Formulary Change Notice HealthPartners may remove drugs from our formulary (list of covered drugs) or add rules about whether and when certain drugs are covered during the year. The chart below contains upcoming changes to the HealthPartners formulary. You may not be taking these drugs now. We provide you with these updates so that you know about future changes to our drug list. Please see Section 4 of your Monthly Prescription Drug Summary (Member Explanation of Benefits) for specific changes to drugs that you are currently taking. Effective Drug Type of Change Reason for Change Other Possible Drugs (if applicable) 02/13/2016 AUVI-Q 0.3MG/0.3 INJECTION AUTO FROM REMOVAL OF FROM DUE TO FDA ** EPIPEN AUTOINJECTOR - 3 INJCT MANDATED MARKET WITHDRAWAL 02/13/2016 AUVI-Q 0.15/0.15 INJECTION AUTO INJCT FROM REMOVAL OF FROM DUE TO FDA MANDATED MARKET ** EPIPEN JR AUTOINJECTOR - 3 06/01/2016 EXELON 13.3MG/24H TRANSDERM. PATCH TD24 06/01/2016 AGGRENOX 25MG- 200MG CPMP 12HR WITHDRAWAL ** RIVASTIGMINE 13.3MG/24HR TRANSDERMAL PATCH - 2 ** ASPIRIN-DIPYRIDAMOLE 25MG-200MG ER - 2 06/01/2016 VIRAMUNE XR 100 MG TAB ER 24H 06/01/2016 ORAP 2 MG 06/01/2016 SURMONTIL 100 MG ** NEVIRAPINE 100MG ER - 2 ** PIMOZIDE 2MG - 2 ** TRIMIPRAMINE 100MG - 2
06/01/2016 SURMONTIL 25 MG ** TRIMIPRAMINE 25MG - 2 06/01/2016 TARGRETIN 75 MG ** BEXAROTENE 75MG - 5 06/01/2016 ORAP 1 MG 06/01/2016 AVODART 0.5 MG 06/01/2016 GLEEVEC 100 MG 06/01/2016 GLEEVEC 400 MG 06/01/2016 PULMICORT 1 MG/2 ML INHALATION AMPUL-NEB 06/01/2016 INVEGA 3 MG TAB ER 24 ** PIMOZIDE 1MG - 2 ** DUTASTERIDE 0.5MG - 2 ** IMATINIB MESYLATE 100MG - 5 ** IMATINIB MESYLATE 400MG - 5 ** BUDESONIDE 1MG/2ML SUSPENSION FOR NEBULIZATION - 2 ** PALIPERIDONE 3MG ER - 2 06/01/2016 INVEGA 6 MG TAB ER 24 ** PALIPERIDONE 6MG ER - 2
06/01/2016 INVEGA 9 MG TAB ER 24 ** PALIPERIDONE 9MG ER - 2 06/01/2016 EXELON 9.5MG/24HR TRANSDERM. PATCH TD24 06/01/2016 EXELON 4.6MG/24HR TRANSDERM. PATCH TD24 06/01/2016 XENAZINE 25 MG 06/01/2016 XENAZINE 12.5 MG 06/01/2016 INVEGA 1.5 MG TAB ER 24 FROM FROM DUE TO ADDITION OF NEW ** RIVASTIGMINE 9.5MG/24HR TRANSDERMAL PATCH - 2 ** RIVASTIGMINE 4.6MG/24HR TRANSDERMAL PATCH - 2 ** TETRABENAZINE 25MG - 5 ** TETRABENAZINE 12.5MG - 5 ** PALIPERIDONE 1.5MG ER - 2 06/01/2016 MEGACE ES 625MG/5ML SUSP ** MEGESTROL 625MG/5ML SUSPENSION - 2 06/01/2016 MIRAPEX ER 4.5 MG TAB ER 24H ** PRAMIPEXOLE 4.5MG ER - 2
06/01/2016 SURMONTIL 50 MG ** TRIMIPRAMINE 50MG - 2 06/01/2016 MIRAPEX ER 2.25 MG TAB ER 24H ** PRAMIPEXOLE 2.25MG ER - 2 06/01/2016 MIRAPEX ER 3 MG TAB ER 24H ** PRAMIPEXOLE 3MG ER - 2 06/01/2016 MESTINON 180 MG ER 06/01/2016 JALYN 0.5-0.4 MG CPMP 24HR 06/01/2016 NDA 10 MG ** PYRIDOSTIGMINE 180MG ER - 2 ** DUTASTERIDE-TAMSULOSIN 0.5MG-0.4MG ER - 2 ** MEMANTINE 10MG - 2 06/01/2016 NDA 5 MG 06/01/2016 NDA 5 MG-10 MG TAB DS PK 06/01/2016 NDA 2 MG/ML SOLUTION 06/01/2016 LOTRONEX 0.5 MG ** MEMANTINE 5MG - 2 ** MEMANTINE 5MG-10MG S IN A DOSE PACK - 2 ** MEMANTINE 2MG/ML SOLUTION - 2 ** ALOSETRON 0.5 MG - 5
06/01/2016 SODIUM CITRATE AND NDC FROM ** SHOHL'S MODIFIED 300-500 MG SOLUTION - 1 CITRIC ACID 334-500MG SOLUTION 06/01/2016 CYTRA-2 334-500MG SOLUTION NDC FROM ** SHOHL'S MODIFIED 300-500 MG SOLUTION - 1 06/01/2016 ABILIFY DISCMELT 10 MG TAB RAPIDS 06/01/2016 ABILIFY DISCMELT 15 MG TAB RAPDIS 06/01/2016 POTASSIUM CITRATE-CITRIC ACID 3300-1002 PACKET 06/01/2016 LOTRONEX 1 MG 08/01/2016 SODIUM FLUORIDE 0.20% DENTAL SOLUTION NDC FROM NDC FROM ** ARIPIPRAZOLE 10 MG DISINTEGRATING - 2 ** ARIPIPRAZOLE 15 MG DISINTEGRATING - ** POTASSIUM CITRATE 5 MEQ, 10 MEQ OR 15 MEQ ER - 2 ** ALOSETRON 1 MG - 5 ** DENTA 5000 PLUS 1.1% DENTAL CREAM - 1 08/01/2016 VITAPEARL 30-1.4-200 CAP IR DR NDC FROM ** VITATRUE 30-1.4-300 COMBO. PKG - 1 08/01/2016 PRENA1 CHEW 1.4 MG TAB CH BPH NDC FROM ** VITAMEDMD REDICHEW RX 1.4 MG TAB CH BPH - 1
