This 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 when you find your medication, you will see at the side 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 plan covers 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:
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:
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.