Description of the Windsor Formulary
Windsor has adopted the USP Model Guideline 1.0 to develop our comprehensive formulary. The formulary is initially arranged by Therapeutic Categories which include pharmacological class and drugs within the class. There is also an alphabetical drug index at the end of the formulary listing the generic and brand name with the page number location. All beneficiaries may receive up to a maximum of 30 days supply of FDA approved dosages or a 90 day supply for maintenance drugs.
All formularies have four tiers. The following list defines terms listed in the formulary.
Tier One — this tier contains ALL Part D eligible generic drugs. This tier is open to all drugs that are identified as generic medications in First Data Bank. The beneficiary co-payment for tier one drugs range from $0 to $10 per 30 day supply depending on the beneficiary’s plan.
Tier Two — this tier contains all Part D eligible drugs that are Preferred Brands. These drugs are identified and recommended by the Windsor P&T Committee. The beneficiary co-payment for tier two drugs range from $0 to $35 per 30 day supply depending on the beneficiary’s plan.
Tier Three — this tier contains all Part D eligible drugs that are Non-Preferred Brands. These drugs are identified and recommended by the Windsor P&T Committee and brand drugs that have generics available. The beneficiary co-payment for tier three drugs range from $0 to $50 per 30 day supply depending on the beneficiary’s plan.
Tier Four — this tier contains all Part D eligible drugs that are Specialty Products. These drugs are identified and recommended by the Windsor P&T Committee and which are typically prescribed by a specialist, have unique uses, or may require special dosing or administration, and are generally more costly than other drugs. The beneficiary co-payment for tier four drugs range from $0 to 33% per 30 day supply depending on the beneficiary’s plan. Most drugs on this tier require a Coverage Determination or Prior Authorization.
Before prescribing a non-preferred drug (Tier 3) for a Windsor Medicare Extra beneficiary, we ask that prescribing physicians consider formulary alternatives which are on Tier ONE or Tier TWO. Beneficiaries will reach the coverage gap more rapidly when non-formulary drugs are prescribed. This means members must pay the entire cost of the drug until catastrophic levels are reached.
All formularies contain the same Prior Approvals, Step Therapies and Quantity Level Limit medications which are described below. Formulary Tier exceptions can be made as long as the drug is not a specialty injectable drug (tier 4). The prescribing physician or beneficiary may initiate the exception process as described below under COVERAGE DETERMINATION PROCESS.
Positive and Negative Formulary Changes
If the Windsor P&T Committee recommends removing a current Medicare Part D formulary drug or adding prior authorizations, quantity limits and/or stepping therapies on a drug, or moving a drug to a higher cost-sharing tier, we must notify providers and beneficiaries of the negative change. All negative drug changes will be adjusted 60-days from the date of the notification was sent.
If the Windsor P&T Committee recommends adding Medicare Part D eligible drugs or removing current prior authorizations, quantity limits and/or step therapies, or moving a drug to a lower cost-sharing tier for the member, we must notify providers and beneficiaries of the positive changes. All positive drug changes will be implemented in the system immediately with at least a 30-day notification sent to beneficiaries and providers.
If the Food and Drug Administration (FDA) 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 providers and beneficiaries affected by the removal within 7 days.
An exception can also be requested for Prior Authorization, Step Therapy, and Quantity Limit drugs.
Medicare Part D Formulary Exclusions
The following classes and example medications have been excluded by Medicare as not being Part D eligible for 2007:
- Agents when used for anorexia, weight loss, or weight gain – Xenical
- Agents when used to promote fertility — Clomid, Lupron
- Agents when used for cosmetic purposes or hair growth — Retin-A, Avita
- Agents when used for the symptomatic relief of cough and colds — Dimetapp
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Nonprescription drugs — Over-the-Counter Drugs
- 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.
- Barbiturates – Phenobarbital
- Benzodiazepines — Valium, Xanax, Ativan
- Erectile Dysfunction Drugs – Viagra, Cialis, Levitra
Early Refills
Network pharmacies cannot dispense refill medications to beneficiaries until the beneficiary has used at least 75% of the original supply. This edit is in place to eliminate stock-piling, sharing medications and to alert pharmacist to a potential compliance issue. If the dose has increased, the pharmacist can obtain an early refill override from the pharmacy claims processor. If the medication was lost or stolen, the beneficiary will be responsible for 100% of the drug cost.
