Formulary (list of covered drugs) 

• 2023 formulary (PDF)  Updated 11/2023 

• 2023 Formulary changes (PDF) Updated 11/2023

• 2024 formulary (PDF)  Updated 10/2023 

• 2024 Formulary changes (PDF) Coming soon 

or 

• Search our online formulary

Are there any restrictions on my drug coverage?  

Yes, some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: 

2023 prior authorization criteria (PDF) Updated 11/2023

2024 prior authorization criteria (PDF) Updated 11/2023  

Mercy Care Advantage requires you (or your physician) to get prior authorization for some drugs. This means that you need to get approval from Mercy Care Advantage before you fill your prescriptions. If you don’t, Mercy Care Advantage may not cover the drug.  

2023 step therapy criteria (PDF) No changes made since 7/2023  

2024 step therapy criteria (PDF) No changes made since 10/2023 

Sometimes Mercy Care Advantage needs you first to try certain drugs to treat your medical condition before it covers another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Mercy Care Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work, you can ask Mercy Care Advantage to cover Drug B. 

As a Medicare beneficiary, you have rights under your Part D prescription drug benefits. The information in the options below will explain the Part D prescription drug benefits available to you and your rights as a Mercy Care Advantage plan member. You, your authorized representative or your doctor has the right to request a coverage determination or exception for a drug that you feel should be covered for you or to request we pay for a prescription drug you already bought. For complete information about the coverage determination process or appeal process, view Part D coverage determinations later on this page or refer to the Evidence of Coverage on this page. 

As a member of Mercy Care Advantage, you, your authorized representative or your doctor has the right to request a coverage determination or exception for a drug that you feel should be covered for you or to pay for a prescription drug you already bought. If your pharmacist tells you that your prescription drug claim was rejected, you will be given a written notice that explains how you can request a coverage determination or exception. This information is also explained in Chapter 9 of the Evidence of Coverage.

Mercy Care Advantage has a list of covered Part D prescription drugs called a “formulary.” Your network doctor will refer to the formulary and typically prescribe a drug from the formulary that will meet your medical needs. Not all prescription drugs are included on the Mercy Care Advantage formulary, and some drugs covered under our formulary may require prior authorization, step therapy or have quantity limits that apply. You can view the formulary, prior authorization criteria and step therapy criteria in the Formulary menu on this page.

A coverage determination is any determination (e.g., an approval or denial) made by Mercy Care Advantage for the following reasons:

1. A decision about whether to provide or pay for a Part D drug (including a decision not to pay) because:
   • The drug is not on the plan’s formulary
   • The drug is determined not to be medically necessary
   • The drug is furnished by an out-of-network pharmacy
   • Mercy Care Advantage determines that the drug is otherwise excluded under section 1862(a) of the Act (if applied to Medicare Part D) that the enrollee believes may be covered by the plan
2. Failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the enrollee;
3. A decision concerning a tiering exceptions request;
4. A decision concerning a formulary exceptions request;
5. A decision on the amount of cost sharing for a drug; or
6. A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement.

There may be times that you, your authorized representative, or your doctor will want to ask for a coverage determination or exception. Mercy Care Advantage must review and process the request within the expedited (24 hours) or standard (72 hours) time frames required by Medicare.

In order for us to cover a formulary exception, your doctor must provide a statement that says you have tried formulary alternatives in the same drug class and they didn’t work for you, or a medical reason why you can’t try the formulary alternatives in the same drug class.

If we approve the request, you will be notified, and the drug or payment will be provided.

If we deny the request, you will be notified and receive a written notice explaining why it was denied and how you can appeal this decision. An unfavorable decision could be because the drug is not on the formulary, excluded from Part D coverage, or determined not to be medically necessary, or you have not tried a similar drug listed on the formulary. It could also be based on whether or not you have satisfied the prior authorization requirement. In most situations, this process cannot be applied to any medications excluded from Part D under federal law (e.g., over-the-counter medications).

Coverage determination requests can be made in writing, by phone or by fax. Members can call Mercy Care Advantage Member Services at the numbers provided below to request a coverage determination or exception. You may also use the Coverage Determination form to submit your request.

Coverage Determination form

• Online Coverage Determination form English | Español

• Print Coverage Determination form (PDF)

• Multi-language interpreter services (PDF)

Providers can call or fax a coverage determination or exception request to Mercy Care Advantage at the numbers below. A request for an exception needs to include a supporting statement from your doctor to provide the medical reasons for the drug requested.

Coverage decisions for Part D prescription drugs

Mercy Care Advantage members can ask us for a coverage determination by:

• Phone: ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). We're here for you ${MCA_MS_hours} 

• Fax: 1-855-230-5544 

• Mail: Mercy Care Advantage  
  Part D Coverage Determination Pharmacy Department  
  4500 E. Cotton Center Blvd.  
  Phoenix, AZ 85040

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). We're here for you ${MCA_MS_hours}.

Requests

1. Request to Satisfy a Prior Authorization (PA) or other utilization management (UM) requirement
   
   Standard coverage determination time frame
   We must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but not later than 72 hours from the receipt of the request.
   
