Restrictions to the Formulary

Restrictions to Our Covered Drugs

For certain prescription drugs, Community CCRx^SM has additional requirements 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 for Community CCRx to help us to provide quality care to our members.

Examples of utilization management tools include:

• Prior Authorization: Community CCRx requires you (or your doctor) to get prior authorization for certain drugs. This means that you will need to get approval from Community CCRx before you fill your prescription. If you do not get approval, Community CCRx may not cover the drug.
• Quantity Limits: For certain drugs, Community CCRx limits the amount of the drug that we will cover per prescription or for a defined period of time. For example, Community CCRx will provide up to 30 tablets of simvastatin per 30 days.
• Step Therapy: In some cases, Community CCRx requires 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, Community CCRx may require your doctor to prescribe Drug A first. If Drug A does not work for you, only then will Community CCRx cover Drug B.
• Generic Substitution: When there is a generic version of a brand-name drug available, Community CCRx network pharmacies will typically give you the equivalent generic version to save you money unless your doctor has told us that you must take the brand-name drug.
• Therapeutic Substitution: When there is a therapeutic alternative to treat your condition, your pharmacist or Community CCRx plan may contact your doctor to see if the alternative drug is appropriate for you. Only your doctor can authorize this change.
• Limited Access: In some cases, a prescription may only be available at certain pharmacies in the Community CCRx network.

Learning if your drug has restrictions

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

Drugs or categories of drugs not covered by law: According to Federal law, certain types of drugs cannot be covered by Medicare Prescription Drug Plans. These drugs or categories of drugs are called Excluded Drugs. They include:

• Nonprescription drugs
• Drugs when used for anorexia, weight loss or weight gain
• Drugs when used to promote fertility
• Drugs when used for cosmetic or hair growth purposes
• Drugs when used for symptomatic relief of cough or colds
• Prescription vitamins and minerals (except for prenatal vitamins and fluoride preparations)
• Drugs when used for the treatment of sexual or erectile dysfunction (ED)
• Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of the sale
• Barbiturates
• Benzodiazepines
• Drug Efficacy Study Implementation (DESI) drugs

In addition, a Medicare Prescription Drug plan is unable to cover a drug if the drug is not approved by the Food and Drug administration or if it would be available under Medicare Part A or Part B. Some drugs are covered under Medicare Part B in certain cases and under Medicare Part D in others. In most cases, your pharmacist or provider will appropriately determine whether to bill Part B or Part D for your drug.