*ED = Part D Excluded Drug: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
*LA = Limited Access: This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-866-245-5360. Hours of operation 8am to 8pm 7 days a week Oct. 1, 2012 to Feb 14, 2013, 8am to 8pm Mon. through Fri. from Feb. 15, 2013 to Sept.30, 2013, 8am to 8pm 7 days a week Oct. 1, 2013 to Feb 14, 2014, TTY/TDD users should call 1-800-955-8771.
*B/D = Part B verses Part D: Prior Authorization. Optimum Healthcare requires authorization to determine whether certain drugs are covered by Medicare Part B or Medicare Part D. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
*GC = GAP Coverage: We provide additional coverage of this prescription drug in the coverage gap. The plans that have additional coverage through the gap are: 1,2,19,23,27,28,29,30,31. Please refer to our Evidence of Coverage for more information about this coverage.
*MO = Mail order: These are drugs that can be obtained at extended days supply, up to a 90 day supply.
*QL = Quantity Limit: For certain drugs, Optimum HealthCare limits the amount of the drug that Optimum HealthCare will cover. For example, Optimum HealthCare provides 4 tablets per prescription for alendronate. This may be in addition to a standard one month or three month supply.
*ST = Step Therapy: In some cases, Optimum HealthCare 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, Optimum HealthCare may not cover drug B unless you try Drug A first. If Drug A does not work for you, Optimum HealthCare will then cover Drug B.
*PA = Prior Authorization: Optimum HealthCare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Optimum HealthCare before you fill your prescriptions. If you don't get approval, Optimum HealthCare may not cover the drug.
Tier 1: Generic and Brand Drugs
Tier 2: Non-Preferred Generics and Preferred Brand Drugs
Tier 3: Non-Preferred Generics and Non-Preferred Brand Drugs
Tier 4: Specialty Tier Drugs