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The formulary is a list of drugs that Citizens Choice Healthplan HMO will pay for during the covered benefit year. The Medicare program allows us to make the changes in our prescription drug formulary list at any time during the calendar year. A change in our drug formulary could affect which drugs are covered, the members copayment, and the limit on usage. If you have any questions about the formulary, please contact Member Services at 1-866-634-CCHP (2247) or TTY/TDD 1-866-516-9366. Our formulary was developed by CVS Caremark's Therapeutics Committee to ensure that included drugs are safe, effective, FDA approved and appropriate. This committee is comprised of physicians and pharmacists.

Citizens Choice Healthplan HMO 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.

All formulary drugs on Tier 1 are covered in the Coverage Gap of your Part D benefits. Use this search function to determine if a medication is covered under the Citizens Choice Healthplan HMO pharmacy benefit.

Help With Paying For Prescription Drugs:

Members who have limited income and resources that need help with paying for their prescription drugs may be able to receive extra help through the Medicare Part D Low Income Subsidy program. Please call Member Services for more information at 1-866-634-CCHP (2247 or TTY/TDD 1-866-516-9366

The benefit chart below lists information regarding your formulary copayments. For additional information please contact Member Services at 1-866-634-CCHP (2247 or TTY/TDD 1-866-516-9366:

Drug Tier

Retail Network Pharmacy (30 day supply)
Retail Network Pharmacy (90 day supply)
Mail Order Pharmacy (90 day supply)
Retail Out-of-Network Pharmacy (20 day supply)

Formulary Costs 2012

	Retail Network Pharmacy (30 day supply)	Retail Network Pharmacy (90 day supply)	Mail Order Pharmacy (90 day supply)	Retail Out-of-Network Pharmacy (20 day supply)
Tier 1 (Generic)	$0	$0	$0	$0
Tier 2 (Preferred Brand)	$15	$45	$30	$15
Tier 3 (Non-preferred Brand)	$60	$180	$120	$60
Tier 4 (Injectable drugs)	33%	33%	33%	33%
Tier 5 (Specialty drugs)	33%	33%	33%	33%

Find a drug 2012
Complete Drug Formulary 2012

An HMO plan with a Medicare contract. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Co-payments/co-insurance may change on January 1, 2013. You must continue to pay your Medicare Part B premium. Limitations, copayments, and restrictions may apply. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486- 2048, 24 hours a day/7 days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or Your State Medicaid Office.