Part D: Prescription Drug Information

Formulary and Utilization Criteria

Mercy Care Advantage Formulary

Search our online 2021 Formulary

2021 MCA Comprehensive Formulary

2021 Prior Authorization Criteria

2021 Step Therapy Criteria

The Mercy Care Advantage formulary is a list of drugs selected in consultation with a team of health care providers. It includes prescription therapies believed to be a necessary part of a quality treatment program. Mercy Care Advantage generally covers the drugs listed in our formulary as follows:

• the drug is medically necessary,
• the prescription is filled at a Mercy Care Advantage network pharmacy,
• and other plan rules are followed

Some covered drugs may have restrictions or limitations such as prior authorization or step therapy. Please review the formulary, prior authorization criteria and step therapy criteria above for more information. The formulary is subject to change during the year.

We offer a robust pharmacy network with participating pharmacies located throughout the Mercy Care Advantage service area. You may use the Find a Provider/Pharmacy webpage to assist you in locating pharmacies in our network.

For more detailed information about MCA prescription drug coverage, you can review MCA member materials, or contact MCA Member Services at 1-877-436-5288, 8:00 a.m. - 8:00 p.m., 7 days a week.

Additional information about MCA Part D prescription drug coverage is available in the menus below.

Opioid requirements and Drug Management Program

Medicare Part D Opioid Policies: Information for Prescribers

The Centers for Medicare and Medicaid Services (CMS) finalized new opioid policies for Medicare drug plans starting on January 1, 2019. Providers are in the best position to identify and manage potential opioid overutilization in the Medicare Part D population. The new policies include improved safety alerts when opioid prescriptions are dispensed at the pharmacy and drug management programs for patients determined to be at-risk for misuse or abuse of opioids or other frequently abused drugs.

Residents of long-term care facilities, those in hospice care, patients receiving palliative or end-of-life care, and patients being treated for active cancer-related pain are exempt from these interventions. These policies should not impact patients’ access to medication-assisted treatment (MAT), such as buprenorphine.

Opioid Safety Alerts

Part D plans are expected to implement safety alerts (pharmacy claim edits) for pharmacists to review at the time of dispensing the medication to prevent the unsafe utilization of drugs. CMS encourages prescribers to respond to pharmacists’ outreach in a timely manner and give the appropriate training to on-call prescribers when necessary to resolve opioid safety edits expeditiously and avoid disruption of therapy.

 

Opioid Safety Alert		Prescriber's Role
Seven-day supply limit for opioid naïve patients (“hard edit”) Medicare Part D patients who have not filled an opioid prescription recently (such as within the past 60 days) will be limited to a supply of 7 days or less. Limiting the amount dispensed with the first opioid prescription may reduce the risk of a future dependency or overuse of these drugs. Important Note: This alert should not impact patients who already take opioids.		Patient may receive up to a 7 days supply or request a coverage determination for full days supply as written. The physician or other prescriber has the right to request a coverage determination on patient’s behalf, including the right to request an expedited or standard coverage determination in advance of prescribing an opioid. Prescriber only needs to attest to plan that the days supply is the intended and medically necessary amount. Subsequent prescriptions written by prescribers are not subject to the 7 days supply limit, as the patient will no longer be considered opioid naïve.

 

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Opioid care coordination alert at 90 morphine milligram equivalent (MME) This policy will affect Medicare patients when they present an opioid prescription at the pharmacy and their cumulative MME per day across all of their opioid prescription(s) reaches or exceeds 90 MME. Some plans use this alert only when the patient uses multiple opioid prescribers and/or opioid dispensing pharmacies. The prescriber will be contacted to resolve the alerts and to be informed of other opioid prescribers or increasing level (MME) of opioids. Important Note: This is not a prescribing limit. Decisions to taper or discontinue prescription opioids are individualized between the patient and prescriber.

Regardless of whether individual prescription(s) are written below the threshold, the alert will be triggered by the fill of the prescription that reaches the cumulative threshold of 90 MME or greater. The prescriber who writes the prescription will trigger the alert and will be contacted even if that prescription itself is below the 90 MME threshold. Once a pharmacist consults with a prescriber on a patient’s prescription for a plan year, the prescriber will not be contacted on every opioid prescription written for the same patient after that unless the plan implements further restrictions. On the patient’s behalf, the physician or other prescriber has the right to request a coverage determination for a drug(s), including the right to request an expedited or standard coverage determination in advance of prescribing an opioid.

