 |
|
CareOregon Advantage Formulary
CareOregon Advantage Formulary Search
What is a formulary?
A formulary is a list of drugs covered by CareOregon Advantage. CareOregon Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a CareOregon Advantage network pharmacy, and other plan rules are followed.
What drugs are covered?
CareOregon 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 as effective as brand name drugs. To find out if a drug is covered, Search on our formulary page or call Customer Service at 503-416-4100 in the Portland area or toll free at 800-224-4840, daily, 8 a.m. to 8 p.m. TTY/TDD users should call 1-877-416-416.
Can the formulary change?
Yes. CareOregon Advantage may add or remove drugs from our formulary during the year. If we remove drugs or add restrictions to a drug, we will notify members who take the drug at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the FDA deems a drug to be unsafe or the drug is removed from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
How much will I pay for covered drugs?
If you qualify for extra help with your Medicare Prescription Drug Plan costs, your drug costs will be lower than the standard Part D benefit. When you join CareOregon Advantage, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. Your ID card will list the copayment for generic drugs and for brand name drugs. If you aren’t getting any extra help, you can see if you qualify by calling:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, or
- Your State Medicaid Office, or
- The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778.
Are there any restrictions on coverage?
Some formulary drugs may have coverage limits. You can find out if your drug has any limits by looking in the Formulary Search tool. These limits may include:
- Generic Drugs: CareOregon Advantage requires you to use Food and Drug Administration approved and equivalent generic drugs when they are available.
- Prior Authorization: CareOregon Advantage requires you to get prior authorization for certain drugs. This means that you will need to get approval from CareOregon Advantage before you fill your prescriptions. If you don't get approval, CareOregon Advantage may not cover the drug.
- Quantity Limits: For certain drugs, CareOregon Advantage limits the amount of the drug that CareOregon Advantage will cover. For example, CareOregon Advantage provides up to 240 tablets per prescription for codeine/acetaminophen.
- Step Therapy: In some cases, CareOregon 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, CareOregon Advantage may not cover drug B unless you try Drug A first. If Drug A does not work for you, CareOregon Advantage will then cover Drug B.
- Age Requirement: For certain drugs, CareOregon Advantage requires you to be less than or greater than a specific age.
- Dosage Form Limitations: For certain drugs, CareOregon Advantage covers a specific dosage form only – not all dosage forms are covered. In this case, the dosage form is listed next to the drug name. For example, hydroxyzine hcl-tablets means that only the tablets are covered.
What if my drug is not on the formulary?
Call Customer Service at 503-416-4100 in the Portland area or toll free at 800-224-4840, daily, 8 a.m. to 8 p.m. (TTY/TDD users should call 877-416-4161) and ask if your drug is covered. If you learn that CareOregon Advantage does not cover your drug, you have two options:
- Ask Customer Service for a list of similar drugs that are covered by CareOregon Advantage and discuss the alternatives with your provider.
OR
- Ask CareOregon 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 CareOregon Advantage formulary?
Call Customer Service at 503-416-4100 in the Portland area or toll free at 800-224-4840, daily, 8 a.m. to 8 p.m. TTY/TDD users should call 1-877-416-4161. When you mail or fax an exception
request, also send a written statement from your physician supporting your request. Generally, we must make
our decision within 72 hours after we receive the physician’s statement.
Generally, CareOregon 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.
|
