Passport Advantage Part D Rules and Information - 2010

Remember that you must follow all plan rules in order for the medicine to be covered.

Passport Advantage covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. This formulary may change during the year.

If your medicine is not on our formulary, you can switch to another medicine on our formulary or ask us to change a medicine on the formulary.

What is a Formulary?

A formulary is a list of covered drugs selected by Passport 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. Passport Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Passport Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

How to Ask for an Exception

You can ask Passport 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 your drug even if it is not on our formulary. 
• You can ask us to change to a medicine on the formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Passport 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 more.

Generally, Passport Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary 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 for an initial coverage decision for a formulary or utilization restriction exception.

When you are requesting a formulary or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’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 your prescribing physician’s supporting statement.

Can the Formulary Change?

We will notify you of the change at least 60 days before the date that the change becomes effective or provide you with a 60 day supply at the pharmacy. This will give you an opportunity to work with your physician to switch to an appropriate drug that we cover or request a formulary exception before the change to the formulary takes effect.

If a drug is removed from our formulary because the drug has been recalled from the pharmacies, we will not give 60 days notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members taking the drug about the change as soon as possible.

How Passport Advantage Created the Formulary

The drugs on the formulary are selected by our Plan with the help of a team of health care providers. Passport Advantage covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. The Centers for Medicaid & Medicare Services has reviewed and approved the Passport Advantage formulary.