Restrictions to the Formulary

For certain prescription medicines, TexanPlus^® HMO has additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these medicines in the most effective way. A team of doctors and pharmacists developed these requirements and limits for TexanPlus^® to help us to provide quality care to our members.

Examples of utilization management tools include:

• Prior Authorization: TexanPlus requires you to get prior authorization for certain medicines. This means that you will need to get approval from TexanPlus before you fill your prescription. If you don’t get approval, TexanPlus may not cover the medicines.
• Quantity Limit: For certain medicines, TexanPlus limits the amount of the medicine that we will cover per prescription or for a defined period of time. For example, TexanPlus^® will provide up to 10 capsules per prescription of TAMIFLU^®.
• Step Therapy: In some cases, TexanPlus requires you to first try one medicine to treat your medical condition before we will cover another medicine for that condition. For example, if Medicine A and Medicine B both treat your medical condition, TexanPlus may require your doctor to prescribe Medicine A first. If Medicine A does not work for you, only then will TexanPlus cover Medicine B.
• Generic Substitution: When there is a generic version of a brand-name drug available, TexanPlus network pharmacies will typically give you the equivalent generic version to save you expense 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 TexanPlus plan may contact your doctor to see if the alternative medicine is appropriate for you. Only your doctor can authorize this change.

Learning if your medicine has restrictions

You can find out if your medicine is subject to these additional requirements or limits by using the Drug Search tool. If your medicine does have these additional restrictions or limits, you can ask TexanPlus 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, unless they are a part of step therapy
• 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
• 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