(Formulary & Medication)
What is a formulary?
A formulary is a list of covered drugs selected by our 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. 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.
Can my formulary change over the course of the year?
AgeWell New York may change the formulary during the year, including adding or removing drugs from our Medicare Part D formulary. Before removing drugs from the formulary or adding prior authorization, quantity limits, and/or step therapy restrictions on a drug, we will notify members of the change via mail and this website, at least 60 days before the date the change becomes effective. Exceptions to this would be when the US Food and Drug Administration (FDA) deems a drug on the formulary to be unsafe or when the drug’s manufacturer removes the drug from the market, in which case Medicare will promptly remove the drug from the Part D formulary.
Are there any restrictions to my formulary?
Some of the prescription drugs on the AgeWell New York Medicare Plan formulary have restrictions on when or how they may be accessed. You can look up individual drugs on our formulary and see if any of these restrictions apply. If you prefer, you can look on the lists available below that show all of the drugs on our formulary that require prior authorization, quantity limits, or step therapy.
This means that your provider will need to contact us before you fill your prescription. If we don’t get the necessary information to satisfy the prior authorization process, we may not cover the drug.
Drugs covered under Medicare Part B or D
Some 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
This means that we limit the quantity of the drug we will cover.
The symbol (QL, units/days supply) in the Notes column indicates that quantities dispensed may be limited. The quantity allowed is listed following the QL symbol and may be read as “units per days supply.”
For example, the drug NEXIUM 2 is listed with the symbol QL (30 ea / 30 days). This means that this drugs availability is limited to a quantity of 30 per 30 days supply of the drug.
If your prescription for any of these medications exceeds the maximum quantity listed, you and your doctor will need to request a formulary exception.
The list of drugs that require quantity limits is found on the current formulary.
In some cases, we require 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
The below policies are aimed to reduce prescription opioid abuse and promote more safe treatment options.
The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.