What is the MetroPlus Medicare Advantage Programs Formulary?
A formulary is a list of covered drugs selected by MetroPlus in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. MetroPlus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a MetroPlus network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2008 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2008 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or improve the safety of your drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: MetroPlus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from MetroPlus before you fill your prescriptions. If you don't get approval, MetroPlus may not cover the drug.
Click here for Prior Authorization Request Form
- Quantity Limits: For certain drugs, MetroPlus limits the amount of the drug that MetroPlus will cover. For example, MetroPlus provides one unit per day per prescription for Protonix. This may be in addition to a standard one month or three month supply.
- Step Therapy: In some cases, MetroPlus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, MetroPlus may not cover drug B unless you try Drug A first. If Drug A does not work for you, MetroPlus will then cover Drug B.
For More Formulary Information, click here Partial List Full List
For Formulary Changes, Click here
Exceptions and Appeals Information:
As a member of the MetroPlus Medicare Advantage Program
, you have the right to file a grievance if you have a complaint about the MetroPlus Medicare Advantage Program or one of our network pharmacies.
What is a Grievance?
A grievance is any complaint, other than one that involves a request for an organization determination, a coverage determination, or an appeal.
If you have a complaint please contact our Customer Services Department at 1-800-303-9626, TTY: 1-800-881-2812. We will try to resolve your complaint over the phone or within 24 hours of receipt of complaint. If you would like a written response to the complaint we will send you a written response to your phone request. If we are unable to resolve your complaint over the phone, we have a formal complaint process called Member Complaints & Grievances Procedure. The Customer Services Representative will advise you that they are forwarding your complaint to our Complaints Unit for investigation and resolution. You also have the option of filing your complaint in writing by submitting your complaint to:
MetroPlus Health Plan
Complaints Unit
160 Water Street (3rd Floor)
New York, N.Y. 10038
You also have the right to contact us to request a coverage determination. When the MetroPlus Medicare Advantage Program makes a coverage determination, we are making a decision about whether or not to provide or pay for a Part D drug and what your share of the cost will be. Coverage determinations include exception requests. (Click link for request form below.) If you would like to ask us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what your share of the cost will be, you have the right to file an appeal.
If you would like to appoint another individual to act as your representative and file an appeal on your behalf, you will need to complete an Appointment of Representative form (below) and fax it to 212-908-8778
You can download the following forms:
Medicare Part D Coverage Determination Request Form
Appointment of Representative Form
Drug Prior Authorization Request Form
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