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Best Medicare Advantage Plans for 2019 Rating is from U.S. News and World Report, a leading publisher of annual authoritative rankings including Best Medicare Plans. Our plan does not have a direct relationship with U.S. News. This award was not given by Medicare. Our overall rating from Medicare for 2019 is 5.0. Our plan’s official CMS Star Rating can be found at www.Medicare.gov.

​Find a Prescription Drug

2019 Comprehensive Formulary (List of Covered Drugs)


PLEASE READ: THIS WEBSITE CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
 
What is the KelseyCare Advantage Formulary?
A formulary is a list of covered drugs selected by KelseyCare Advantage in consultation with a team of health care 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. 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.
 

Drug Search - See if your drug is covered

Search the 2019 KelseyCare Advantage Formulary
This drug search is used for Rx, Rx+Choice and Metropolitan Transit Authority Preferred and Preferred+Choice Plans.
 
This searchable formulary is current as of 8/23/2018. To get additional information about the drugs covered by KelseyCare Advantage or 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, 8:00 a.m. to 8:00 p.m., seven days a week (October 1 through March 31) and from 8:00 a.m. to 8:00 p.m., Monday through Friday (April 1 through September 30). TTY/TDD users should call 1-866-302-9336
 

Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 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. Below are changes to the drug list that will also affect members currently taking a drug:

  • Drugs removed from the market. 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.
  • Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.
 

Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may 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 30-day 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.
You can find out if your drug has any additional requirements or limits by looking in the searchable formulary. You can also get more information about the restrictions applied to specific covered drugs here. We have posted on line documents that explain our prior authorization and step therapy restrictions below under Documents for Download. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on this webpage.

You can ask KelseyCare Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the KelseyCare Advantage’s formulary?” in the “Frequently Asked Questions” below for information about how to request an exception.
 

What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), 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 that is 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.
 

How do I request an exception to the KelseyCare Advantage’s Formulary?
You can ask KelseyCare Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
  • You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, KelseyCare Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

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. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
 

Part D Temporary Transition Supply
Under certain circumstances, the plan can offer a temporary supply when your drug is not on the Drug List or when it is restricted in some way. These guidelines define the eligibility criteria for a temporary transition supply.  

 
​Rx and Rx+Choice Copayments
Preferred Cost-Sharing Pharmacy
Tier
30-Day Supply
90-Day Supply
1
$3
$7.50
2
$17
$42.50
3
$40
$100
4
$60
$150
5
32%
NA* 
Standard Cost-Sharing Pharmacy
Tier
30-Day Supply
90-Day Supply
1
$8
$24
2
$20
$60
3
$45
$135
4
$70
$210
5
32%
NA* 

*A long-term supply is not available for drugs in Tier 5

 
Formulary Document Request
If you would like an Abridged Formulary, Comprehensive Formulary and/or Formulary Addendum mailed to you, here are your options:
Formulary Addendum/Changes
The Formulary may change at any time. You will receive notice when necessary. To review and/or print formulary changes made during the year, download the 2019 Formulary Addendum. 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
 
Documents for Download
Frequently Asked Questions