   Expedited coverage determination time frame
   We must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the request.

2. Request to Waive a Prior Authorization (PA) or other utilization management (UM) requirement — Formulary Exception Request
   
   Standard coverage determination time frame
   If an enrollee or an enrollee's prescribing physician or other prescriber is asking us to waive a PA or other UM requirement because the physician or other prescriber feel that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support this type of request. 
   We must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 72 hours after receiving the physician's or other prescriber's supporting statement for standard cases.
   
   Expedited coverage determination time frame
   If an enrollee or an enrollee's prescribing physician or other prescriber is asking us to waive a PA or other UM requirement because the physician or other prescriber feels that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support this type of request. 
   We must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the physician's or other prescriber's supporting statement for standard cases.

3. Request for Reimbursement for drug already received that involves waiving a Prior Authorization (PA) or other utilization management (UM) requirement — Exception Request
   
   Standard coverage determination time frame
   If an enrollee is asking to be reimbursed for a drug purchased that requires us to waive a PA or other UM requirement because the physician or other prescriber feels that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support the request. 
   We must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision (and make payment when appropriate) no later than 14 calendar days after receiving the request.
   
   Expedited coverage determination time frame
   Reimbursement requests do not qualify for expedited processing.

4. Request for Tiering Exception — drug not yet received
   
   Standard coverage determination time frame 
   If an enrollee wishes to obtain a tiering exception for a drug not yet received, his or her prescribing physician or other prescriber must provide the plan sponsor with a statement to support the request.
   We must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 72 hours after receiving the physician’s or other prescriber's supporting statement.
   
   Expedited coverage determination time frame
   
   If an enrollee wishes to obtain a tiering exception for a drug not yet received, his or her prescribing physician or other prescriber must provide the plan sponsor with a statement to support the request.
   We must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the physician’s or other prescriber's supporting statement.

5. Request for Tiering Exception Reimbursement
   
   Standard coverage determination time frame
   If an enrollee is asking for a reimbursement related to a tiering exception, the prescribing physician or other prescriber must submit a statement to support the request.
   We must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision (and make payment when appropriate) no later than 14 calendar days after receiving the request.
   
   Expedited coverage determination time frame 
   Reimbursement requests do not qualify for expedited processing.

How to file a Part D grievance 

You have the right to file a complaint (also called a “grievance”) if you have a problem or concern. A grievance is any complaint or dispute, other than one that involves a coverage determination or an LIS (Low-Income Subsidy) or LEP (Late Enrollment Penalty) determination, expressing dissatisfaction with any aspect of the operations, activities or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times and the customer service you receive. 
 
You may file a grievance if you have a problem with Mercy Care Advantage or one of our network providers or pharmacies. Some examples of why you might file a complaint/grievance include:

• You believe your plan's customer service hours of operation should be different.

• You have to wait too long for your prescription.

• The plan is sending you materials that you didn’t ask to get and aren’t related to the drug plan.

• The plan didn’t make a timely decision about a coverage determination in level 1 and didn’t send your case to the IRE.

• You disagree with the plan’s decision not to grant your request for an expedited (fast) coverage determination or first-level appeal (called a “redetermination”).

• The plan didn't provide the required notices.

• The plan's notices don't follow Medicare rules.

We may use your complaint type to track trends and identify service issues. Please see Chapter 9 of the Evidence of Coverage on this page for detailed information and timelines for filing a grievance. 
 
If you want to file a grievance, contact us promptly — either by phone or in writing. Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can reach Member Services at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). We're here for you ${MCA_MS_hours}.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works:

• If you ask for a written response, file a written grievance or your complaint is related to quality of care, we will respond to you in writing.

• If we cannot resolve your complaint over the phone, we will respond to your complaint within 30 calendar days.

Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 days after you had the problem you want to complain about. If you need an interpreter, one can be provided at no cost to you. Please submit written complaints by:

• Fax: 1-602-351-2300

• Mail:  Mercy Care Advantage 
  Attn: Grievance Department 
  4500 E. Cotton Center Blvd. 
  Phoenix, AZ 85040

You may file a request for a "fast complaint" (expedited grievance) if you disagree with our decision not to process your request for a "fast response" to a coverage decision or appeal. If you request a fast complaint, we must give you an answer within 24 hours.

If you have a complaint about your quality of care, you may file a grievance with the plan by calling Member Services and filing the complaint over the phone. The plan Quality Team will research the complaint and send a response to you. You may also file a grievance with Arizona's Quality Improvement Organization, Livanta by:

• Phone: 1-877-588-1123 (TTY 1-855-887-6668)

• Fax: 1-833-868-4063

• Mail: Livanta LLC
  BFCC-QIO
  10820 Guilford Road, Suite 202
  Annapolis Junction, MD 20701-1105

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). We're here for you ${MCA_MS_hours}.

Appeals

If you are notified of a coverage determination denial by Mercy Care Advantage, you or your appointed representative may submit a redetermination request (1st level of appeal) within 60 calendar days from the date of the written notice. You may submit an appeal after this time frame if you have good cause.

