Formulary
A formulary is a list of covered drugs that represents the prescription therapies believed to be a necessary part of a quality treatment program. The formulary is selected by Capital Health Plan in consultation with a team of health care providers.
Capital Health Plan Medicare Advantage (HMO) Formulary
You may view the entire formulary in the attached document CHP Medicare Advantage Formulary (pdf 526.10 kB) . Certain drugs on our formulary may require that you get approval from Capital Health Plan before you fill your prescription. These drugs will contain a "PA" in the notes section of the formulary document. Other drugs may require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. These drugs will contain a "ST" in the notes section of the formulary document. You may review the coverage criteria for each of these drugs in the attached PA document (pdf 119.10 kB) and ST document (pdf 24.88 kB) .
Capital Health Plan covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient formulary as brand name drugs. Generic drugs usually cost less than brand name drugs and are rated by the United States Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
The formulary may change during the year. We update the formulary on our website each month. Generally, if you are taking a Part D drug on our 2010 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the Part D drug during the 2010 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a Part D drug from our formulary, will not affect members who currently are taking the drug. That drug will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year.
By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plans. Please see the list of these excluded drugs here.
For more information on prescription drug coverage, please review your Evidence of Coverage.
To learn more about our grievances, coverage determinations, exceptions, and appeals processes, and the procedure members must follow to file a grievance or request a coverage determination, exception, or appeal, please review our Determinations, Grievances & Appeals section. You also may click on the Part D Exceptions button to the left to learn how to seek an exception to the CHP Medicare Advantage Formulary.
