We use CMS data for drug pricing and formulary information in Amplicare.
In some cases, the CMS may have not yet updated their Part D formulary to include new brand or generic medication.
Unfortunately in these cases, there is no way for us to add these drugs within Amplicare and show accurate pricing and formulary information.
We recommend conducting the comparison without the drug, and then checking with individual plans to make sure they cover it.
Most Medicare plans now have easily accessible online formularies with downloadable PDFs or a webpage where one can search by drug name.
For example you can view PDF files of all Humana plans here.
You can search Silverscript's formulary here (you'll need to enter a zipcode to search).
You can download Cigna PDP and MA-PDP formularies here.
You can search by zipcode to find Aetna's formularies here.
You can search the First Health formulary here.
You can search AARP / UnitedHealthCare formularies here (you'll need to enter the patient's zipcode to search).
Some drugs are not covered under Medicare Part D because they are considered either high risk, or safe but not effective (DESI). These drugs are frequently covered by Medicaid if the patient is dual eligible.
Some examples of drugs that are not covered under Medicare Part D include:
Donnatal, Quadrapax (Atropine / Hyoscyamine / Phenobarbital / Scopolamine combination)
Covaryx, Estratest, EEMT (esterified estrogen & methyltestosterone)
Rosula (Sodium Sulfacetamide and Sulfur)
Some other drugs are not covered by Part D because they were never approved by the FDA (pre-1938) but instead grandfathered in as prescription drugs. Some examples include:
Tincture of Opium
Some diabetic supplies are not covered under Part D
Insulin, as well as syringes and pen needles are covered by Part D, but pricing and formulary data about syringes and pen needles are not included in CMS data.
V-Go Insulin Delivery Device is covered under Part D but is not included in the CMS data.
Test strips, machines, lancets, and lancet devices (other diabetic supplies not related to directly injecting insulin) are usually covered under Part B.
Another example of a drug not on the CMS formulary but covered by some Part D plans is Relion , which is a brand intermediate-acting insulin--essentially the same as Novolin N--but specifically manufactured for Wal-Mart. Unfortunately, since this drug is not on the CMS Part D formulary for not yet known reasons, there is no way for us to add it into Amplicare with any accuracy regarding copay and reimbursements. In a case like this, we recommend you do the plan comparison without the drug, and then check the individual formularies for the plans to see if they cover it.
If you are certain a certain drug should be on the CMS formulary and you can't find it searching by the drug's name, you can also search for any drug by searching the NDC without the dashes.
If a drug is not on the CMS formulary, try using our Formulary Lookup tool to find therapeutic alternatives to your patients' drugs.