Part D: Prescription Drug Information

As a contracted provider in the Mercy Care Advantage (MCA) network, you should receive a copy of the MCA Formulary, also called the Preferred Drug List (PDL) when you receive your updated provider manual each year. However, the best place to find the most up-to-date MCA Formulary is on our website.

For additional information and guidelines about the MCA PDL, please review Chapter 17 of your provider manual. The menus below are also available to assist you.

Mercy Care Advantage Formulary


Search our online 2023 Formulary


Comprehensive Formulary
 Updated 2/2023

Formulary Changes Updated 2/2023

Prior Authorization Criteria Updated 2/2023

Step Therapy Criteria  No changes made since 10/2022

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.

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.

 


 

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.

 


 

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.


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.


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.

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.

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.

 

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.

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 (1st 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

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 2023 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 / $1.45 / $4.15 (each prescription)

Copayment amount for all other drugs is no more than:
$0 / $4.30 / $10.35 (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 Part D prescription benefit coverage in the current calendar year.

Medication Therapy Management Program

The Mercy Care Advantage Medication Therapy Management (MTM) Program is all about you and your health. The MTM Program helps you get the most out of your medications by:

  • Preventing or reducing drug-related risks
  • Supporting good lifestyle habits
  • Providing information for safe medication disposal options

 

Who qualifies for the MTM Program?
You will be enrolled in the Mercy Care Advantage MTM Program if you meet one of the following:

  1. Have coverage limitation(s) in place for medication(s) with a high risk for dependence and/or abuse, or
  2. Meet the following criteria:
    • You have three or more of these conditions:
      • Asthma
      • Chronic heart failure (CHF)
      • Chronic obstructive pulmonary disease (COPD)
      • Diabetes
      • Dyslipidemia
      • Hypertension
      • Chronic alcohol & drug dependence
      • HIV/AIDS
    • You take eight or more maintenance medications covered by your plan
    • You are likely to spend more than $4,935 in prescription drug costs in 2023

Your participation in the MTM Program is voluntary and does not affect your coverage. This is not a plan benefit and is open only to those who qualify. There is no extra cost to you for the MTM Program.

 

How will I know if I qualify for the MTM Program?

If you qualify, we will mail you a letter. You may also receive a call to set up your one-on-one medication review.  

 

What services are included in the MTM Program?

In the MTM Program, you will receive the following services from a health care provider:

  • Comprehensive medication review
  • Targeted medication review

 

What is a comprehensive medication review?

The comprehensive medication review is completed with a health care provider in person or over the phone. This review is a discussion that includes all your medications:

  • Prescriptions
  • Over-the-counter (OTC)
  • Herbal therapies
  • Dietary supplements

 

This review usually takes 20 minutes or less to complete. During the review, you may ask any questions about your medications or health conditions. The health care provider may offer ways to help you manage your health and get the most out of your medications. If more information is needed, the health care provider may contact your prescriber.

At the end of the review, the health care provider will provide you with a summary of what you discussed. The summary will include the following:

  • Recommended To-Do List. Your to-do list may include suggestions for you and your prescriber to discuss during your next visit.
  • Medication List. This is a list of all the medications discussed during your review. You can keep this list and share it with your prescribers and/or caregivers.

 

Who will contact me about completing the review?

You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You can choose to complete the review in person or over the phone.

A health care provider may also call you to complete your review over the phone. When they call, you can schedule your review at a time that is best for you.

 

Trusted MTM Program partners: CVS Caremark Pharmacist Review Team, Outcomes Patient Engagement Team, MedWatchers, and Pack4U Connected Health

 

Why is this review important?

Different prescribers may write prescriptions for you without knowing all the medications you take. For that reason, the MTM Program health care provider will:

  • Review all your medications
  • Discuss how your medications may affect each other
  • Identify any side effects from your medications
  • Help you reduce your prescription drug costs

 

How do I benefit from talking with a health care provider?

By completing the medication review with a health care provider, you will:

  • Understand how to safely take your medications
  • Get answers to any questions you may have about your medications or health conditions
  • Review ways to help you save money on your drug costs
  • Receive a Recommended To-Do List and Medication List to keep and share with your prescribers and/or caregivers

 

What is a targeted medication review?

The targeted medication review is completed by a health care provider who reviews your medications at least once every three months. With this review, we mail, fax, or call your prescriber with suggestions about prescription drugs that may be safer or work better for you. As always, your prescriber will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your prescriber decide to change them. We may also contact you by mail or phone with suggestions about your medications.

 

How can I get more information about the MTM Program?

Please contact us if you would like more information about the Mercy Care Advantage MTM Program or if you do not want to participate. Our number is 602-586-1730 or 1-877-436-5288, 24 hours a day, 7 days a week. TTY users, call 1-877-436-5288 (TTY 711).

 

How do I safely dispose of medications I don’t need?

The Mercy Care Advantage MTM Program is dedicated to providing you with information about safe medication disposal. Medications that are safe for you may not be safe for someone else. Unneeded medications should be disposed of as soon as possible. You can discard your unneeded medications through a local safe disposal program or at home for some medications. 

  • Locating a community safe drug disposal site

A drug take back site is the best way to safely dispose of medications. To find drug take back sites near you, visit the website below and enter your location:

https://apps2.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e2s1

Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs, and other ways for safe disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you.

 

  • Mailing medications to accepting drug disposal sites

Medications may be mailed to authorized sites using approved packages. Information on mail-back sites can be found at www.deatakeback.com

 

  • Safe at-home medication disposal

You can safely dispose of many medications through the trash or by flushing them down the toilet. Visit the following website first to learn what medications are safe to dispose of at home:

https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html

 

Steps for medication disposal in the trash:

    • Remove medication labels to protect your personal information
    • Mix medications with undesirable substances, such as dirt or used coffee grounds
    • Place mixture in a sealed container, such as an empty margarine tub

 

 

To get order forms and information about filling your prescriptions by mail  call Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. – 8:00 p.m., 7 days a week to request a mail order form. 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:

BIN: 610591

Group: RX8803

PCN: MEDDADV

  • Mercy Care Advantage