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 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 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.
Formulary Changes - If there are any changes to the formulary, a description of the change will be posted here at least 30 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).
Provider and Pharmacy Directory
Medica HealthCare 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 Counties. 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.
Generally, Medica HealthCare 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 Appeals & Grievances process, how to file an appeal or grievance, or for related forms, please follow this link. 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 2016 will be:
|Level 1||$ 3.40||$ 8.50|
|Level 2||$ 1.25||$ 3.80|
|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 (HMO SNP), 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 website.)
Medica HealthCare 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.