The Alliance Medicare PPO and HAP Senior Plus formulary (Requires Adobe Reader) lists all prescription drugs that we cover.

The Alliance Medicare Rx formulary (Requires Adobe Reader) lists all prescription drugs covered by our stand alone prescription drug plan.

To be covered by the plan, you must have your prescriptions filled at either:

• Plan pharmacies or
• Our mail-order pharmacies

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits are described in the Evidence of Coverage for each plan.

In some cases, prescriptions filled at a non-plan pharmacy may also be covered.
More information on using non-plan pharmacies

Table of Contents

What is a Formulary?
What are Drug Tiers?
Can the Formulary Change?
What is Utilization Management?
    Prior Authorization
    Quantity Limits
    Step Therapy
    Generic Substitution
What is Medication Therapy Management?
    Chronic Disease Management
    Polypharmacy
    Management of High Cost Specialty Drugs

What is a Formulary?

A formulary is a list of drugs selected by the 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.

Our plans will generally cover the drugs listed in the applicable formulary as long as:

• the drug is medically necessary, and
• the prescription is filled at a plan pharmacy, and
• all other plan rules are followed

You can ask us to make an exception and cover a drug prescribed for you that isn't on our formulary.

Both brand-name drugs and generic drugs are included on our formulary.

• Brand name drugs are only listed when there is no generic alternative available for a particular medication.
• A generic drug is listed on the formulary when there is a generic alternative available. A generic drug has the same active ingredient formula as a brand-name drug but is made by a different drug manufacturer. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as the original brand-name drugs.

The plan formulary is updated at least monthly. You may obtain a current copy of the formulary for your plan by contacting Client Services or by clicking on one of the links below.

Comprehensive Formulary List for Alliance Medicare PPO and HAP Senior Plus plan options with prescription drug benefits (Requires Adobe Reader)

Comprehensive Formulary List for Alliance Medicare Rx plan options (Requires Adobe Reader)

What are Drug Tiers?

Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your cost may vary by drug tier. You can ask us to make an exception to your drug's tier placement.

Can the Formulary Change?

We may add or remove drugs from our formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription.

If the formulary changes:

• We will send written notice of changes to our formulary to all members who are using a drug affected by the change.
• This notice will be sent at least 60 days before the change will take effect and will also be posted on this website.

Changes in the formulary (Requires Adobe Reader)

What is Utilization Management?

For certain prescription drugs, Alliance Medicare PPO, HAP Senior Plus and Alliance Medicare Rx have additional requirements for coverage or limits on coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits to help us provide quality care to our members.

Learn more about quality assurance.

Examples of utilization management tools are described below:

Prior Authorization (PA): We require you to get prior authorization for certain drugs, to be certain these drugs are used correctly and only when truly necessary. This means that you will need to get approval from us before you fill your prescription. If you don't get approval, we may not cover the drug.

Prior Authorization Criteria

Quantity Limits (QL): For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.

Drugs with a Quantity Limit

Step Therapy (ST): 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, we will then cover Drug B.

Step Therapy Criteria

Generic Substitution: When there is a generic version of a brand name drug available, our plan pharmacies will automatically give you the generic version. If your condition requires that you must take the brand name drug, your physician must submit a prior authorization request.

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

What is Medication Therapy Management?

Alliance Medicare PPO, HAP Senior Plus and Alliance Medicare Rx offer medication management programs to assist in assuring that our members are using appropriate drugs to treat their medical condition and help us to identify possible medication errors. The programs were developed for Alliance Medicare PPO, HAP Senior Plus and Alliance Medicare Rx members by a team of pharmacists and doctors. We use these medication management programs to help us provide better care for our members.

The following lists the medication management programs offered to members of the Alliance Medicare PPO, HAP Senior Plus and Alliance Medicare Rx:

Chronic Disease Management: This program is designed for members with two or more chronic diseases commonly affecting the adult population. Examples of chronic diseases include the following: Arthritis, Asthma, Benign Prostate Hypertrophy, Congestive Heart Failure, COPD, Coronary Artery Disease, Depression, Diabetes, Hypertension, Stroke. This list is not exhaustive, therefore, patients with multiple other diseases would also qualify for the program.

Polypharmacy: This program is designed to reduce polypharmacy (the misuse, underuse, or overuse of prescription drugs) for members using multiple medications for the management of multiple diseases.

Management of High Cost Specialty Drugs: This program is designed to assure members receiving high cost drugs have an appropriate indication for its use (e.g. benefit outweighs risk, literature supports use of drug), and the physician monitors for safety and efficacy within appropriate timeframes.

To learn more about our medication management programs, or to join a program, contact Client Services.