About MVP Health Care Tiered Prescription Drug Benefits - 2017
MVP Health Care offers pharmacy programs that support your health, wellness and safety, while reducing costs for employers and members. The cost of prescription drugs varies widely, even for drugs that are used to treat the same condition. Our Covered Drug List (Formulary) can help you and your doctor choose lower-cost drug options that work just as well, and save you money.
What is a Formulary?
- A Formulary, sometimes called a Covered Drug List, is a list of prescription drugs generally covered by your pharmacy benefit. Both brand-name and generic drugs are included on MVPs Formulary.
- MVP uses a 6-Tier Formulary for our Part D plans. See below for a description of each tier.
- The Formulary was developed and approved by the MVP Pharmacy & Therapeutics (P&T) Committee. The Committee is comprised of practicing physicians, representing a variety of medical specialties, practicing pharmacists and clinical health plan staff including medical directors and registered pharmacists. A physician and pharmacist with training and experience in the care of the elderly and disabled are also included on the Committee.
- Drugs on the Formulary have been approved by the U.S. Food and Drug Administration (FDA) as safe and effective and are considered cost effective by MVP.
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Why are prescription drugs divided into tiers?
Prescription drugs come in a wide range of prices, even for those that are used to treat the same condition. MVP divides prescription drugs into six tiers to make it easier for you and your doctor to choose the lower-cost option for the drugs you may need. If you receive Low Income Subsidy (LIS), EPIC (in New York) or VPharm (in Vermont) your co-payments may be different.
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What is the difference between tiers?
Each tier has a co-pay level for covered prescription drugs within that tier. Your employer or health plan sets the co-pay for the drugs covered under your pharmacy benefit. If you receive Low Income Subsidy (LIS), EPIC (in New York), or V-Pharm (in Vermont), your co-payments may be different.
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Tier 1-Preferred Generic Drugs
Tier 1 includes select drugs for diabetes, blood pressure control, glaucoma, gout, bone health, heartburn and ulcers, mental health conditions, pain management, cholesterol control, and thyroid conditions. The drugs in Tier 1 are provided at little or no cost to you.
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Tier 2-Generic Drugs
Tier 2 includes generic drugs (Note: Not all generic drugs will be Tier 2 drugs). Generic drugs have the same active ingredients, strength, and effectiveness as the brand-name versions, but at a much lower cost.To reduce out-of-pocket costs, consider using Tier 2 Generics if you and your doctor decide they are right for you.
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Tier 3-Preferred Brand Name Drugs
Tier 3 includes preferred brand drugs that have the lowest cost sharing for brand name drugs. If you and your doctor decide that a brand name drug is right for you, try using a Tier 3 brand name drug to save you money.
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Tier 4-Non-preferred Drugs
Tier 4 includes brand name and generic drugs. In addition, Part D drugs excluded from our Formulary must go through an exception process in order for MVP to cover them. If they are approved, they may be covered in Tier 4.
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Tier 5-Specialty Drugs
Tier 5 includes all drugs (brand name and generic) that cost $670 or more for a 30-day supply. Most drugs in this tier are restricted to a 30-day supply at retail, and are excluded from the mail order program.
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Tier 6-Vaccines
Tier 6 includes the most common Part D vaccines: the shingles vaccine (Zostavax), tetanus vaccines, and combination tetanus / diphtheria / pertussis vaccines (such as Tenivac, Adacel and Boostrix). The vaccines in Tier 6 are provided at no cost to you.
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Who determines the tier a drug falls under?
Our Pharmacy Benefit Manager (CVS/caremark) and Pharmacy & Therapeutics (P&T) Committee, consisting of doctors and pharmacists from our community, work together to create and review the MVP Part D Formulary. Drugs are selected based on the role they play in treating a given disease or condition. Only medications that have passed U.S. Food and Drug Administration (FDA) testing are considered for coverage.
- CVS/caremark reviews clinical information on the medications being considered for the Prescription Drug List and provides comments to the P&T Committee.
- The P&T Committee reviews information from different sources for each medication. Each medicine is included in the Formulary according to how it compares with other drugs that are used to treat the same disease or condition.
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What is a tier exception?
You can ask MVP to provide a higher level of coverage for your drug. For example, if your drug is contained in our Tier 4, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Tier 3 instead. This would lower the amount you must pay for your drug. All requests submitted for tier exception must be signed by a physician. They should also include documentation (chart notes) to support the request.
Please note that if we grant your request to cover a drug that is not in our Formulary (see excluded drug below), you may not ask us to provide a higher level of coverage for that drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Tier (Tier 5).
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What are excluded drugs?
Excluded drugs are those not covered on MVPs Part D Formulary. There are two types of Part D excluded drugs: Medicare excluded and Formulary excluded. Medicare excluded drugs include vitamins, over the counter products, cosmetic agents, weight loss/weight gain medications, erectile dysfunction medications, DESI drugs, and unapproved drugs. These drugs are excluded by Medicare and can not be covered by MVP per government regulations. Formulary excluded drugs include new medications out on the market and brand name drugs that have generic equivalents. You can ask us to cover a Formulary excluded drug as a Formulary exception (see below).
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What can I do if my drug is excluded from the Formulary?
If you learn that MVP does not cover your drug, you can ask your doctor to consider changing your medication to one that is on our Formulary. If your doctor does not feel that another drug is appropriate, you or your doctor can ask MVP Health Care to cover an excluded drug as a Formulary exception by submitting a request to us. All requests submitted for Formulary exception must be signed by a physician. They should also include documentation (chart notes) to support the request. Please note that MVP can not approve a Formulary exception request for a Medicare excluded drug, only Formulary excluded drugs will be considered.
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Why are generic drugs less expensive?
There are generic versions of many brand-name drugs that can save you money. Choosing lower-cost generic drugs is like using store-brand products at your grocery store you can get the same product at a lower price.
- Generic drugs have been approved by the FDA. They are as safe and effective as brand-name versions.
- Generics contain the same active ingredients in the same amounts as the brand-name products.
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How can I save money on prescriptions?
Consider the following options to help you save money on your prescription drugs:
- Talk with your doctor or pharmacist about using generic drugs; and
- Shop around (especially if your Part D coverage has a coverage gap or "donut hole"). Many area pharmacies are offering discounts on hundreds of medications. if the price of a medication is less than your co-pay, you will be charged the lesser amount. Also, the lower the cost of your medications, the longer it will take to get into the coverage gap or donut hole.
- Use your mail order benefityou pay only 2 monthly co-pays for a 3 month supply.
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What is Prior Authorization?
"Prior Authorization is a process in which MVP works with you and your health care provider to make sure you receive medically-necessary, high-quality medical treatment at a reasonable cost. It also makes sure that you meet clinical criteria for the service or procedure that your doctor is recommending.
View the complete list of drugs that require Prior Authorization in 2017
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What is a Specialty Pharmacy?
MVP works with CVS Specialty Pharmacy. CVS Specialty Pharmacy provides selected specialty medications to members with chronic conditions. This helps you better manage your medication. Prescriptions are delivered by next-day service to your home or office. Please visit www.CVScaremarkspecialtyrx.com for additional information.
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Last updated: October 2016
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