You may submit a redetermination request by calling Mercy Care Advantage or sending a request in writing. You or your physician may request a fast (expedited) appeal if it is believed that applying the standard time frame could seriously affect your health. If Mercy Care Advantage does not agree, you will be notified, and your redetermination will be automatically moved to the standard process.

Because Mercy Care Advantage denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 calendar days from the date of our "Notice of Denial of Medicare Prescription Drug Coverage" to ask us for a redetermination. 

Coverage Redetermination forms

• Online Coverage Redetermination form English | Español

• Print Coverage Redetermination form (PDF)

• Multi-language interpreter services (PDF)

Who may make a request: Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.

You can submit a redetermination request by:

• Phone: Call ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). We're here for you ${MCA_MS_hours}. 

• Fax: 1-855-230-5544

• Mail: Mercy Care Advantage 
  Attn: Part D Appeals 
  Pharmacy Department 
  4500 E. Cotton Center Blvd. 
  Phoenix, AZ 85040

When you or your representative requests a redetermination, a special team will review your request, collect evidence and findings that the denial was based on and any additional evidence from you or your doctors. The case will then be reviewed by a different physician than the one who made the original determination. Mercy Care Advantage will notify you and your doctor of the redetermination decision, following the time frames below.

If Mercy Care Advantage fails to make a redetermination decision and notify you within the time frame, Mercy Care Advantage must submit your redetermination case file to IRE for review. Mercy Care Advantage will notify you if this action should occur. You have the right to a timely redetermination (see table below) and may file an expedited grievance if we do not notify you of our decision within this timeframe (see Grievances).

If Mercy Care Advantage notifies you of an unfavorable decision, and you disagree, you may submit a reconsideration request (second-level appeal) to the Independent Review Entity. Additional instructions will be included in the written notice.

Appeals

1. Appeal level: Redetermination by Mercy Care Advantage
   
   Standard appeal
   Upon receipt of your appeal (redetermination), the Appeals Unit Coordinator will gather evidence on the basis of the denial of the Part D prescription drug, and additional evidence from you or your representative and prescribing doctor. Your appeal will be evaluated by a clinical expert. Mercy Care Advantage will notify you by telephone as fast as your health condition requires but not later than 7 calendar days from the receipt of the appeal.
   
   Expedited appeal
   You or your doctor may request Mercy Care Advantage to expedite your appeal if it believes that waiting for the standard time frame will cause you serious harm. Mercy Care Advantage will notify you of the decision by telephone as fast as your health condition requires but not later than 72 hours after receipt of your appeal. If Mercy Care Advantage does not agree that your appeal requires a fast review, you will be notified that the standard time frame will be applied.

2. Reconsideration by Independent Review Entity (IRE)
   
   Standard appeal
   If Mercy Care Advantage upholds the original denial for your prescription drug, you may send your appeal to the CMS-contracted IRE within 60 calendar days of the Mercy Care Advantage notice. The IRE will review your appeal and make a decision within 7 calendar days.
   
   Expedited appeal
   You may file a fast appeal with the IRE if you or your doctor believes that waiting for the standard time frame will cause you serious harm. The IRE will review your appeal and notify you if they do not agree that your appeal requires a fast review and will apply the standard time frame. If the IRE agrees, they will notify you of their decision within 72 hours from the time your appeal was received.

3. Hearing with Administrative Law Judge (ALJ)
   
   Standard appeal
   If the IRE decision is unfavorable and the amount in dispute meets the requirements, you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE.
   
   Expedited appeal
   Same as standard appeal.

4. Review by Medicare Appeals Council (MAC)
   
   Standard appeal
   If the ALJ decision is unfavorable, you may appeal to the MAC, which is within the Department of Health and Human Services. The MAC oversees the ALJ decisions.
   
   Expedited appeal
   Same as standard appeal.

5. Federal District Judge
   
   Standard appeal 
   If you do not want to accept the decision, you might be able to continue to the next level of the review process. It depends on your situation. Whenever the reviewer says no to your appeal, the notice you get will tell you whether the rules allow you to go on to another level of appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.
   
   Expedited appeal 
   Same as standard appeal.

More information on appeals

The prescription drug coverage expedited appeals (redetermination) process: 
You may file a request for an expedited appeal for drug coverage if you believe that applying the standard appeals process could jeopardize your health. If Mercy Care Advantage decides that the time frame for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.

1. You, your appointed representative or your doctor or other prescriber can request an expedited appeal. An expedited request can be submitted orally or in writing to Mercy Care Advantage and your doctor or other prescriber may provide oral or written support for your request for an expedited appeal.

2. Mercy Care Advantage must provide an expedited appeal if it determines that applying the standard time frame for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

3. A request made or supported by your doctor or other prescriber will be expedited if he/she tells us that applying the standard time frame for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

Please see Chapter 9, Section 7 of the Evidence of Coverage on this page for more information about Part D prescription drug coverage determinations and appeals.

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). We're here for you ${MCA_MS_hours}.