PrimeTime Health Plan formulary covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

The PrimeTime Health Plan Formulary is subject to change during the year. Most of the changes in drug coverage happen at the beginning of each year (January 1); however, the plan may make changes during the year, with CMS approval. In cases of any changes to our formulary including addition of a prior authorization, adding quantity limits, step therapy, making a drug non-formulary and changing cost share due to a tier level change of formulary drugs, PrimeTime Health Plan will send a letter to the members that have been affected by the change.

If one of your drugs is not covered in the way you would like it to be covered, you have the right to ask for a “coverage determination”. A coverage determination is when we make a decision about whether a drug is covered by the plan and the amount, if any, you are required to pay for the prescription.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. (You cannot ask for coverage of any “excluded drugs” or other non-Part D drugs which Medicare does not cover).

You, your representative, or your doctor (or other prescriber) can request a coverage determination by calling, emailing, writing, or faxing our plan. In addition, you may contact us for the most recent list of covered drugs or visit www.pthp.com

For more detailed information, please refer to the “Coverage Determination” link on the Additional Information Page or your Plan's Evidence of Coverage.