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Frequently Ask Questions (FAQ) for Part D Prescription Formulary

Frequently Asked Questions (FAQ) for
Part D Prescription Formulary

A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers that are necessary for a quality treatment. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed.

Yes. The Formulary is a document that changes throughout the year with the purpose of adding medications or replacing them for their generic version, which is usually less costly. You can visit our webpage, www.mcsclassicare.com, select the “Prescription Drug Coverage” section and press the “Prescription Drug Formulary” option to look for the Formulary Addendums, which contain the formulary changes or updates throughout the year.

Remember that, if we remove a brand medication from our formulary because its generic version is already available in the market, we will notify affected members of the change 30 days after the change becomes effective.

If we remove drugs from our formulary due to security issues, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we will notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the medication.

The Formulary can help you learn more information about your medication coverage, for example, its requirements or their copayment level. One way to find your medication in the formulary is to identify it under its category according to the medical condition it treats. For example, medications used to treat a heart condition are listed under the category, “Cardiovascular Agents”. You can also find it by its name, using its first letter and looking for it according to the alphabetical list. Look in the Index and find your medication. Next to your medication, you will see the page number where you can find its coverage information.

A generic drug is a copy of the brand medication that is approved by the FDA because it has the same active ingredient as the brand name drug. Our Formulary contains both generic and brand medications. Generally, generic drugs cost less than brand name drugs.

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include, but are not limited to:

  • Prior Authorization: This means that the plan needs to verify if you meet certain medical requirements in order to authorize the drug.
  • Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover during a time period. Usually this limit is established due to security measures or to improve the dose.
  • Step Therapy: In some cases, our plan requires you to first try certain medications to treat your medical condition before we cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary or in the documents that are published online in our webpage, www.mcsclassicare.com. You may also ask us to send you a copy.

If your medication is not included in the Formulary, you can request a list of alternatives to the medication that is not in our Formulary to our Call Center. When you receive it, you can take it to your doctor, so he can select a medication that is covered by our plan. You can also ask our plan to evaluate if we can make an exception to cover your medication.

In case you need a medication that is not in our Formulary and the available alternatives are not adequate for you, you can ask our plan to make an exception to our coverage rules. To do this, you must submit a statement from the prescriber or your doctor that justifies your request. There are several types of exceptions that you can ask for:

  • You can ask us to cover a medication even if it is not on our formulary. If approved, this medication will be covered at a pre-determined cost-sharing level, which is usually higher.
  • You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your medication.
  • You can ask us to waive coverage restrictions or limits on your medication, if your doctor justifies it.

Before you request an exception, you must talk with your doctor to decide if you can change to an alternative to your medication that is on the formulary. If it is not favorable for your health, your doctor may request a formulary exception so we can cover your medication. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your transition 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

  • PA – Prior Authorization
  • BvsD - This prescription drug may be covered under Medicare Part B or D. Contact the Plan for coverage details.
  • QL – Quantity Limit
  • ST – Step Therapy
  • GC – Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
  • EXCL – Excluded Drugs. 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 toward 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. Excluded drugs are covered only for MCS Classicare SuperRx (HMO) & MCS Classicare MAPD Group (HMO).
  • LA – Limited Access. This prescription may be available only at certain pharmacies. For more information, consult your Providers and Pharmacies Directory or call our Call Center at 1-866-627-8183, Monday through Sunday from 8:00 a.m. to 8:00 p.m., October 1st through March 31st. From April 1st through September 30th from Monday through Friday from 8:00 a.m. to 8:00 p.m. and Saturdays from 8:00 a.m. to 4:30 p.m TTY users should call 1-866-627-8182.
  • FFQL  – First Fill Quantity Limit. In order to provide you and your doctor with an opportunity to properly assess the effectiveness of a drug, only the first prescription fill will be covered for 30 days for some of the drugs available for a long-term supply.
  • NEDS  Non-Extended Day Supply. Drugs identified will not be available as an extended days’ supply. These drugs will only be available up to a 30-day supply for every fill.
  • MO – Mail Order. We provide coverage for some prescriptions through mail order pharmacy. For more information, call our Call Center.
  • SSM – Senior Savings Model program is offered for this medication at a reduced or no copay for 30-90 day’s supply. Please refer to our Evidence of Coverage for more information about this program.
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