Pharmacy Program and Drug Formulary Secure Horizons Group Retiree Medicare Advantage Plan n Pharmacy Program Description n Platinum Plus Enhanced Formulary California Benefits Effective January 1, 2006 Table of Contents Your Secure Horizons Group Retiree Medicare Advantage Plan Prescription Drug Benefit........................................................................................................ iii Secure Horizons Pharmacy Program Definitions .................................................................... iii What Is the Platinum Plus Enhanced Formulary? ....................................................................iv Where to Have Your Prescriptions Filled .................................................................................iv Preferred and Non-Preferred Network Pharmacies .................................................................iv Network Preferred Pharmacy Locations ..................................................................................iv How to Fill a Prescription at a Network Pharmacy ...................................................................v Mail Service Pharmacy ..............................................................................................................v Secure Horizons Group Retiree Medicare Advantage Plan Offers a Two-Part Prescription Drug Benefit ..........................................................................vii Part 1 – Medicare Part D Prescription Drug Coverage ...................................................vii How Your Medicare Part D Prescription Drug Coverage Works ........................................vii What Is the Explanation of Benefits? .................................................................................viii Coverage Determinations ...................................................................................................viii Secure Horizons Prescription Drug Appeals and Grievances .............................................. x Medicare Part D Formulary Limitations and Exclusions ................................................... xiii Extra Help With Your Medicare Part D Covered Drug Costs ............................................ xiii Low Income and Resource Chart — Extra Help With Medicare Part D Covered Drugs .........................................................................................xiv Part 2 – Additional Formulary Drug Coverage .............................................................. xvi How Your Additional Formulary Drug Coverage Works ................................................... xvi What to Do if You Have a Problem With Drugs Not Covered by Medicare Part D on Part 2 of the Formulary ................................................................ xvi Pharmacy Limitations and Exclusions ................................................................................. xxiv Drugs Covered Under the Secure Horizons Group Retiree Medicare Advantage Plan Medical Benefit............................................................................ xxv How the Formulary Is Organized ......................................................................................... xxv How to Read the Secure Horizons Drug Formulary Listing ................................................ xxiv What Is on the Formulary ................................................................................................... xxiv Part 1 – Formulary Drugs Covered Under Your Medicare Part D Drug Coverage .......................................................................................1 Part 2 – Additional Covered Formulary Drugs ........................................................................52 Formulary Index ......................................................................................................................99 Your Secure Horizons Group Retiree Secure Horizons Pharmacy Medicare Advantage Plan Program Definitions Prescription Drug Benefit Brand Name Drug – a drug that has met the safety, purity, strength and efficacy standards for Beginning January 1, 2006, PacifiCare will FDA approval. This category includes drugs that offer Secure Horizons Group Retiree Medicare are single-source (one manufacturer) and drugs Advantage benefit plans that include a Medicare- that are cross-licensed. approved Part D drug benefit. As a member of the Secure Horizons Group Retiree Medicare Copayment – the amount you pay for Generic Advantage Plan, you will automatically receive and Brand Name Formulary and Covered Drugs Medicare Part D prescription drug coverage as in accordance with your Secure Horizons Group a part of your benefit plan. Only members of Retiree benefit plan. Copayment amounts are the Secure Horizons Group Retiree Medicare listed in the Retiree Benefits Summary Insert or Advantage Plan may access the Medicare-approved the Schedule of Benefits. Part D drug benefit offered through PacifiCare. Formulary – a list of drugs selected by PacifiCare Members enrolled in a Secure Horizons Group in consultation with health care professionals that Retiree benefit plan which offers Medicare your contracting health care providers may use in Part D drug coverage may not enroll in any your medical treatment. The Formulary is updated other Medicare Part D drug plan. If you periodically and is subject to change with notice enroll in any other Medicare Part D drug during the contract year. Your Secure Horizons plan, you will be disenrolled from the Group Retiree Medicare Advantage benefit Secure Horizons Group Retiree Medicare plan’s Formulary is the Platinum Plus Enhanced Advantage Plan. Formulary. In addition to the prescription drug coverage Generic Drug – a drug that has met the standards offered under Medicare Part D, your Secure set by the FDA to assure its equivalency to the Horizons Group Retiree Medicare Advantage original patented Brand Name drug. The levels benefit plan allows you to access hundreds of of safety, purity, strength and effectiveness of a prescription drugs on the Formulary that are not Generic drug approved by the FDA are the same available under Medicare Part D. This additional as the Brand Name drug. drug coverage provides you and your doctor Prescription Unit – the maximum amount with more choices in treating your particular (quantity) of drug that may be dispensed per medical conditions. prescription for a single Copayment amount. All You pay a Copayment at network retail pharmacies outpatient prescription drug Copayment amounts for Formulary and Covered Drugs. You may also are charged on a per Prescription Unit basis. For pay a Copayment and receive a 90-day supply most oral drugs, the Prescription Unit represents of your prescription drugs through Prescription a 30-day supply of the drug. Certain drugs have Solutions,® PacifiCare’s contracting mail service quantity limits and/or require Prior Authorization. pharmacy provider. The PacifiCare retail For drugs that could be habit-forming, the network pharmacy that you choose may allow Prescription Unit is set at a smaller quantity for you to receive a 90-day supply for the applicable your protection and safety. Copayments (for example, 3 Copayments) for Prior Authorization – a requirement for selected your Formulary and Covered Drugs. (To find out drugs to be Prior Authorized by PacifiCare to if your pharmacy will fill a prescription for a determine if they are medically necessary and 90-day supply, please call Customer Service or being prescribed according to treatment guidelines visit our Web site at www.securehorizons.com) consistent with standard professional practice. The Copayment amounts that you pay for drugs Step Therapy – a process by which you may be on the Formulary are listed in the Retiree Benefits required to try a certain drug to treat your medical Summary Insert or the Schedule of Benefits. If condition before you can be covered for another you have special needs, this document may be drug for that condition. available in other formats. Tier I Generic Drugs – Generic drugs included on the Formulary. When the FDA approves a new Generic drug, the Secure Horizons Group Retiree For more information, please call Customer Service at 1-800-228-2144 (for the hearing impaired, 1-800-685-9355), 7 a.m. to 9 p.m., Monday through Friday. iii Medicare Advantage Plan may cover the Generic pharmacies nationwide. Also included in the drug in place of the Brand Name drug listed on PacifiCare network of contracted pharmacies the Formulary. are long-term care pharmacies, Indian Health Tier II Brand Name Drugs – Brand Name drugs Service/Tribal/Urban Indian Health Program included on the Formulary and designated by (I/T/U) pharmacies and home infusion PacifiCare as a Tier II drug. Certain Tier II drugs pharmacies. Sometimes a particular pharmacy may require Prior Authorization from PacifiCare may leave the PacifiCare contracting network. before they are covered. In that situation, have your prescriptions filled at another network pharmacy. Tier III Drugs – Generic and Brand Name drugs If you are away from home and have an urgent that are more costly or specialized than the Tier or emergency situation which requires a I Generic and Tier II Brand Name drugs listed on prescription, and you do not have access to a the Formulary. You pay a higher Copayment for PacifiCare network pharmacy, you may have these Tier III drugs than you do for the Tier I and your prescription filled at any pharmacy. You Tier II drugs on the Formulary. Tier III drugs may may also have your prescriptions filled at a non-