Pharmacy & prescriptions

• 4-tier QHP full formulary

Complete formularies:

• 4-tier full formulary
• 3-tier full formulary
• 2-tier full formulary

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

Please contact MercyCare’s customer service department at 800.895.2421 if you wish to receive a printed copy of any formulary.

4-tier QHP full formulary

05.09.23 - 60 day formulary change

Negative Formulary Change:

Negative Formulary Changes include but are not limited to:

• A drug product or chemical entity being removed from the formulary.
• A drug being moved to a higher tier.
• The addition of or more aggressive use of utilization criteria such Prior Authorization, Step Therapy, or Quantity Limits.

All Negative Formulary Changes and appropriate alternatives are approved by the P&T Committee prior to implementation with the following exceptions;

• Branded medications that have A-rated equivalent generics or an equivalent chemical entity available at an equal or lower tier.
• Products that have been recalled by the FDA

MercyCare will continue members currently taking the medications at the same level of coverage, until the end of the current plan year

If you are affected by a negative formulary change, MercyCare will notify you sixty (60) days in advance of the change. This notification will include.

• The reason for the change,
• A list of common formulary alternatives,
• The transitional coverage tier and time period when applicable.

MercyCare will also notify your prescriber of the negative formulary change. You or your prescriber can submit a request a coverage determination and exception, this should include a statement of certification of medical necessity by your prescribing provider, which will result in continuation of coverage at the existing level to the end of the current plan year.

Prior authorization forms

For additional information and a complete list of Formularies, Pre Authorization criteria and forms please use the Portal below:

Prescriber Portal - home (navitus.com)

• Amitiza or Linzess
• Benlysta
• Fibromyalgia agents
• Hematopoietic agents
  
• Infliximab Criteria
• Long-acting narcotics
• Psoriasis immunomodulators
• Rheumatoid arthritis immunomodulators
• Rituximab Criteria
• Testosterone
• Lyrica
• Xolair
• Formulary Exception & Preauthorization form
• Medical benefit drug request form
• Viscosupplements criteria

To submit the form and start the formulary exception process or pre authorization request, click here: mcare@mhemail.org

• Explanation of drug plans
• Prescription drug policies and coverage criteria
• Mail order program
• Specialty pharmacy
• Preferred medication list for provider administered medications
• IL uniform prior authorization form for prescription drug benefits

Medication Synchronization is offered at both Riverside and Mall Pharmacies—allowing patients fewer trips to the pharmacy as most of their medications are due on the same monthly/quarterly cycle. Med Sync can be compared to an automatic refill program. Mercy pharmacists work with each patient to align their medication to a 30- or 90-day refill cycle. Patients are then contacted before their refills are due to make sure there have not been any changes to their therapy. Mercy pharmacy then gets the prescriptions ready for delivery to the patient in their preferred method—either pick up at the pharmacy or mailed to their home. This leads to better adherence rates, and it is convenient for patients as they make less trips to the pharmacy. Med Sync also eliminates the need to call the pharmacy to order your refills. There is no additional cost to Med Sync—if shortened fills are needed to align the medications, MercyCare also prorates the copay for those fills.

• Foreign claim – direct member reimbursement
• Compound claim
• Direct member reimbursement
• OTC-COVID 19 at home test claim – direct member reimbursement

Two-tiered drug plan

This drug plan has an extensive list of covered prescription medications divided into two tiers. Tier 1 is the lowest co-pay level and includes preferred generics and over-the-counter medications. Tier 2 is the higher co-pay level and includes preferred brands. All medications listed in the formulary have been reviewed for safety and effectiveness and are chosen by a committee of physicians and pharmacists.

Three-tiered drug plan

The list of medications has been divided into three tiers. Tier 1 is the lowest co-pay level and includes preferred generics and over-the-counter medications. Tier 2 is the higher co-pay level and is composed of preferred brands. Tier 3 is the highest co-pay level and includes non-preferred brands and generics. All medications listed in the formulary are reviewed for safety and effectiveness and chosen by a committee of physicians and pharmacists. Other changes may occur to this formulary as determined by MercyCare Health Plans.

Four-tiered drug plan

This four-tiered drug plan incorporates four levels of benefits. Tier 1 is for preferred generic drugs, preferred tier 1 brand name drugs, and covered over-the-counter (OTC) drugs, and has the lowest co-payment. Tier 2 covers selected generic drugs and our preferred tier 2 brand name drugs, and has the second lowest co-payment. Tier 3 represents all non-preferred drugs, except specialty drugs, and has the third lowest co-payment. Tier 4 covers only selected generic drugs, selected brand name drugs, specialty drugs, and clinically-appropriate non-covered drugs by approval, and has the highest co-payment. This drug plan is a closed formulary, which means that only those drugs listed in the formulary are available to our members. All medications listed in the formulary are reviewed for safety and effectiveness and chosen by a committee of physicians and pharmacists. Other changes may occur to this formulary as determined by MercyCare.

Prescription drug benefits are not available for the following:

• Replacement of any lost, stolen or destroyed medications.
• Fertility drugs (only applicable for Wisconsin coverage)
• Therapeutic devices or appliances including hypodermic needles or syringes (except for diabetic supplies).
• Any drug or medicine administered or delivered to you by the prescriber.
• Any drug or medicine taken by or administered to you while 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 (FDA), 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 FDA 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 your plan.
• Medication other than prescription drugs with or without a prescription order.
• Prescription drugs, which the eligible person is entitled to receive without charge from any worker's compensation laws or any municipal state or federal program.
• Nutritional supplements
• Any prescription drugs dispensed to prior to the effective date of coverage under the plan or after the termination date.
• Any drug used for cosmetic treatment of the aging process.
• Any drug used for treatment of hair loss
• Any medication or device used to obtain, treat or enhance sexual performance and/or function, including 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 and covered under the pharmacy benefit.
• Homeopathic medications
• Special formulations of covered drugs such as sustained release intended primarily for convenience.
• Special packaging of covered drugs intended primarily for convenience.
• Tretinoin topical (e.g., Retin A), for members over the age of 40.

Drug Recalls