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Prescription Coverage

Prescription Drugs Covered by Medicare Part D

Check the 2020 KelseyCare Advantage Formulary to see if your prescription drug is covered. This searchable formulary is current as of 04/01/2020.

Search the Prescription Drug List

To request a hard copy of the Abridged Formulary, Comprehensive Formulary, and/or Formulary Addendum, call 1-866-535-8343 or email memberservices@kelseycareadvantage.com.

Preferred Cost-Sharing Pharmacy vs. Standard Cost-Sharing Pharmacy

 Preferred Cost-Sharing Pharmacy

Standard Cost-Sharing Pharmacy

Tier 30-Day Supply 90-Day Supply  Tier 30-Day Supply 90-Day Supply
 1 $3 $7.50   1 $8 $24
 2 $5 $12.50   2 $10 $30
 3 $40 $100   3 $45  $135
 4 $60 $150   4 $70 $210
 5 31% NA*   5 41% NA*

Prescription Copayments for Rx, Rx+Choice, and Rx Select Plans

  • What is the KelseyCare Advantage formulary?
    • A formulary is a list of covered drugs, selected by KelseyCare Advantage in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.
    • KelseyCare Advantage covers both brand name drugs and generic drugs.
    • A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
  • Can I talk to someone about prescription drug coverage?

    To get additional information about the drugs covered by KelseyCare Advantage, or to request a copy of the Formulary Addendum be mailed to your home, please call Member Services at 713-442-CARE (2273) or 1-866-535-8343, 8 a.m. to 8 p.m., seven days a week from October 1 through March 31 and from 8 a.m. to 8 p.m., Monday through Friday from April 1 through September 30. TTY/TDD users should call 711.

  • Can the formulary (drug list) change?
    • Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we won’t discontinue or reduce coverage of the drug during the 2020 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market.
    • Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year.
    • If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
  • What if my drug is not on the formulary?
    If your drug is not included in this formulary drug list, you should first contact Member Services and ask if your drug is covered. If you learn that KelseyCare Advantage does not cover your drug, you have two options:
    • You can ask Member Services for a list of similar drugs that are covered by KelseyCare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug covered by KelseyCare Advantage.
    • You can ask KelseyCare Advantage to make an exception and cover your drug. See below for information about how to request an exception.

     

  • Are there any restrictions on my coverage?

    Some covered drugs may have additional requirements or limits on coverage that may include prior authorization, quantity limits, and step therapy. This information can be found by searching the formulary.

     

     

  • How do I request an exception to the KelseyCare Advantage formulary?

    You can request an exception by:

    • Asking us to cover a drug not on our formulary. If approved, the drug will be covered at a predetermined cost-sharing level.
    • Asking us to cover a formulary drug at a lower cost-sharing level if it is not on the specialty tier, lowering the amount you pay for the drug.
    • Asking us to waive coverage restrictions or quantity limits on a drug.

    Generally, KelseyCare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

  • Does my plan cover Medicare Part B drugs or Part D drugs?

    KelseyCare Advantage Rx, Rx+Choice and Rx Select cover both Medicare Part B and Medicare Part D prescription drugs. KelseyCare Advantage Essential, Essential+Choice and Essential Select cover Medicare Part B Covered Drugs. They do NOT cover Medicare Part D prescription drugs.

  • What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

    You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. 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 supply of up to 30 days.

  • What if I have unexpected medication changes due to level-of-care changes?

    When you transfer from one treatment setting to another, such as moving from an inpatient hospital setting to home, it is called a level-of-care change. These types of changes often do not leave you enough time to determine if a new prescription contains a drug that is on the plan formulary. In these unexpected situations, KelseyCare Advantage will cover a temporary transition supply of up to 30 days. If your level-of-care change involves moving to a long-term care facility and a new drug is prescribed, the plan covers a temporary supply of up to 31 days.

  • What is a Medication Therapy Management program?

    The Medication Therapy Management (MTM) Program is a free service we may offer that provides services to members who meet the following CMS-directed MTM qualification criteria:

    • Have any three of the following chronic diseases: Alzheimer’s disease; chronic heart failure (CHF); diabetes; hepatitis C; HIV/AIDS; multiple sclerosis; respiratory diseases such as asthma, chronic lung disorders, or chronic obstructive pulmonary disease (COPD); or bone diseases such as osteoarthritis, osteoporosis, or rheumatoid arthritis
    • Take eight or more Part D medications
    • Spend an expected total of more than $4,255.00 per year for Part D medications (the expected total is the amount paid by the plan for Part D medications, added to the amount the member pays)

Always at Your Service


Call KelseyCare Advantage at 713-442-JOIN (5646) from 8 a.m. to 8 p.m., seven days a week, from October 1 to March 31 and 8 a.m. to 8 p.m., Monday through Friday, from April 1 to September 30.


We’ll help you evaluate your options and find a solution that meets your needs.

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