 

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Concurrent opioid and benzodiazepine use or duplicative long-acting opioid therapy (“soft edits”) The alerts will trigger when opioids and benzodiazepines are taken concurrently or if on multiple duplicate long-acting opioids.

The pharmacist will conduct additional safety reviews to determine if the patient’s opioid use is safe and clinically appropriate. The prescriber may be contacted.

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Optional Safety Alert at 200 MME or more (“hard edit”) Some plans may implement a hard safety alert when a patient’s cumulative opioid daily dosage reaches 200 MME or more. Some plans use this alert only when the patient uses multiple opioid prescribers and/or opioid dispensing pharmacies. Important Note: This is not a prescribing limit. Decisions to taper or discontinue prescription opioids are individualized between the patient and prescriber.

This alert stops the pharmacy from processing the prescription until an override is entered or authorized by the plan. On the patient’s behalf, the physician or other prescriber has the right to request a coverage determination for a drug(s), including the right to request an expedited or standard coverage determination in advance of prescribing an opioid. In the absence of other approved utilization management requirements, once the prescriber(s) attests that the identified cumulative MME level is the intended and medically necessary amount, the medication will be dispensed to the patient.

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Drug Management Programs (DMPs)

Medicare Part D plans may have a DMP that limits access to opioids and benzodiazepines for patients who are considered to be at-risk by the plan for prescription drug abuse.

The goal of a DMP is better care coordination for safer use. Coverage limitations under a DMP can include requiring the patient to obtain these medications from a specified prescriber and/or pharmacy, or implementing an individualized POS edit that limits the amount of these medications that will be covered for the patient. The coverage limitation tools may be put in place for 12 months and extended for an additional 12 months (total of 24 months).

Potential at-risk patients are identified by their opioid use which involve multiple doctors and pharmacies. After the plan conducts case management with prescribers, and before implementing a coverage limitation tool, the plan will notify the patient in writing. Plans are required to make reasonable efforts to send the prescriber a copy of the letter. After this 30 day time period, if the plan determines based on its review that the patient is at-risk and implements a limitation, it must send the patient a second written notice confirming the specific limitation and its duration.

If the plan decides to limit coverage under a DMP, the patient and their prescriber have the right to appeal the plan’s decision. The patient or prescriber should contact the plan for additional information on how to appeal.

Transition of Coverage

Mercy Care Advantage provides new enrollees with a one-time temporary fill if the drug they were taking before they joined our plan is not covered. We also provide existing members with a transition fill if a drug they are currently taking is not going to be covered on the MCA Formulary in the new plan year.   This is called the Transition of Coverage (TOC) process.

Members, who receive a transition fill for a drug, will get a letter explaining that the drug was filled under the Transition of Coverage process. The prescribing provider will also receive notification. The letter explains the action required for the member to receive plan approval for their existing drug or how to switch to another drug covered on the plan formulary. This one-time temporary fill gives the member an opportunity to work with their doctor to decide if they need to continue on their current drug to avoid disruption in treatment or if they can be prescribed another drug on the MCA Formulary. If your MCA patient needs to remain on their existing drug, please follow the instructions under the Coverage Determination and Exception Request menu to submit a request to MCA for review.

Specialty Drugs

How to order specialty drugs for Mercy Care Advantage members

For authorization to administer a specialty drug covered under the members Medicare Part D benefit:

• Call Mercy Care Advantage at 1-877-436-5288 and select option #2 for providers.

Or

• Complete the Coverage Determination Request Form and fax to the Mercy Care Advantage Pharmacy Department at 1-855-230-5544.

For authorization to administer a specialty drug covered under the members Medicare Part B benefit:

• You can fax your authorization request to 1-800-217-9345.
• Or call Mercy Care Advantage Member Services at 602-586-1730 or 1-877-436-5288, 8:00 a.m. - 8:00 p.m., 7 days a week, (TTY: 711) to initiate an organization determination (prior authorization) for the requested specialty medication.
• For additional information about Medicare Part B verses D coverage rules, please see Appendix C of Chapter 6 of the Medicare Prescription Drug Manual.

 

Coverage Determinations & Exception Requests

We generally cover the drugs listed in our formulary as long as they are medically necessary. Providers can request a Part D coverage determination on behalf of a member. When requesting a formulary or utilization restriction exception, please include a supporting statement to explain the medical reason for the exception request.

