Drug Exclusions
Drugs not covered under Medicare Part D and not available under exception including agents used to treat the following:
- anorexia
- weight loss or gain
- cosmetic purposes or hair growth
- symptomatic relief of cough and colds
- prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee as a condition of sale
- nonprescription drugs (other than select over-the-counter drugs on RxAmerica's formulary)
- barbiturates
- benzodiazepines
Non-Formulary Drugs
Any drug not listed on the Star formulary is considered non-formulary. However, members can obtain these non-formulary drugs through RxAmerica's exception policy if criteria is met.
Prior Authorizations
Some formulary brand drugs will require prior use of an alternative formulary drug in order to be covered. Some drugs may have quantity limitations.
Transition
RxAmerica expects that many enrollees will identify formulary conflicts before their next refill and that the process of transitioning to a formulary alternative or instituting an exception request can start before the member seeks a refill. A one-time only, up to 30-day first fill transition supply of Part D covered drugs will be provided under the benefit during the first 90 days. The member will be notified by the pharmacy when a drug is not on the formulary. Information will be provided to the member describing formulary alternatives, how to make an exception request and how to access the Appeals process.
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