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Please note the formulary may change during the year.

Find a Prescription Drug

The KelseyCare Advantage Rx and Rx+Choice plans use a Drug Formulary (a list of prescription drugs approved for coverage by KelseyCare Advantage). KelseyCare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a KelseyCare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Part D Temporary Transition Supply

Under certain circumstances, the plan can offer a temporary supply of drug when your drug is not on the Drug List or when it is restricted in some way. Click here for more information.

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Part D Temporary Transition Supply

Under certain circumstances, the plan can offer a temporary supply of a drug when your drug is not on the Drug List or when it is restricted in some way. Click here for more information.

Drug Search - See if your drug is covered

Click here to search the 2012 KelseyCare Advantage Formulary for the Rx and Rx+Choice plans.
Preferred Pharmacy
Tier 30-Day Supply 90-Day Supply
1 $5 $12.50
2 $35 $87.50
3 $40 $100
4 $70 $175
5 33% 33%

Non-preferred Pharmacy
Tier 30-Day Supply 90-Day Supply
1 $10 $30
2 $38 $114
3 $50 $150
4 $80 $240
5 33% 33%
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Formulary Addendum/Changes

The formulary may change during the year. To review and/or print formulary changes made during the year, click here for Formulary Addendum PDF PDF. If you would like to request a copy of the formulary addendum to be mailed to your home, please call Member Services at 713-442-CARE (2273) or 1-866-535-8343, 8:00a.m. to 8:00 p.m., 7 days a week. TTY/TDD users should call 1-866-302-9336.

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Documents for Download

  • Abridged Formulary PDF  PDF 2012  En Español PDF PDF 2012
  • Comprehensive Formulary PDF  PDF 2012  En Español PDF PDF 2012 
  • Pharmacy Directory PDF  PDF 2012  En Español PDF PDF 2012 
  • Prior Authorization Criteria PDF  PDF 2012 
  • Step Therapy Criteria PDF  PDF 2012 
  • Quantity Limit Amounts PDF  PDF 2012 
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8900 Lakes at 610 Dr., Suite 1100, Houston, TX 77054
Hours of Operation: 8a-8p, M-F
713-442-CARE (2273)  /  TTY/TDD: 1-866-302-9336
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H0332_WB12001_CMSDateApproved_10/18/2011
Last Updated: 10/1/11