The medications we cover are listed in our Drug List, also known as the formulary. There are two ways to see if your drugs are covered:
- If you are already a member, look in the printed formulary that we sent to you.
- To find out if your drugs are covered in plan year 2016, use our comprehensive Medicare formulary for plan year 2016.
You can also look up a drug to see if it is covered in plan year 2016 using our comprehensive online formulary search tool for plan year 2016. This lets you search a comprehensive formulary listing of the drugs we cover. 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: You [or your physician] need prior authorization for certain drugs. This means that you will need to get approval from FamilyCare Health before you fill your prescriptions. If you don’t get approval, FamilyCare Health may not cover the drug. Click here for a list of 2016 PA drugs.
- Quantity Limits: For certain drugs, there may be limits to the amount of the drug that we will cover. For example, we provide 12 tablets per 30-day prescription for RELPAX. This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, FamilyCare Health 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, 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. Click here for updates to the 2016 Step Therapy list.
If the drug you are being prescribed is not on the formulary or has additional requirements (above), you or your doctor may request a coverage determination/formulary exception. Please see coverage determination/exception 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 Medicare 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/Mail-Order Drugs
There are two main ways FamilyCare members can find a participating pharmacy: Use our Pharmacy Locator to search for a FamilyCare pharmacy near you.
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 co-pay as a 30-day supply. To sign up, use this form, register on the Caremark website or call 855-771-9290. Your doctor’s office can call 800-378-5697 or fax 800-378-0323 to place a new or updated prescription for you.
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 CVS Caremark Customer Care toll-free at 855-771-9290.
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 Plans, Inc., is an HMO and PPO plan with contracts with Medicare and the Oregon Health Plan (Medicaid). Enrollment in FamilyCare Health 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.
Y0103_WEB_00317v2 — Approved (Updated 06/12/2017)