Find a Drug

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
H3660_08-56/10-07

What is the SummaCare Secure Formulary?
This formulary is a list of drugs covered by SummaCare Secure and designated by Medicare in consultation with a team of healthcare providers. This formulary represents the prescription therapies believed to be a necessary part of a quality treatment program. SummaCare Secure will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SummaCare plan (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 change?
Yes, SummaCare may add or remove drugs from our formulary during the year. This formulary is current as of July 1, 2008. To get updated information about the drugs covered by SummaCare Secure, please call 888-464-8440. From November 15, 2007, through March 1, 2008, a representative will be available to speak with you from 8:00 a.m. to 8:00 p.m. seven days a week. Beginning March 2, 2008, through November 14, 2008, a representative will be available to speak with you from 8:00 a.m. to 8:00 p.m. Monday through Friday. Persons with hearing impairments, please call TTY at 800-750-0750.

Generally, if you are taking a drug on our 2008 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2008 coverage year except when a new, less 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. 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 when you chose our plan, except for cases in which you can save additional money or improve the safety of your drugs.

If SummaCare Secure:

• Removes drugs from our formulary; or
• Adds a prior authorization restriction; or
• Adds a quantity limit restriction; or
• Adds a step therapy restriction; or
• Moves a drug to a higher cost-sharing tier

We must notify members who take the drug at least 60 days before the change becomes effective.

If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

How do I use the formulary?
There are two ways to find your drug within the formulary:
1. Medical Condition
The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list. Then look under the category name for your drug.
2. Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index. 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.

What are generic drugs?
SummaCare Secure covers both brand-name drugs and generic drugs. A generic drug has the same active-ingredient formula as the brand name drug. Generic drugs usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).

How much will I pay for SummaCare Secure Covered Drugs?
If you qualified for extra help with your drug costs, your costs for your drugs may be different than those described below. Please refer to your Evidence of Coverage book or call SummaCare Secure to find out what your costs are. The amount you pay depends on which tier your drug is in under our plan and whether you fill your prescription at a plan pharmacy. You can find out which tier your drug is in by looking in the formulary. You will pay a copayment for your drugs until your total drug costs (the amount you paid, plus the amount SummaCare Secure has paid) reaches $2,510 under the Silver Plus plan, $3,300 under the Gold Plus plan or $2,510 under the Platinum plan.

Copayments are as follows:

• Tier I Drugs: $3 for up to a 30-day supply
  $7.50 for up to a 90-day supply through mail order
• Tier II Drugs $30 for up to a 30-day supply
  $75 for up to a 90-day supply through mail order
• Tier III Drugs $60 for up to a 30-day supply
  $180 for up to a 90-day supply through mail order
• Tier IV Drugs 25% for up to a 30-day supply
  25% for up to a 90-day supply through mail order

After you have paid $4,050 out of pocket under the Silver Plus, Gold Plus or Platinum plan, you will pay the greater of 5% coinsurance or $2.25 for a generic drug or $5.60 for all other drugs.

You can ask SummaCare Secure to make an exception to your drug’s tier placement. See the section “How do I request an exception to SummaCare Secure’s Formulary?” for more information.

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: SummaCare Secure requires you to get prior authorization for certain drugs. This means that you will need to get approval from SummaCare Secure before you fill your prescriptions. If you don’t get approval, SummaCare Secure may not cover the drug.
• Quantity Limits: For certain drugs, SummaCare Secure may limit the amount of the drug that we will cover. For example, SummaCare Secure limits prescriptions for Imitrex (25 mg tablets) to nine tablets per 30-day supply or 27 tablets per 90-day supply.
• Step Therapy: In some cases, SummaCare Secure requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, SummaCare Secure may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SummaCare Secure will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary. You can ask SummaCare Secure to make an exception to these restrictions or limits. See the section, “How do I request an exception to SummaCare Secure’s Formulary?” for more information.

What if my drug is not on the SummaCare Secure Formulary?
If your drug is not included in this formulary, you have two options:

1. Ask Customer Service for a list of similar drugs that are covered by SummaCare Secure. When you receive the list, show it to your doctor and ask that a similar drug be prescribed that we cover. OR

2. Ask SummaCare Secure to make an exception and cover your drug. See below for information about how to request an exception.

