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Medicare Prescription Drug Information

What is a Formulary?

A formulary is a list of covered drugs selected by MetroPlusHealth 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. MetroPlusHealth will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a MetroPlusHealth network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

To access more information about your prescription drug benefits click here: CVS-Caremark – MetroPlusHealth Prescription Drug Provider. You will be transferred to the CVS Caremark site. Use the information on your Medicare Member ID card to register. Follow the step-by-step instructions located on the site.

All MetroPlusHealth Medicare members have access to a mail order option for their medications. Access the mail order form here.

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.

MetroPlusHealth 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.

View your Medicare Comprehensive Formulary on the MetroPlusHealth Pharmacy page.

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.

Step Therapy Resources

Step Therapy Criteria

Part B Drugs Criteria

Click here for Medicare Exception form information.

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: MetroPlusHealth 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.

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 MetroPlusHealth Medicare member and are receiving any Part B drugs, this does not apply to you.

 

Step Therapy Resources

Step Therapy Criteria

Part B Drugs Criteria

The Inflation Reduction Act (IRA): Changes to Your Drug Coverage

Effective 4/1/2023, coinsurance for certain Part B rebatable drugs will be reduced, if the drug’s price has increased at a rate faster than the rate of inflation.

Effective 7/1/2023, insulin covered under Part B (for example, insulin administered via a pump that qualifies as an item of durable medical equipment (DME)) will not exceed $35 total for a one month’s supply and the Medicare Part B deductible will not apply.

Important Message About What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Member Services for more information.

Important Message About What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.

Temporary Supply Information

To obtain a temporary supply or have questions, call MetroPlusHealth Customer Service.
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 Member 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 31 day supply of your medication per fill, for up to a maximum of 31 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 MetroPlusHealth prescription drug coverage, rules and regulations, please review your Evidence of Coverage document. If you have any questions about MetroPlusHealth Medicare plans, please call 1-866-986-0356 (TTY: 711), 24 hours a day, 7 days a week.

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
CVS Caremark
P.O. Box 52066
Phoenix, AZ 85072-2066

1-866-693-4615 (TTY: 711), 24 hours a day, 7 days a week.

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 Low Income Subsidy (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

Additional Resources

Member Reimbursement Form

Medicare Part B Diabetes Monitoring Device and Supply Policy

Prescription Member Reimbursement Paper Claim Form

MetroPlus Health Plan is an HMO, HMO SNP plan with a Medicare contract. MetroPlus Health Plan has a contract with New York State Medicaid for MetroPlusHealth UltraCare (HMO-DSNP) and a Coordination of Benefits Agreement with the New York State Department of Health for the MetroPlus Advantage Plan (HMO-DNSP). Enrollment in MetroPlus Health Plan depends on contract renewal. MetroPlus Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-986-0356 (TTY: 711).

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MetroPlusHealth Virtual Visit is the fast, easy way for our members to see a provider for common physical, mental, emotional, and behavioral health issues that are not emergencies. MetroPlusHealth Virtual Visit is available anytime, from anywhere in New York State, 24/7 – and in your language.

Know your rights and protections against surprise medical bills!

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

Are you receiving care at an NYC Health + Hospitals facility?

Manage Your Health Online With MyChart. Members who receive care at NYC Health + Hospital facilities now have access to MyChart. MyChart is a free secure portal you can use to manage your health information. MyChart allows you to:

  • Message your primary care provider’s office
  • Request refills of your prescription drugs
  • Access your test results
  • Schedule appointments
Preventive Services Resources

Learn about all of the free preventive services for adults, women and children. Preventive care includes immunizations, physical exams, lab tests and prescriptions. If you have any questions, call one of our Member Services Representatives. We’re here to help.

IMPORTANT INFORMATION: MONKEYPOX CASES ARE RISING IN NYC.

Monkeypox cases are rising in NYC. Learn more about Monkeypox, including prevention and treatment, here.

last updated: October 1, 2022

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