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Great Plans Medicare Advantage South Dakota 2018 ...

H1787_2018_drug01 Accepted Great Plans Medicare Advantage South Dakota 2018 comprehensive formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved formulary File Submission ID, 00018345 Version 16 This formulary was updated on 11/01/ 2018 . For more recent information or other questions, please contact Great Plains Medicare Advantage Member Services at 1-844-637-4760 or, for TTY users, 711, Hours of operations: 8 to 8 , seven days a week (except Thanksgiving and Christmas) from October 1 through February 13, and Monday to Friday (except holidays) from February 14 through September 30, or visit Great Plains Medicare Select complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

H1787_2018_drug01 Accepted Great Plans Medicare Advantage South Dakota 2018 Comprehensive Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

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1 H1787_2018_drug01 Accepted Great Plans Medicare Advantage South Dakota 2018 comprehensive formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved formulary File Submission ID, 00018345 Version 16 This formulary was updated on 11/01/ 2018 . For more recent information or other questions, please contact Great Plains Medicare Advantage Member Services at 1-844-637-4760 or, for TTY users, 711, Hours of operations: 8 to 8 , seven days a week (except Thanksgiving and Christmas) from October 1 through February 13, and Monday to Friday (except holidays) from February 14 through September 30, or visit Great Plains Medicare Select complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

2 Great Plains Medicare Select cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Great Plains Medicare Select erfu llt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht ab. ATENCI N: si habla espa ol, tiene a su disposici n servicios gratuitos de asistencia ling stica. Llame al 1-844-637-4760 TTY: : Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verf gung. Rufnummer: 1-844-637-4760 TTY: 711. 1 Note to existing members: This formulary has changed si nce last year. Please review this document to make sure that it still contains the drugs you take. When this drug list ( formulary ) refers to we, us , or our, it means Great Plains Medicare Advantage .

3 When it refers to plan or our plan, it means Great Plains Medicare Advantage . This document includes a list of the drugs ( formulary ) for our plan which is current as of 11/01/ 2018 . For an updated formulary , please contact us. Our contact information, along with the date we last updated the formulary , appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary , pharmacy network, and/or copayments/coinsurance may change on January 1, 2018 , and from time to time during the year. 2 What is the Great Plains Advantage formulary ? A formulary is a list of covered drugs selected by Great Plains Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.

4 Great Plains Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Great Plains Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, le ss 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 drug from our formulary , will not affect members who are currently taking the drug.

5 It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available whe n you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drug s from our formulary , or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the t ime the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug . I f the Food and Drug Administration deems a drug on our formulary to be unsaf e or the drug s manufacturer removes t he drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

6 The enclosed formulary is current as of 11/01/ 2018 . To get updated information about the drugs covered by Great Plains Advantage , please contact us. Our contact information appears on the front and back cover pages. In the event that Great Plains Advantage has CMS-approved non-maintenance changes to the formulary throughout the plan year ( remove drugs from our formulary , add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, Great Plains Advantage will update our formulary and post in on our website. How do I use the formulary ? There are two ways to find your drug within the formulary : Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat.)

7 For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents-Misc. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 109. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. 3 What are generic drugs? Great Plains Medicare Advantage covers both brand name drugs and generic drugs.

8 A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization (PA): Great Plains Medicare Advantage requires you [or your physician] to getprior authorization for certain drugs. This means that you will need to get approval from Great PlainsMedicare Advantage before you fill your prescriptions. If you don t get approval, Great PlainsMedicare Advantage may not cover the drug. Prior Authorization Restriction for Part B vs Part D Determination (PA BvD): This drug may beeligible for payment under Medicare Part B or Part D. You (or your physician) are required to get priorauthorization from Great Plains Medicare Advantage to determine that this drug is covered underMedicare Part D before you fill your prescription for this drug.

9 Without prior approval, Great PlainsMedicare Advantage may not cover this drug. Prior Authorization Restriction for New Starts Only (PA NSO): If you are a new member, you (oryour physician) are required to get prior authorization from Great Plains Medicare Advantage beforeyou fill your prescription for this drug. Without prior approval, Great Plains Medicare Advantage maynot cover this drug. Quantity Limits (QL): For certain drugs, Great Plains Medicare Advantage limits the amount of thedrug that Great Plains Medicare Advantage will cover. For example, Great Plains Medicare Advantageprovides 9 tabs per prescription for sumatriptan tab. This may be in addition to a standard one month orthree-month supply. Step Therapy (ST): In some cases, Great Plains Medicare Advantage requires you to first try certaindrugs to treat your medical condition before we will cover another drug for that condition.

10 For example,if Drug A and Drug B both treat your medical condition, Great Plains Medicare Advantage may notcover Drug B unless you try Drug A first. If Drug A does not work for you, Great Plains MedicareAdvantage will then cover Drug B. Non-Mail-Order Drug (NM): You may be able to receive greater than a 1-month supply of most of thedrugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail-orderbenefit are noted with NM in the notes column of your formulary . Limited Distribution (LD): The symbol (LD) next to a drug name indicates that the drug has beennoted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs canonly be obtained at specialty designated pharmacies able to appropriately handle the can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7.


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