NOTE: Due to a change in Medicare, most Medicare Drug Plans will no longer cover erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra and Caverject. For more information, you can contact Customer Service at 888-464-8440. From November 15, 2007, through March 1, 2008, a representative will be available to speak with you from 8:00 a.m. to 8:00 p.m. seven days a week. Beginning March 2, 2008, through November 15, 2008, a representative will be available to speak with you from 8:00 a.m. to 8:00 p.m. Monday through Friday. Persons with hearing impairments, please call TTY at 800-750-0750.

How do I request an exception to SummaCare Secure’s Formulary?
You can ask SummaCare Secure to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. For example:

• You can ask us to cover your drug even if it is not on our formulary
• You can ask us to waive coverage restrictions or limits on your drug. For example, if your drug has a quantity limit, you can ask us to waive the limit and cover more. Generally, SummaCare Secure will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You can call us at 888-464-8440 or submit a supporting statement from your physician to request a formulary, drug tier or utilization restriction exception. From November 15, 2007, through March 1, 2008, a representative will be available to speak with you from 8:00 a.m. to 8:00 p.m. seven days a week. Beginning March 2, 2008, through November 15, 2008, a representative will be available to speak with you from 8:00 a.m. to 8:00 p.m. Monday through Friday. Persons with hearing impairments, please call TTY at 800-750-0750. Generally, we must make our decision within 72 hours of your request.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan, you may be taking drugs that are on our formulary but have certain requirements or limits on coverage. You should talk to your doctor to decide if you should switch to a drug that we cover without restrictions or request a formulary exception. SummaCare Secure may cover your drug in certain cases during the first 90 days you are enrolled. For each of your drugs that may have additional requirements or limits on coverage, such as prior authorization, SummaCare Secure will cover a temporary 30-day transition supply (unless your prescription is written for fewer days) when you go to a plan pharmacy. Additional refills will be subject to the plans requirements. For additional information on restrictions of coverage refer to “Are there any restrictions on coverage?”

If you are a resident of a long-term care facility, SummaCare Secure will cover a temporary (31-day) transition supply (unless your prescription is written for fewer days.) We will cover more than one refill for these drugs for the first 90 days you are a member of our plan. If you are past the first 90 days of membership, SummaCare will cover a 31-day emergency supply (unless your prescription is for fewer days) while you pursue an exception.

If you are a current member of SummaCare Secure and experience change in your level of care from one treatment setting to another, we will cover a transition supply of each drug that is on our formulary but may have certain requirements or limits on coverage.

If you are entering a long-term care facility from another care setting, SummaCare Secure will cover a temporary (31-day) transition supply (unless your prescription is written for fewer days.) We will cover more than one refill for these drugs for the first 90 days you are a member of our plan. If you are past the first 90 days of membership, SummaCare Secure will cover a 31-day emergency supply (unless your prescription is for fewer days) while you pursue an exception. We will allow early refills upon admission or discharge to or from a long-term care facility.

If you are transitioning from one treatment setting to the retail setting, SummaCare Secure will cover a one-time 30-day supply (unless your prescription is for fewer days.)

For More Information
For more detailed information about your SummaCare Secure prescription drug coverage, please review your SummaCare Secure Evidence of Coverage book and other plan materials.

If you have any questions about SummaCare Secure, please call Customer Service at 888-464-8440. From November 15, 2007 through March 1, 2008, a representative will be available to speak with you from 8:00 a.m. to 8:00 p.m. seven days a week. Beginning March 2, 2008, through November 14, 2008, a representative will be available to speak with you from 8:00 a.m. to 8:00 p.m. Monday through Friday. Or visit our Web site at www.summacare.com.

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.

SummaCare Secure’s Formulary
The formulary provides coverage information the drugs covered by SummaCare Secure. If you have trouble finding your drug in the list, refer to the Index. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The number listed in the “Tier” column tells you the Tier number that the corresponding drug falls under. Copayment amounts for Tier I, Tier II, Tier III and Tier IV drugs are as follows:

• Tier I Drugs: $3 for up to a 30-day supply
  $7.50 for up to a 90-day supply through mail order
• Tier II Drugs $30 for up to a 30-day supply
  $75 for up to a 90-day supply through mail order
• Tier III Drugs $60 for up to a 30-day supply
  $180 for up to a 90-day supply through mail order
• Tier IV Drugs 25% for up to a 30-day supply
  25% for up to a 90-day supply through mail order

The information in the “Requirements/Limits” column tells you if SummaCare Secure has any special requirements for coverage of that drug. Within the Requirements/Limits column, the abbreviations stand for the following terms:
QL = Quantity Limit
PA = Prior Authorization
ST = Step Therapy