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About Prescription Drug Benefits

What drugs are covered under my prescription drug benefits?
  • The Drug Formulary or “Drug List” for short tells you which Part D prescription drugs are covered under the Part D benefit included in your KelseyCare Advantage plan. You can search the drug list by clicking the button below or contact member services at 713-442-CARE (2273) for assistance with navigating the drug list (formulary). You can also download a copy of the formulary in the Plan Documents section.

  • Is the drug you’re looking for not on the list or does it have specific restrictions?
    • If a drug has certain restrictions that need to be met before the plan will provide coverage, you, your representative or your provider need to take additional steps by asking the plan to make a coverage decision to determine if you meet those requirements.
    • Drug restrictions are safety nets created by a group of doctors and pharmacists to ensure the best outcomes for your medications. Examples of these restrictions include:
      • Prior Authorization: KelseyCare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from KelseyCare Advantage before you fill your prescriptions. If you don’t get approval, KelseyCare Advantage may not cover the drug.
      • Quantity Limits: For certain drugs, KelseyCare Advantage limits the amount of the drug that KelseyCare Advantage will cover. For example, KelseyCare Advantage provides 30 tablets per prescription for JANUVIA. This may be in addition to a standard one-month or three-month supply.
      • Step Therapy: In some cases, KelseyCare Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, KelseyCare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, KelseyCare Advantage will then cover Drug B.
    • If a drug is not on the list or is not covered in the way you would like it to be covered, you, your representative or your provider need to take additional steps by asking the plan to make an “exception.” An exception is a type of coverage decision.
    • In certain situations, you may be able to get temporary coverage for drugs that your plan wouldn’t normally cover. If you are new to the plan, have been affected by a formulary change, or have recently been discharged from an inpatient hospital stay, long-term care facility, skilled nursing facility, or hospice, you may be eligible for a temporary supply. To learn more, visit our transition benefit page.
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