Optima Medicare (PPO)
Drug Lists
The Optima Medicare Drug List is available for use by Optima Medicare Plus Members only. This list does not apply to members that have enrolled in Optima Medicare Preferred or Optima Medicare Value Plans (MA only).
Adobe Reader is required to view the Optima Medicare drug list – get Adobe Reader.
Download the 2010 Optima Medicare Drug list
Instructions to search an Adobe PDF File:
- To search for a specific drug, download the document.
- With Adobe Reader open, choose the binoculars icon located on the toolbar OR choose “Edit” and then “Find.”
- Enter the name of the drug. It is important to spell the drug name correctly in order to receive results. You may enter the partial name of the drug as well.
- Click "Find."
- View results in the table to determine tier placement and any additional requirements.
Drug Authorization Forms: Take these forms to your doctor to authorize coverage of your drugs. Access drug authorization forms
Medication Therapy Management Program: Important information if you take four (4) or more Part D covered drugs and your annual drug costs are likely to exceed $4,000. Read more
Utilization and Quality Assurance Program: Optima Medicare works with physicians to make sure members get the most appropriate, safe and cost-effective drugs. Read more
Transition Process Information: If a drug you are currently taking is not on the Optima Medicare drug list, this information will help you understand the transition process. Read more
Optima Medicare Grievance and Appeals: If a drug you are currently taking is not on the Optima Medicare drug list, you may file an appeal. Read more
Drug pre-authorization forms are available for you to view and print online.
Our downloadable forms require Adobe Reader in order to view and print -- get Adobe Reader.
Non-specific Drug Authorization Form
Non-specific Prescription Coverage Determination Form
Drug Authorization Forms for Medicare Preferred Plus
Chorionic
Differin
Epogen/Procrit
Leukine/Neumega/Neupogen
Retin-A
Synarel
Transplant Drugs
Tretinoin
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Optima Medicare has a Medication Therapy Management (MTMP) program that meets the Medicare Modernization Act requirements. Our Medication Therapy Management program is approved by CMS for program year 2010. Members are eligible for Optima Medicare's Medication Therapy Management program if they have at least 2 of the following conditions:
- Asthma
- COPD (chronic obstructive pulmonary disease)
- Diabetes
- Dyslipidemia (high cholesterol)
- Heart Failure
- Hypertension (high blood pressure)
Members must also be taking four (4) or more Part D covered drugs and must be likely to exceed $4,000 in annual costs for medications. Optima Medicare has a network of community pharmacies that provide services for members eligible for the MTMP. While this program is not considered a benefit, members eligible for Optima Medicare's MTMP can receive these services at no cost to them. Members not eligible for the program can also receive the services, but must pay the full cost to the participating pharmacy.
Please contact our Member Services for more information about our Medication Therapy Management program.
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Optima Medicare works with physicians to make sure members get the most appropriate, safe and cost-effective drugs. The plan's Utilization Management and Quality Assurance program is designed to assure adverse drug events and drug interactions are avoided and ensure optimum medication use. The Utilization Management and Quality Assurance program is provided at no additional cost to members or providers.
Utilization Management and Quality Assurance programs incorporate tools to encourage appropriate and cost-effective use of Part D drugs. These tools include prior authorization, quantity limits, additional charges and clinical interventions. Other tools may be used if necessary.
- PA = Prior Authorization. Optima Medicare requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from Optima Medicare before you fill your prescriptions. If you don’t get approval, Optima Medicare may not cover the drug.
- QL = Quantity Limits. For certain drugs, Optima Medicare limits the amount of the drug that it will cover. This may be in addition to a standard one-month or three-month supply.
- AN = Additional Charge. If you obtain a brand name drug when a generic equivalent is available, you will be required to pay the difference between the cost of the generic drug (which is paid by Optima Medicare and the cost of the brand name drug in addition to the appropriate brand copay).
See Optima Medicare's formulary for drugs that have prior authorization requirements, quantity limits or where additional charges may apply.
As part of the Utilization Management and Quality Assurance program, all prescriptions are screened by systems to detect and address the following:
- drug-drug interactions that are clinically significant
- duplication of drugs (taking more than one drug in the same drug class)
- inappropriate drugs
- incorrect drug
- patient-specific drug contraindications
- over-utilization of drugs
- under-utilization of drugs
- abuse or misuse of drugs.
A review of prescriptions is performed before the drug is dispensed. These are concurrent drug reviews and are clinical edits at the point-of-sale (at the pharmacy counter).
Retrospective drug utilization reviews identify inappropriate or medically unnecessary care. Optima Medicare performs periodic reviews of claims data to evaluate prescribing patterns and drug use that may indicate inappropriate use.
Physicians treating patients who are receiving potentially inappropriate drug therapy will receive provider-specific reports detailing the patient's drug utilization. The providers receive educational materials explaining the report and the intervention it addresses. The reports identify individual patients who may require evaluation, the reason for the report and options for the provider to consider.
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New members in our plan may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary or coverage restricted drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary or coverage restricted drug if you need a refill for the drug during the first 90 days of the new plan year in order to provide you with the opportunity to request an exception.
For each of the drugs that isn’t on our formulary or that has coverage restrictions or limits, we will cover a temporary 31-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). After we cover the temporary 31-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan, when that member is a resident of a long-term-care facility. If a new member, who is a resident of a long-term-care facility and has been enrolled in our Plan for more than 90 days, needs a drug that isn’t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 34-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.
If a current member transitions to a different level of care, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days) and cover more than one refill during the first 90 days if the member transitions into a long-term care facility. If the transition is out of a long-term care facility, we will cover a temporary 31-day supply (unless the prescription is written for fewer days) when the member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). After we cover the temporary 31-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
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If you are a member of Optima Medicare Plans, and you have a concern about your health plan, the quality of your care or your coverage for certain services, you may follow an established process to resolve your concern. You cannot be disenrolled from Optima Medicare Plans or penalized in any way if you make a complaint.
More information about Optima Medicare Appeals and Grievances*
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