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Prescription Drug Coverage FAQs
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.
What if my drug is not on the formulary or there are restrictions on my coverage?
If your drug isn’t included on this formulary “drug list” or there are restrictions on your coverage, you should first contact Member Services and ask if the drug is covered. If KelseyCare Advantage doesn’t cover the drug or there are restrictions, you have two options:
- You can ask Member Services for a list of similar drugs that are covered by KelseyCare Advantage. Show the list to your doctor and ask him or her to prescribe one of the similar drugs covered by KelseyCare Advantage.
- You can ask KelseyCare Advantage to make an exception and cover your drug. Coverage Determination & Payment Request (Prescriptions Part D)
How do I request an exception to the KelseyCare Advantage formulary?
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 $4,376.00 ($4,225 in 2020) 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)
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