Rx Drugs
What is a formulary (drug list)?
What does the formulary (drug list) include?
What is not on the formulary?
Why do some drugs have restrictions?
What is a prior authorization?
What is Step Therapy?
What is a Quantity Limit?
Does my plan cover Medicare Part B drugs or Part D drugs?
Can the formulary change?
How will I find out if my drug’s coverage has changed?
Are there programs to help people with limited resources pay for their prescription drugs?
- What is a formulary (drug list)?
The plan has a Formulary. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan’s formulary.
- What does the formulary (drug list) include?
The formulary includes both brand-name and generic drugs. A generic drug is a prescription drug that has the same active ingredients as the brand-name drug. It works just as well as the brand-name drug, but it costs less. There are generic drug substitutes available for many brand-name drugs.
- What is not on the formulary?
The plan does not cover all prescription drugs.
- In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more information about this, refer to your Evidence of Coverage, Chapter 5).
- In other cases, we have decided not to include a particular drug on the formulary.
- Why do some drugs have restrictions?
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.
In general, our rules encourage you get a drug that works for your medical condition and is safe. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.
- What is a prior authorization?
For certain drugs, you or your doctor need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes plan approval is required so we can be sure that your drug is covered by Medicare rules. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan
- What is Step Therapy?
This is a type of requirement that encourages you to try safer or more effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.
- What is a Quantity Limit?
For certain drugs, we limit the amount of the drug that you can have. For example, the plan might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
- Does my plan cover Medicare Part B drugs or Part D drugs?
KelseyCare Advantage cover a limited number of Medicare Part B drugs, all Medicare Part D drugs on the plan’s formulary and some prescription drugs that are not normally covered in a Medicare Prescription Drug Plan.
- Can the formulary change?
Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the formulary. For example, the plan might:
- Add or remove drugs from the formulary. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the formulary because it has been found to be ineffective.
- Move a drug to a higher or lower cost-sharing tier.
- Add or remove restriction on coverage for a drug.
- Replace a brand-name drug with a generic drug.
In almost all cases, we must get approval from Medicare for changes we make to the plan’s formulary.
- How will I find out if my drug's coverage has changed?
If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time. Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the formulary. We will let you know of this change right away. Your doctor will also know about this change, and can work with you to find another drug for your condition. For questions regarding the formulary, please call KelseyCare Advantage toll-free at (877) 853-9075 8 a.m. to 5 p.m., Monday through Friday. TDD (866) 302-9336. You can also call the number on the back of your prescription ID card 24 hours a day, 7 days a week.
- Are there programs to help people with limited resources pay for their prescription drugs?
You might qualify to get help in paying for your drugs. There are two basic kinds of help:
- “Extra Help” from Medicare. This program is also called the “low-income subsidy” or LIS. People whose yearly income and resources are below certain limits can qualify for this help. See Section III of the new Medicare & You 2010 Handbook or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.
- Help from your state’s pharmaceutical assistance program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (Please refer to your Evidence of Coverage, Chapter 2).
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