse effects of medications, or gaps in care. Every quarter, we automatically enroll qualified members in our MTM program so they may begin receiving this extra support. Eligible MTM members will receive a letter notifying them that they have been auto-enrolled into the MTM Program.

As an MTM member, you are also eligible to receive a comprehensive medication review. We will offer participation by mail and in some cases by phone. The comprehensive medication review will give you the opportunity to review all of your current medications with a pharmacist. This is a one-on-one conversation by phone that takes about 30 minutes.

After completing the review, you will be mailed a personal medication list and a medication action plan. The list will include your current prescription medications, over-the-counter medications and dietary and herbal supplements. The medication action plan will summarize what you and the pharmacist discussed during the medication review and discussion topics for you and your doctor. We will also conduct ongoing Targeted Medication Reviews and your doctor may be contacted by mail if we identify any issues with your medications.

Members who meet the MTM criteria are requested to participate in the program. Members are allowed to decline this service at any time during the contract year. During the contract year members may enroll into the MTM if they still meet the criteria.

The MTM is not a benefit, but a service provided by Samaritan Advantage. Members are encouraged to contact the plan’s Customer Service department at 1-800-832-4580 (toll free) or TTY 1-800-735-2900 daily from 8 a.m.to 8 p.m.

H3811_MA4001-3_2019a, Page updated 12/7/2018