Formulary – Medica Healthcare Plans uses a formulary of covered drugs.
The drugs on the formulary are separated into different tiers by a team of physicians and pharmacists with expertise in treating Medicare beneficiaries. Medica HealthCare Plans covers both generic and brand name drugs. Generic drugs have the same active ingredient formula as brand name drugs and usually cost less than brand name drugs. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
Medica HealthCare Plans also has implemented utilization management tools to further ensure safety and appropriateness of use for some drugs like prior authorization, step therapy, or quantity level limits. This information is also described in the formulary.
Depending on what tier your drug is on will determine how much you are charged at the pharmacy.
- Medica HealthCare Plans 2013 Formulary - Last Updated May 7, 2013
- 2013 Prior Authorization Criteria
- 2013 Transition Process
- 2013 Quantity Level Limits Requirements
- 2013 Step Therapy Requirements
Formulary Changes – If there are any changes to the formulary, a description of the change will be posted here at least 60 days before the change becomes effective (unless the change is due to a drug that has been deemed unsafe by the Food & Drug Administration or removed from the market by the manufacturer at which point the change will be made immediately).
Medica HealthCare Plans has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. The Provider and Pharmacy Directory has a list of the pharmacies in Miami-Dade and Broward County. We have pharmacies in our network in all 50 states and Puerto Rico.
Please contact the Member Services Department to see if a pharmacy outside of the service area is contracted.
Medication Theraphy Management Program
Medica HealthCare Plans offers a medication therapy management program at no additional cost to members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. These programs were developed by a team of pharmacists and doctors with expertise in treating Medicare beneficiaries. The medication therapy management program helps us provide better coverage for our members even though the program is not a benefit. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.
We may contact members who qualify for these programs. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you don’t need to pay anything extra to participate. If you are selected to join a medication therapy management program we will send you information about the specific program, including information about how to access the program. This document explains our Medication Therapy Management Program.
Out of Network Coverage
Generally, Medica HealthCare Plans will only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available, for example, if you are traveling in the United States but are outside of the service area and become ill or have an emergency and a network pharmacy is not readily available, if you are unable to get a covered drug in a timely manner within our service, or if you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail pharmacy. You may ask Medica HealthCare Plans to reimburse you by submitting a claim form. You can contact the Member Services Department for more information.
Appeals & Grievances
For more information on the Medica HealthCare Plans Appeal & Grievance process, how to file an appeal or grievance, or for related forms, please follow the link at the top of this page. See sections 8, 9, and 10 of the Evidence of Coverage for additional information.
Low Income Subsidy
If you qualify for extra help with your Medicare Prescription Drug costs, the cost sharing for your medications will generally be lower. Depending on the amount of additional help you receive, your copayments in 2013 will be:
|Level 1||$ 2.65||$ 6.60|
|Level 2||$ 1.15||$ 3.50|
|Level 3||$ 0.00||$ 0.00|
You also receive assistance with your monthly plan premium. This table shows your premium amount for Medica HealthCare Plans depending on the amount of assistance you receive:
If you are a member of Medica HealthCare Plans MedicareMax Plus, you are receiving Medicaid benefits. For more information about your premiums and cost sharing, please see Section 10 of the MedicareMax Plus Evidence of Coverage.
If you would like more information about whether you qualify for additional assistance with your prescription drug costs, you can contact Social Security at 1-800-772-1213.
TTY users call 1-800-325-0778.
You can also apply online at the Social Security website at www.ssa.gov. (clicking on this link will take you away from the Medica HealthCare Plans website.)
Medica HealthCare Plans is a health plan with a Medicare contract. Contracts with Medicare are on a calendar yearly basis and may not be renewed by either party the following year.
Last Update: June 10, 2013 at 7:27 pm