Q&A: Pharmacy benefit guideline

Generally, if you are taking a drug on our current year formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

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. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

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 60 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 60-day supply of the drug.

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.

If your drug is not included in the formulary, you should first contact our Customer Care Center and ask if your drug is covered. If you learn that Medica Central Health Plan does not cover your drug, you have two options:

You can ask our Customer Care Center for a list of similar drugs that are covered by Medica Central Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that we cover.

You can ask Medica Central Health Plan to make an exception and cover your drug. See above for information about how to request an exception.