To learn which drugs require prior authorization or have utilization restrictions, please review our MCA Formulary and prior authorization criteria available on this website. Coverage determinations and exception requests may be initiated by phone, fax, or mail. Our Pharmacy Department will review the request and make a determination within the timeframes required by Medicare and you and the member will be notified of the decision.

To request a coverage determination or exception:

1. Verify member eligibility prior to the provision of services.
2. Download, print and complete the Coverage Determination Request form and fax with supporting documentation (if applicable) to 1-855-230-5544.
3. Complete and submit the online version of the Coverage Determination Request form.
4. Submit a request by phone by calling MCA Member Services at 602-586-1730 or 1-877-436-5288. Representatives are available 8:00 a.m. - 8:00 p.m., 7 days a week.
5. Submit a request by mail:

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

In order for us to cover an formulary exception, the doctor must provide a statement that says the member has tried at least two formulary alternatives in the same drug class and it didn’t work for the member, or a medical reason why the member can’t try at least two formulary alternatives in the same drug class.

Part D Appeals

If a member or their physician is notified that Mercy Care Advantage has denied their coverage determination request, the member or their appointed representative may submit a redetermination request (1st level of appeal) to MCA within 60 calendar days from the date of the written notice. Physicians may initiate a redetermination (1^st level of appeal) on a member’s behalf.   Physicians may request a fast (expedited) appeal if it is believed that applying the standard appeal timeframe could seriously affect the member’s health. If Mercy Care Advantage does not agree, the redetermination will be automatically moved to the standard appeal process. In order for a physician to request an appeal after Level 1, the member must appoint their physician as their appointed representative. A copy of the Appointment of Representative form is available on our Mercy Care Advantage Forms webpage.  

You may use any of the following options to submit a redetermination request for an MCA patient:

You can call our MCA Appeals department at 602-586-1719 or 1-877-436-5288.

You can use our online redetermination form to submit a request.

You can print and complete the redetermination form and fax it to 1-855-230-5544.

You can submit by mail to:

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

Low-Income Subsidy (LIS) Information

The Low-Income Subsidy (LIS) Program, also called “Extra Help” helps cover the cost of prescription drugs for people with low incomes who are eligible for the Medicare Part D program. Mercy Care Advantage plan members typically qualify for Extra Help and receive a copy of the Low Income Subsidy Rider that explains their Part D prescription drug cost sharing responsibilities. The information below provides the 2021 cost sharing amounts for members who qualify for extra help.

Low Income Subsidy Eligibility and Benefits Information:

MCA monthly plan premium is: $0

MCA yearly deductible is: $0

Copayment amount for generic/preferred multi-source drugs is no more than:
$0 / $1.30 / $3.70 (each prescription)

Copayment amount for all other drugs is no more than:
$0 / $4.00 / $9.20 (each prescription)

* There is $0 cost share required for members in a long-term care facility or who have reached the catastrophic coverage stage of your Part D prescription benefit coverage in the current calendar year.

Medication Therapy Management

The Mercy Care Advantage (HMO SNP) Medication Therapy Management (MTM) program helps members get the greatest health benefit from their medications by:

• Preventing or reducing drug-related risks
• Increasing their awareness
• Supporting good habits

Who qualifies for the MTM program?

MCA will automatically enroll members in the Mercy Care Advantage MTM program at no cost if they meet the following three conditions:

1. Take eight or more Medicare Part D covered maintenance drugs, and
2. Have three or more of these long-term health conditions:

• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Diabetes
• Depression
• Osteoporosis
• Chronic Heart Failure
• HIV
• Cardiovascular Disorders such as high blood pressure, high cholesterol, or Coronary Artery Disease and,

3. They reach $4,376 in yearly prescription drug costs for the current year paid by the member and the plan.

Member participation is voluntary, and does not affect their plan coverage. The program has no cost to members and is open only to those who are invited to participate. The program is not a benefit for all plan members. To learn more about the services provided under the MTM program, view the Mercy Care Advantage Part D page for members and select Medication Therapy Management Program from the menu options.

Electronic Prior Authorization (ePA)

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

• Time saving
  • Decreasing paperwork, phone calls and faxes for requests for prior authorization
• Quicker Determinations
  • Reduces average wait times, resolution often within minutes
• Accommodating & Secure
  • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

• Visit the CoverMyMeds® website
• Call CoverMyMeds® toll-free at 866-452-5017
• Visit the SureScripts website
• Call SureScripts toll-free at 866-797-3239

BIN: 610591

Group: RX8803

PCN: MEDDADV

• Mercy Care Advantage