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Customer Service: (877) 210-1719
TTY users should call 711

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Formulary "Drug List"

The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells which Part D prescription drugs are covered by Piedmont Medicare Advantage. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists and include both brand name and generic drugs. For 2018 and 2019, every drug on the Drug List is in one of five cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug:

  • 2018: Preferred generics - Tier 1 (lowest tier), Generics - Tier 2, Preferred brands - Tier 3, Non-preferred drugs - Tier 4, Specialty Tier - Tier 5 (highest tier)
  • 2019: Preferred generics - Tier 1 (lowest tier), Generics - Tier 2, Preferred brands - Tier 3, Non-preferred drugs - Tier 4, Specialty Tier - Tier 5 (highest tier)

 

Formulary “Drug List”

2019

2019 Formulary "Drug List" (Printable Format - Updated Monthly)

2019 Step Therapy Criteria

2019 Prior Authorization Criteria

Formulary Changes (Updated XX/XX/XXXX)

2018

2018 Formulary "Drug List" (Printable Format - Updated Monthly)

2018 Step Therapy Criteria

2018 Prior Authorization Criteria

Formulary Changes (Updated 11/26/2018)

  

Effective January 1, 2019, our network will include pharmacies that offer standard cost-sharing and pharmacies that offer preferred cost-sharing. You may go to either type of network pharmacy to receive your covered prescription drugs. Your cost-sharing may be less at pharmacies with preferred cost-sharing.  

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

  • The prescription is for a medical emergency or urgent care.
  • You are unable to get a covered drug in a time of need because there are no 24-hour network pharmacies within a reasonable driving distance.
  • The prescription is for a drug that is out-of-stock at an accessible network retail or mail service pharmacy (including high-cost and unique drugs).
  • If you are evacuated or otherwise displaced from your home because of a Federal disaster or other public health emergency declaration.
  • Illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Piedmont Select Medicare Option One, Piedmont Select Medicare Option Two or Piedmont Select Medicare Option Three. For a description of the prescription drug benefits, please refer to the Summary of Benefits “Outpatient Prescription Drugs” section.


Transition Policy

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. This is also known as the transition policy. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

       Transition Policy (Chapter 5, Section 5.2 of the Evidence of Coverage) 

To get the most up-to-date information call Caremark Customer Care at one of the telephone numbers listed below, 24 hours a day, seven days a week.

Caremark Customer Care toll-free number:
(866) 494-9927
TTY users should call 711

 

Piedmont Medicare Advantage is a PPO plan with a Medicare contract. Enrollment in Piedmont Medicare Advantage depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Piedmont Medicare Advantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Piedmont Medicare Advantage’s pharmacy network includes limited lower-cost, preferred pharmacies in Amherst, Appomattox, Bedford*, Campbell, Charlotte, Halifax, Lynchburg City, Pittsylvania, and Prince Edward. The lower cost advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call 1-877-210-1719 (TTY - 711) or consult the online Provider/Pharmacy Directory above.

*denotes partial county (specifically zip codes: 24095, 24104, 24121, 24122, 24174, 24502, 24503, 24523, 24526, 24536, 24550, 24551, 24556, 24570, and 24571).

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Last Updated: 11/26/2018