Part D: Prescription Drug Information

Formulary

What is the Mercy Care Advantage Formulary?

2018 MCA Comprehensive Formulary PDF Opens In New Window

2018 Prior Authorization Criteria PDF Opens In New Window

2018 Step Therapy Criteria PDF Opens In New Window

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 refer to the formulary and our prior authorization and step therapy criteria for more information.

The formulary is subject to change during the year. This website has the current version of the formulary available for your review.

We offer a robust pharmacy network with participating pharmacies located throughout the Mercy Care Advantage service area. This website offers a “Find a Pharmacy” search tool to assist you in locating pharmacies in our network.

For more detailed information about our Mercy Care Advantage prescription drug coverage, please review the Mercy Care Advantage 2018 Evidence of Coverage PDF Opens In New Window and other member materials, or contact Member Services at 1-800-624-3879 (8:00 a.m. - 8:00 p.m., 7 days a week).

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

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 1-800-624-3879, select option #2 for providers, then select option 1 to initiate a coverage determination for the requested specialty medication.

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 602-263-3000 (Phoenix Metro Area) or 1-800-624-3879 (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. Print and complete the Coverage Determination Request form PDF Opens In New Windowavailable on this website 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 Opens In New Window.
1. Submit a request by phone by calling 602-263-3000 or 1-800-624-3879. Representatives are available 8:00 a.m. - 8:00 p.m., 7 days a week.
2. Submit a request by mail:

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

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 “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 602-453-6098 or 1-800-624-3879.

You can use our online redetermination form Opens In New Windowto submit a request

You can print and complete the redetermination form PDF Opens In New Window and fax it to 602-351-2300

You can submit by mail to:

Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Blvd., Bldg. D
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 2018 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 / $1.25 / $3.35 (each prescription)

Copayment amount for all other drugs is no more than:

$0 / $3.70 / $8.35 (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 your awareness
• Supporting good habits

Who qualifies for the MTM program?

MCA will automatically enroll members in the Mercy Care Advantage Medication Therapy Management Program at no cost if they meet the following three (3) 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
• COPD
• Diabetes
• Depression
• Osteoporosis
• Chronic Heart Failure
• HIV
• Cardiovascular Disorders such as High Blood Pressure, High Cholesterol, or Coronary Artery Disease and,

1. They reach $3,967 in yearly prescription drug costs paid by the member and the plan.

Member participation is voluntary, and does not affect their plan coverage. This program is free of charge and is open only to those who are invited to participate. The MTM program is not considered a benefit for all members. To learn more about the services provided under the MTM program, view the Mercy Care Advantage Part D page Opens In New Window and select Medication Therapy Management Program from the purple menu options.