Medicare

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Covered Drugs

Our Formulary

The medications we cover are listed in our Drug List, also known as the formulary. 

  • To find out if your drugs are covered in plan year 2017, view our 2017 formulary.
  • To find out if your drugs are covered in plan year 2018, view our 2018 formulary.

You can also look up a drug to see if it is covered using our comprehensive online formulary search tool for 2017 and our comprehensive online formulary search tool for 2018. It includes any changes to prior authorization or step therapy rules and is updated whenever changes occur.

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: 

  • Prior Authorization: Our plans require you or your physician to get prior authorization (PA) for certain drugs. This means that you will get an approval from us before you fill your prescriptions. If you don’t get approval, our plans may not cover the drug. View our 2017 Prior Authorizations. View our 2018 Prior Authorizations.
  • Quantity Limits: For certain drugs, our plans limit the amount of the drug that we will cover. For example, our plans provide 12 tablets per prescription for RELPAX. This may be in addition to a standard one-month or three-month supply. 
  • Step Therapy: In some cases, our plans require 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. View our 2017 Step Therapy Drugs. View our 2018 Step Therapy Drugs.

You can find out if your drug has any additional requirements or limits by looking in the formulary.

If the drug you are being prescribed is not on the formulary or has additional requirements (see above), you or your doctor may request a coverage determination/formulary exception. Please see the Request for Medicare Prescription Drug Coverage Determination form.

Were you denied your request for coverage of (or payment for) a prescription drug? You have the right to ask us for a redetermination (appeal) of our decision. Please see the Request for Redetermination of Medicare Prescription Drug Denial form.

How to request an exception for a drug

We want to hear if you have problems getting a Medicare Part D drug, if you want us to pay you back for a Part D drug, or if a drug is not covered in the way you would like it to be covered. 

If you are asking us to make a change just for you to our formulary or our drug tiers, your doctor or other prescriber must give us a statement that explains the medical reasons for “requesting an exception.” Examples of a request for an exception include:

  • Asking us to cover a Part D drug that is not on our list of covered drugs
  • Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
  • Asking to pay a lower cost-sharing amount for a covered non-preferred drug
  • To request an exception specifically for prescription drug coverage, you may use this Request for Medicare Prescription Drug Coverage Determination form.

For more information about your rights when we change our formulary (for example, if you are taking a drug that was covered differently on the previous formulary), see our Prescription Drug Transition Policy.

Find a Pharmacy
Our pharmacy network has more than 63,000 participating pharmacies nationwide, including major retail chains, independent pharmacies, and mail order. Show your FamilyCare ID Card at a participating pharmacy and the pharmacy will handle the paperwork. You only pay your applicable copay or coinsurance amount. You must use network pharmacies to access your prescription drug benefit except under non-routine circumstances. 

To find a pharmacy near you, use our Pharmacy Locator or search our Provider/Pharmacy Directory.

Mail Order 
Or, save money using our mail-order pharmacy. With our mail-order pharmacy, you can purchase a 90-day supply of medications you take regularly for the same copay as a 30-day supply. To sign up, use this form, register on the Caremark website, or call 855-771-9290. 

Note: You should receive your mail-order pharmacy prescription within 10 days after placing your order. If you have not received your prescription within 10 days, please call Caremark at 855-771-9290.

Quality Improvement and Utilization Management
FamilyCare Health works hard to provide quality programs for our members. We're here to help ensure that medication options for our members are appropriate, safe, and effective. We do concurrent drug utilization reviews and safety initiatives to give our members the best possible health benefits from their medications, while lowering risks for adverse events, medication errors, drug interactions, or therapy duplications. We base our medication policies and procedures on careful review of scientific information and input from practicing physicians. Our ultimate goal is to enhance health outcomes with improved medication use for our members.

Medication Therapy Management Program
If you have several complex health conditions or take many drugs, our no-cost Medication Therapy Management (MTM) program is designed to help you manage your drugs and cut your risk for problems. 

FamilyCare Health is an HMO with a Medicare and Oregon Health Plan (Medicaid) contract. Enrollment in FamilyCare Health Medicare Advantage plans depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. If you enroll in FamilyCare Community (HMO SNP), the Oregon Health Plan will pay your Part B premium for you. FamilyCare Community (HMO SNP) is available to people who qualify for Medicare and the Oregon Health Plan (Medicaid). Premiums, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Y0103_WEB_00354 — Approved (Updated 10/05/2017)

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