Pharmacy

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Formulary 

Abbreviated Formulary	Complete Formulary
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• The website formulary files are updated on a continuous basis.  Please check back regularly to ensure you are aware of any changes to the formulary.

• Please contact the MercyCare Customer Service department at (800) 895-2421 if you wish to receive a printed copy of either formulary format.

A current version of the MercyCare Health Plans formulary can also be found by visiting  www.epocrates.com.

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Explanation of Drug Plans

Two-Tiered Drug Plan (closed)

This drug plan has an extensive list of prescription medications. All medications listed in the formulary have been reviewed for safety and effectiveness and were chosen by a committee of MercyCare Insurance physicians and Pharmacists.

Three-Tiered Drug Plan (open)

This drug plan is an open formulary, which means that all drugs are available to our members unless otherwise determined to be excluded. Our designated Pharmacy Benefit Manager (PBM) and/or MercyCare determine the placement of drugs with each tier of this open formulary. Other changes may occur to this formulary as determined by MercyCare or our designated PBM.   

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Prescription drug benefits are not available for the following:

Birth Control and Fertility Drugs:

• Contraceptives, other than oral contraceptives, diaphragms, and Transdermal patches.

• Fertility drugs.

Miscellaneous:

Replacement of any lost, stolen, or destroyed medications.

• Therapeutic devices or appliances, including hypodermic needles or syringes (except or diabetic supplies)

• Any drug or medicine that is administered or delivered by the prescriber to you.

• Any drug or medicine which is taken by or administered to you while you are a patient in a licensed hospital, rest home or sanitarium, extended care facility, convalescent hospital, skilled nursing facility or similar institution.

• Any drug labeled "Caution: limited by Federal Law to investigational use" or wording having similar intent, or experimental drugs, even though a charge is made to you, except that coverage shall be provided for any prescription drug which meets the following criteria:

  1. Is prescribed for the treatment of HIV infection or illness or medical condition arising from or related to HIV infection; AND 

  2. Is approved by the Federal Food and Drug Administration, including phase-3 investigational drugs; AND 

  3. If the drug is an investigational new drug, is prescribed and administered in accordance with the treatment protocol approved by the Federal Food and Drug Administration for the investigational new drugs.

• Anabolic steroids.

• Anti-obesity and anorexients.

• Growth hormones.

• Any prescription drug for a non-covered procedure.

• Any prescription drug for a sickness or bodily injury not covered by the plan.

• Medication other than prescription drugs with or without a prescription order.

• Prescription drugs, which the eligible person is entitled to receive with out charge from any Worker's Compensation laws or any municipal state or federal program.

• Nutritional supplements.

• Any prescription drugs dispensed to a member prior to the member's effective date of coverage under the plan or after the member's termination date.

• Any drug when used for cosmetic treatment of the aging process.

• Any drug when used for treatment of hair loss.

• Any medication or device used to obtain, treat, or enhance sexual performance and/or function. This includes dysfunction caused by organic diseases.

• Any prescription drugs administered by injection except for insulin injections and injections approved by the Plan's Pharmacy and Therapeutics Committee to be covered under the Pharmacy Benefit.

• Homeopathic Medications.

• Special formulations of covered drugs such as sustained release intended primarily for convenience of the patient; as deemed by MercyCare, are not covered.

• Special packaging of covered drugs intended primarily for convenience of the patient; as deemed by MercyCare, are not covered.

• Tretinoin topical (example: Retin A), for members over the age of 40.

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