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MetroPlus FIDA Participant Comprehensive Formulary 
 
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MetroPlus FIDA Prior Authorization 
MetroPlus FIDA STEP Criteria 
MetroPlus FIDA Part B Diabetes Monitoring Device and Supply Policy

Updated 05/2017

 

The FIDA formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary

Non-English resources will be published when approved.

MetroPlus FIDA 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 Participant Handbook (Evidence of Coverage).

For further assistance regarding CVS Caremark and your prescription benefits, call Customer Care toll-free at 1.800.552.8159. Or vist the CVS Caremark website.

Formulary Notice of Change

In the case of any changes to the formulary, MetroPlus will notify you at least 60 days before the restriction on a drug or when you next ask for a refill. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next.

Formulary Transition Process

We will provide up to 90 days of a temporary supply of your medication, as needed, during the first 90 days you are a member if:
  • you are taking a drug that is not on our Drug List (Formulary)
  • health plan rules do not let you get the amount ordered by your prescriber
  • you are taking a drug that is part of a step therapy restriction
This will allow you to talk to your doctor to decide if there is a similar drug on the Drug List (Formulary) that you can take instead.

If you are in a nursing or long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 98 days. This gives your prescriber time to change your medication to ones on the Drug List (Formulary).
 
If your level of care changes after the first 90 days that you are a member, we will provide you with an emergency supply of up to 31 days (unless your prescription is for less).

Part D Prescription Drug Transition Policy

During the first 90 days of your enrollment in MetroPlus FIDA Plan, our Transition Policy provides for at least a one-time, temporary 30-day refill, If your prescription is for less than 30 days, multiple refills are allowed to provide you with a 30 days supply. You are also allowed a ninety (90) day supply of drugs if you request a refill of a non-Part D drug that is covered by Medicaid.

Request for Medicare Prescription Drug Coverage

To request an exception, ask your provider to fill out the Medicare Part D Coverage Determination Form. Download a Determination Request Form and mail to:

CVS Caremark 
1300 E. Campbell Road
Richardson, TX 75081
 
If applicable, download the Redetermination Request Form and mail to the address above.

What is Prior Authorization?

Prior authorization means that you must get approval from MetroPlus FIDA Plan or your Interdisciplinary Team (IDT) before you can get a specific service, item, or drug or before you can see an out-of-network provider. MetroPlus FIDA Plan may not cover the service, item, or drug if you don’t get approval from MetroPlus FIDA Plan or your IDT. A small number of services require prior authorization by a specialist and not by MetroPlus FIDA Plan or your IDT. Please refer to Chapter 4 of your Participant Handbook for more information. MetroPlus FIDA Plan can also provide you with a list of services or procedures that require you to get prior authorization from a provider other than your IDT.

Some services do not require any prior authorization, such as emergency or urgently needed care, out-of-area dialysis services, primary care provider visits, and women’s health specialist services. For the full list of services that do not require prior authorization, please see Chapter 4 of your Participant Handbook or call MetroPlus FIDA Plan. Learn which drugs need Prior Authorization on this PA Drug List.

Prior Authorization List
 
Download the Prior Authorization Request Form and return to MetroPlus by mail:
 
MetroPlus Health Plan
160 Water Street, 3rd Floor
New York, NY 10038
Prior Authorization Request
 
or Fax to: 1.866.255.7569

What is Step Therapy?

In some cases, MetroPlus FIDA Plan requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For Members of the plan for more than 90 days who are residents of a long-term care facility and need a supply right away: MetroPlus FIDA Plan will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

For more information about Step Therapy.