Prescription Drug Coverage FAQs

A formulary is a list of prescription drugs covered by your KelseyCare Advantage plan. We work with a team of healthcare professionals to develop this list and ensure it includes medications that are safe, effective, and appropriate for treating a variety of health conditions.

Prescription drugs may be available as either brand-name or generic medications. Generic drugs contain the same active ingredients as their brand-name counterparts and are approved to work in the same way. In most cases, generic drugs cost less than brand-name drugs, helping you save money while receiving the medication you need.

If you have questions about your prescription drug coverage or would like a printed copy of the Formulary mailed to you, please contact Member Services at  713-442-CARE (2273) or 1-866-535-8343.

Representatives are available:

• October 1 through March 31: 8 a.m. to 8 p.m., seven days a week
• April 1 through September 30: 8 a.m. to 8 p.m., Monday through Friday

TTY/TDD users should call 711.

Our Member Services team is available to help answer questions about covered medications, formulary changes, and prescription drug benefits.

If a medication you take is not included on our formulary, or if there are limits on how you can receive it, talk with your doctor about your options. Together, you can determine whether a covered alternative is appropriate for you or whether a formulary exception should be requested.

To help ensure you have access to needed medications while you and your doctor explore the best course of action, KelseyCare Advantage may provide a temporary supply of certain drugs during your first 90 days of plan membership. In most cases, a temporary supply can be provided for up to 30 days.

When you move from one care setting to another, such as being discharged from a hospital and returning home, you may be prescribed new medications. This type of transition is known as a level-of-care change.

Because these changes can happen unexpectedly, you may not have enough time to determine whether a newly prescribed drug is included on the KelseyCare Advantage formulary. In these situations, KelseyCare Advantage may provide a temporary transition supply of the medication for up to 30 days.

If your level-of-care change includes admission to a long-term care facility and a new medication is prescribed, KelseyCare Advantage may provide a temporary supply for up to 31 days.

The Medication Therapy Management (MTM) Program is designed to help eligible members get the most benefit from their medications. If you take multiple prescription drugs, you may qualify for this program, which offers personalized support to help you understand and manage your medications safely and effectively.

Participation is voluntary and does not affect your health plan benefits or prescription drug coverage. Members who meet specific eligibility criteria may be invited to participate. The MTM Program is not available to all members.

Learn more about our Medication Therapy Management program.