08/01/2016 PRENAISSANCE DHA 27-1-50 MG COMBO. PKG NDC FROM ** CITRANATAL DHA 27-1-50 MG COMBO. PKG - 1 08/01/2016 PRENATABS RX 29 MG-1 MG 08/01/2016 TRINATE 28 MG-1 MG 08/01/2016 VINATE-M 27 MG-1 MG 08/01/2016 VINATE ONE 60 MG- 1 MG NDC FROM NDC FROM NDC FROM NDC FROM ** PRENATAL PLUS 29 MG-1 MG - 1 ** VIRT-NATE 28 MG-1 MG - 1 ** PRENATAL LOW IRON 27 MG-1 MG - 1 ** POLY IRON PN 60 MG-1 MG - 1 08/01/2016 ICAR-C PLUS 100-250-1 NDC FROM ** FE C PLUS 100-250-1-1 ** This drug is on our drug list (formulary). Please talk with your doctor to find out if this drug is right for you. Note: The amount you will pay for this drug depends on which coverage period you are in. You can call Member Services to find out how much you will pay for this drug. HealthPartners MSHO is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. HealthPartners Freedom and HealthPartners Retiree National Choice are offered by HealthPartners, a Cost plan and a PDP with a Medicare Contract. Enrollment in HealthPartners depends on contract renewal.
What you and your doctor can do We are telling you about these changes now, so that you and your doctor will have time (at least 60 days) to decide what to do. Depending on the type of change, there may be different options to consider. For example: Perhaps you can find a different drug covered by the plan that might work just as well for you. o You can call us at HealthPartners Member Services to ask for a list of covered drugs that treat the same medical condition. o This list can help your doctor to find a covered drug that might work for you and have fewer restrictions or a lower cost. You and your doctor can ask the plan to make an exception for you. This means asking us to agree that the upcoming change in coverage or cost-sharing tier of a drug does not apply to you. o Your doctor will need to tell us why making an exception is medically necessary for you. o To learn what you must do to ask for an exception, see the Evidence of Coverage that we sent to you. Look for Chapter 9, What to do if you have a problem or complaint. o (Section 6 of your Monthly Prescription Drug Summary tells how to get a copy of the Evidence of Coverage if you need it.) For more information To get updated information about the drugs covered by HealthPartners please visit our Web site at www.healthpartners.com/medicarerx or call Member Services at 952-883-7979 (Freedom and Retiree National Choice) or 952-883-7373 (MSHO) or toll free at 1-800-233-9645 (Freedom and Retiree National Choice) or 1-877-816-9539 (MSHO) from 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, or from February 15 through September 30 call us 8 a.m. to 8 p.m. Monday through Friday to speak with a representative. Calls to these numbers are free. TTY/TDD users should call 952-883-6060 or toll free at 1-800- 443-0156. If you disagree with our decision to remove or change coverage for any of these drugs, you may also file a grievance with us. Please call us at HealthPartners Member Services if you want to file a grievance. You may also send your grievance to us in writing to HealthPartners Member Rights & Benefits PO Box 9463 Minneapolis, MN 55440-9463 For more information on filing a grievance, look for Chapter 9, What to do if you have a problem or complaint. This document may be made available in other formats such as Braille, large print or other alternate formats. Please call Member Services at [952-883-7979] [952-883-7373] or toll free at [1-800-233-9645] [1-877-816-9539] for additional information. TTY users should call 952-883-6060 or toll free at 1-800-443-0156. We are available from 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, or from February 15 through September 30 call us 8 a.m. to 8 p.m. Monday through Friday to speak with a representative. For more detailed information about your HealthPartners prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800- 633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov. Medicare s Extra Help Program You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or Your Medicaid Office. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. The formulary, may change at any time. You will receive notice when necessary.