Medica currently offers members the following Medicare Part D formulary designs:
- A formulary in which all Part D eligible medications are covered, but at various levels of cost sharing. Utilization management edits such as prior authorization, step therapy, and quantity limits still apply to this type of formulary.
- Within a given therapeutic class, a closed formulary limits the number of eligible Part D medications that will be reimbursed by the plan. Utilization management edits such as prior authorization, step therapy, and quantity limits apply to this type of formulary.
View Part D Formularies.
The open Part D formulary is structured with the following drug tiers for coverage:
Tier 1 – Formulary Generics
All Part D eligible generics that are available from multiple manufacturers. Tier 1 drugs are typically the lowest available copay for the member.
Tier 2 – Preferred Formulary Brands/Non-Preferred Generics
All Part D eligible preferred brand name drugs and some-single source generic drugs. Tier 2 drugs are the lowest available brand name copay for the member.
Tier 3 – Non-Preferred Formulary Brands
All Part D eligible non-preferred brand drugs and multisource brands (with an equivalent generic drug available). Tier 3 drugs are available to members, but at a higher copay.
Tier 4 – Specialty Drugs (Generics & Brands)
Part D eligible drugs that cost on average of $600 or more per month. Tier 4 drugs are often specialty biologics or used to treat rare conditions. Members have a higher cost-sharing on these drugs (average copay of 25%). For Part D, specialty drugs are not restricted to a specialty pharmacy network.
The open Part D formulary is structured with the following drug tiers for coverage:
Tier 1 – Formulary Generics
All Part D eligible generics that are available from multiple manufacturers. Tier 1 drugs are typically the lowest available copay for the member.
Tier 2 – Formulary Brands/Non-Preferred Generics
All Part D eligible preferred brand name drugs and some-single source generic drugs. In a closed formulary, Tier 2 drugs also includes specialty drugs.
Medica’s Part D formulary is fixed on a calendar year. The formulary is submitted to CMS and receives final approval around August of the preceding calendar year. Medica may make formulary changes that have positive impact on members throughout the calendar year (formulary additions, removal of utilization management, or reducing a drug’s covered tier level).
Formulary changes that have a negative impact on members require pre-approval by CMS prior to implementing the formulary change. Medica’s policy is to limit negative formulary changes throughout the calendar year to the following reasons:
- Removal or up-tiering a brand name drug due to generic product introduction (brand patent expiration).
- FDA or drug manufacturer instructed recall of the drug from the U.S. marketplace
- Publication of significant change in safety of a medication recommending limited use of the drug (FDA black-box safety warnings).
Member Notification All Medica member’s will receive notification of upcoming negative formulary changes on their monthly Explanation of Benefit (EOB) statements, explaining the type of formulary change, the reason for the change, the effective date of the change, and relative formulary alternatives 60 days prior to the formulary change. In the case of an immediate formulary removal (FDA lead drug removal), members will receive a formulary change letter explaining the change if they have evidence of using the medication per their medication claims history.
Provider Notification Medica posts all upcoming negative changes to our Part D formularies online 60 days prior to the effective date.
Go to Part D Drug Formulary Changes.
Changes to the Medica drug formulary are communicated through the
Medica Connections newsletter, which is available online.
View Medica Connections.
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