FORMULARY

Welcome to the Community Health Partnership, Inc. (CHP) Formulary/Prescription Drug List.

Our formulary provides coverage information about drugs covered through our Partnership Program. You can search our formulary by either drug category or drug name.

Please note: If there is a special requirement for coverage of a drug such as prior authorization, quantity limit, or step therapy, this information will be noted in your search results.

SEARCH OUR 2010 FORMULARY HERE

2010 Tier Description

The Partnership Program offers a variety of prescription coverage options that may have different benefits and exclusions. Please call our Customer Service Department at 1-800-546-5677 for details, 24 hours a day, seven days a week. (TTY/TDD Users should call 1-866-706-4759).

Prior Authorizations

Certain drugs may require prior authorization (prior approval) for a variety of reasons. CHP’s Pharmacy Benefit Manager (PBM) determines the prior authorization status of drugs on the basis of program requirements and ongoing evaluation of the drugs’ utilization, therapeutic efficacy, safety, and cost. Our Pharmacy Benefits Manager revises the various policies, procedures, and criteria related to prior authorizations on an ongoing basis as clinical information changes, new guidelines, and standards of care are updated.

A CHP contracted provider can contact our Pharmacy Benefit Manager at 1-800-546-5677 to request a Coverage Determination Form or the form can be accessed here - Coverage Determination Form. The completed Coverage Determination Form can be faxed to: 1-866-632-7946.

Please Note: If a Prior Authorization is needed, a CHP member’s provider will need to contact CHP's Pharmacy Benefit Manager before the prescription is filled. If the necessary information is not received to satisfy the Prior Authorization criteria, CHP may not be able to cover the drug.

Medication Therapy Management Program (MTMP)

The Medication Therapy Management Program (MTMP) provides members with additional assistance in managing their medications. The Partnership Program MTMP is provided by pharmacists who:

• Review drug claims, lab data, and diagnostic information of the member.
• Work with member prescribers and Teams to seek to improve medication regimens.

The purpose of this additional support is to help members get the best therapeutic effect from the medications they receive while minimizing adverse effects. Participation in the Medication Therapy Management Program requires that members meet the following criteria:

1. Have three of four chronic diseases which include - Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF), Diabetes or Dyslipidemia; AND
2. Have been prescribed seven disease-specific Medicare Part D drugs related to chronic disease (COPD, CHF, Diabetes, Dyslipidemia); AND
3. The member will incur a $750.00 threshold for Medicare Part D Drugs based on data from the previous quarter.

Formulary Changes

The Partnership Program may add or remove drugs from the formulary during the year. Before removing drugs from the formulary or adding prior authorization, quantity limits and/or step therapy restrictions on a drug, the Partnership Program will notify providers of the change via this website at least 60 days before the date that change becomes effective. Exceptions to this would be when the US Food and Drug Administration deems a drug on the formulary to be unsafe or when the drug’s manufacturer removes the drug from the market, in which case the Partnership Program will promptly remove the drug from the formulary.

When changes are made, the 60 day notices will be listed below, by month. Additionally, affected members will be notified of the changes in their monthly statements, referred to as their Part D Explanation of Benefits (EOB).

Changes effective July 1st, 2010

Changes effective May 1st, 2010

Changes effective January 1st, 2010

General Transition Notice

A Transition Notice is a description of special consideration given to new or existing members who are currently taking prescription drugs that are not or are no longer on our current formulary.  The Partnership Program will provide a transition process on prescription drugs for a temporary time period of 30 days for all new members, members stabilized on formulary drugs that require a prior authorization or step therapy and for unplanned transitions as members change a treatment setting due to a change in the type of care they require.

Exceptions and Appeals Processes

A particular medicine may not always be listed on the Partnership Program Formulary. In some instances, a brand name medicine is covered, but our member may ask that it be covered at a lower brand name co-pay rather than the lower cost. These requests are called exceptions. Members can ask for a review and a decision from CHP.

There may be times when a member will contact CHP with a complaint. If he/she is unable to get a prescription that they think they should get under our plan, this type of complaint is an appeal. If the Partnership Program did not pay for the member's prescription, or if he/she thinks their portion of the cost was too high, this is also considered an appeal.

For more information on exceptions and appeals, please see Coverage Determination (Exception), Appeal and Grievance Process.