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Formulary Information
4-Tier Standard Member Formulary (PDF), Dec. 30, 2009
What is a formulary?A formulary is a list of all the drugs that SelectCare Covers. We have a formulary that lists all the drugs that are covered. We will generally cover the drugs listed on the formulary as long as the drugs are medically necessary, and other coverage rules are followed. The drugs on our formulary are selected by our Plan with the assistance of a team of health care providers and clinicians. SelectCare covers both brand-name drugs as well as generic drugs. Not all drugs are included on SelectCare's formulary. In some cases, the law prohibits coverage of certain types of drugs. Some drugs cannot be covered under the Medicare program. Under certain circumstances, SelectCare may also cover prescriptions filled at an out-of-network pharmacy. See additional information about filling prescriptions at out-of-network pharmacies. Can the formulary change?Yes, SelectCare may add or remove drugs from the formulary during the year. These changes may effect which drugs are covered and how much you will pay when filling your prescriptions. If drugs are removed from the formulary, or if SelectCare adds prior authorization requirements, step therapy or quantity limits on a drug that you are taking, you will be notified of the change(s) at least 60 days before the date the change becomes effective. How do you find out what drugs are on the formulary?You may get updated information about the drugs covered by SelectCare by visiting our website. You may also call Member Services to find out if the drug you are taking is on the formulary or not. In addition you may request a copy of SelectCare's formulary. Are there any quantity limits on medications on the formulary?You may receive up to a 90 days supply on most medications on SelectCare's formulary. What if your drug is not on the formulary?If your prescription is not listed or does not appear on SelectCare's formulary, you should first contact SelectCare's member services department. If Member Services confirms that SelectCare doesn't cover the drug in question you have three options:
How can you request an exception to SelectCare's formulary?There are several types of exceptions that you can ask SelectCare to make. You may ask the plan to make one of several different types of exceptions.
In general we will only approve your request for an exception if the alternative drugs included on the plan's formulary would not be as effective in treating your medical condition or if the preferred drugs would cause you to have an adverse medical effect(s).
Ask your physician to submit the Prior Authorization form (PDF, 1p.) with a statement medically supporting your exception request. Generally, SelectCare will make a decision within 72 hours of the completed request. What drugs might be excluded from coverage under Part D?By law, certain types of drugs or categories of drugs are not covered under Medicare Part D plans. However, some drugs may be covered under your expanded benefits under Medi-Cal. Drugs traditionally "excluded" under Part D may include the following:
How does the enrollment in SelectCare affect the coverage of Part A and Part B drugs?As a member of SelectCare, and a member with Medicare, you are entitled to coverage of drugs covered under Medicare Part A and Part B. Your enrollment in SelectCare does not affect the coverage of drugs under Medicare Part A & Part B. Also as a member of SelectCare you are entitled to all Part A and B services. SelectCare also covers your Part D benefit. How much do you pay for drugs covered by this plan and what are drug tiers?As a member of SelectCare you will not have a deductible for your drug coverage. In most cases you will have to pay a co-payment when you fill your prescriptions. Drugs on SelectCare's formulary are separated into two different drug tiers. Being Generic versus a Brand name drug separates these drugs into the two different tiers. Your co-payment depends on which drug tier your drugs are in. When you fill a prescription for a covered drug, you may have a co-payment. The amount you pay depends on what coverage level you are in (initial coverage level or catastrophic level), and whether or not you are institutionalized in a skilled nursing facility (SNF).
Your co-payments for the initial coverage level are:
$1.05 for each prescription of a generic drug $3.10 for each prescription of a brand name drug
Your co-payment for Catastrophic Coverage: If you are institutionalized, you will pay nothing for your drugs. How does your prescription drug coverage work if you go to a hospital or skilled nursing facility?If you are admitted to a hospital for a Medicare-covered stay, SelectCare will provide your medication under your medical benefit. When you are released from the hospital, SelectCare will provide your prescription drugs under your outpatient drug benefit. If you are admitted to a skilled nursing facility for a Medicare covered stay, you will not have to pay your co-payments on covered Part D drugs.
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