Prescription Drug Information
What is a 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.
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 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.
MetroPlus will provide at least 60 days notice prior to making changes to the formulary except in cases of safety where we have been notified of a possible safety issue by the FDA or the drug manufacturer has removed the drug.
Drug Utilization Management Information
Prior Authorization: We require you to get prior authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don't get the necessary information to satisfy the prior authorization, we may not cover the drug.
Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to a 30-day supply per 30-day period for a formulary drug.
Step Therapy: In some cases, we require 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 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.
Beginning in 2019, some drugs covered by Medicare Part B may be subject to the Step Therapy process. This means that, in some cases, you may be asked to try a less costly but just as effective drug before the Plan will cover a different drug. If you are currently a MetroPlus member and are receiving any Part B drugs, this does not apply to you.
Part B Drugs (Coming Soon)
Part D Drugs (Coming Soon)
Temporary Supply Information
To obtain a temporary supply or have questions, call MetroPlus Customer Services.
Options after you have used up your temporary supply:
- You can change to another drug - In some cases, there is a different drug covered by the plan that might work just as well for you. Please talk to your doctor about this. You can call Customer Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor to find a covered drug that might work for you.
- You can file an exception - You and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule.
Formulary Transition Process
We will provide up to 30 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 your prescription is for less than 30 days, multiple refills are allowed to provide you with up to a 30 day supply. Only drugs that are Part D drugs may receive a transition fill. Any drug that may be considered either Part B drugs or may be considered Part B or Part D drugs, are excluded from the transition process.
If you are in a long-term care facility, we will provide you up to a 34 day supply of your medication per fill, for up to a maximum of 34 days of medication during the first 90 days you are a member (depending on how your prescription is written). If you have been a member for longer than 90 days, we may cover up to a 31 day supply of your medication. Oral brand solid medications are limited to a 14 day supply with exception as required by CMS guidance. This gives your prescriber time to change your medication to a medication on the Drug List (Formulary).
If your level of care changes after the first 90 days that you are a member, we may provide you with an emergency supply of up to 31 day (unless your prescription is for less). Oral brand solid medications are limited to a 14 day supply with exception as required by CMS guidance.
For additional detailed information about MetroPlus prescription drug coverage, rules and regulations, please review your Evidence of Coverage document. If you have any questions about MetroPlus Medicare plans, please call 1-866-986-0356 Monday to Saturday from 8am to 8pm. For After Hours, Sunday and Holidays, please call 1-800-442-2560.
Submitting a Paper Claim
When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. When that happens, you may have to pay the full cost of your prescription and then ask us to pay you back using a paper claim.
To submit a paper claim, you must send CVS Caremark a copy of the receipt for the prescription drugs from the pharmacy where you bought them and a completed paper claim form. Please send your paper claim to the following address:
Paper Claims Department – RxClaim
P.O. Box 52066
Phoenix, AZ 85072-2066
You may access our Prescription Member Reimbursement paper claim form here or at bottom of this page.
For more information, please call Member Services at 1.866.986.0356 (TTY 711), 24 hours a day, 7 days a week.
Best Available Evidence
If you believe that you qualify for extra help and you may be paying the wrong copayment amount for prescription drugs, please contact Member Services. We will work with you to update your LIS status based on the best available evidence. For example, you might provide us with evidence of Medicaid status, which may show that you qualify you for Extra Help. Once you provide us with acceptable evidence, we will update our system and notify CMS. When you go to the pharmacy, the copayment you pay will be based on the latest information we receive.
Best Available Evidence Policy
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|Member Reimbursement Form
|Medicare Part B Diabetes Monitoring Device
and Supply Policy
|Prescription Member Reimbursement Paper Claim Form
The formulary and pharmacy network may change at any time. You will receive notice when necessary. You must use contracted network pharmacies to access your prescription drug benefit except under non-routine circumstances, in which case, quantity limitations and restrictions may apply. MetroPlus is an HMO plan with a Medicare contract and a Coordination of Benefits Agreement with the New York State Department. MetroPlus complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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