Restrictions to the Formulary
Restrictions to Our Covered Drugs
Today's Options® HMO has additional requirements or coverage limits for certain prescription drugs. A team of doctors and pharmacists developed these requirements and limits for Today's Options HMO, in order to help us to provide quality care to our members.
Examples of additional requirements or limits on coverage include:
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Prior Authorization: Today's Options HMO requires you (or your doctor) to get prior authorization for certain drugs. This means that you will need to get approval from Today's Options HMO before you fill your prescription. If you do not get approval, Today's Options HMO may not cover the drug.
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Quantity Limits: For certain drugs, Today's Options HMO limits the amount of the drug that we will cover per prescription or for a defined period of time. For example, Today's Options HMO will provide up to 30 tablets of simvastatin per 30 days.
- Step Therapy: In some cases, Today's Options HMO 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, Today's Options HMO may require your doctor to prescribe Drug A first. If Drug A does not work for you, only then will Today's Options HMO cover Drug B.
- Limited Access: In some cases, a prescription may only be available at certain pharmacies in the Today's Options HMO 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. You can also access prior authorization forms, exceptions forms and criteria. If your drug has these additional restrictions or limits, you can ask Today's Options HMO 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 Advantage Prescription Drug plans. These drugs or categories of drugs are called Excluded Drugs. They include:
- Nonprescription drugs (also called over-the-counter 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 and benzodiazepines
In addition, Medicare Advantage Prescription Drug plans are unable to cover the following:
- Drugs that would be covered 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.
- Drugs that are not approved by the Food and Drug Administration (FDA) or are purchased outside the United States and its territories.
- Off-label use usually cannot be covered. "Off-label use" is any use of the drug other than those indicated on a drug's label as approved by the Food and Drug Administration. (Generally, coverage for "off-label use" is allowed only when use is supported by certain reference books.)
Read about the Today's Options HMO Transition Policy.