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Which drugs are covered?
The formulary is the list of drugs covered by the Medicare Part D portion of your plan. Additional coverage is provided by City of Mesa that covers certain drugs not covered by Medicare Part D.
The plan covers generic and brand drugs:
- Generic drugs (Tier 1) – most cost effective drugs to buy. The active ingredients in generic drugs are exactly the same as the active ingredients in brand drugs whose patents have expired. They are required by the Food and Drug Administration (FDA) to be as safe and effective as the brand drug.
- Preferred Brand drugs (Tier 2) – brand drugs that do not have a generic equivalent and are included on a preferred drug list. They are usually available at a lower cost than Non-Preferred Brand drugs.
- Non-Preferred Brand drugs (Tier 3) – brand drugs that are not on a preferred drug list and usually are a high cost.
The formulary may change throughout the year. Drugs may be added, removed or restrictions may be added or changed. These restrictions include:
- Quantity Limits (QL)
For certain drugs, SilverScript limits the amount of the drug that it will cover.
- Prior Authorization (PA)
SilverScript requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before we fill your prescription. If you don’t get approval, SilverScript will not cover the drug.
- Step Therapy (ST)
In some cases, SilverScript requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, SilverScript will not cover Drug B unless you try Drug A first. If Drug A does not work for you, SilverScript will then cover Drug B.
You will need to check the formulary to find out which tier your drug is on or if there are any restrictions on your drug, as well as to determine your cost. The amount you pay depends on the drug's tier and whether you are in the Deductible, Initial Coverage, Coverage Gap or Catastrophic Coverage stage. If the actual cost of a drug is less than your normal copayment or coinsurance for that drug, you will pay the actual cost, not the higher copayment or coinsurance amount.
Drug not on the formulary? Call SilverScript Customer Care
City of Mesa provides additional coverage so that you can get drugs that are not covered by Medicare Part D, such as:
- Prescription drugs when used for anorexia, weight loss or weight gain
- Prescription vitamins and mineral products not covered by Part D
- Prescription drugs when used for the symptomatic relief of cough or cold
- Prescription drugs when used for treatment of sexual or erectile dysfunction
- Certain diabetic drugs and supplies not covered by Part D.
These drugs are not subject to SilverScript appeals and exceptions process and the cost of these drugs will not count toward your Medicare total drug costs or Medicare out-of-pocket costs. However, your deductible and coinsurance or copayments for these additional drugs will count toward your City of Mesa individual annual prescription drug out-of-pocket maximum.
If you do not see your drug on the formulary, contact SilverScript Customer Care to find out if your drug is covered through the additional coverage from City of Mesa.
Options for Filling Your Prescription
The plan has a network of more than 65,000 pharmacies nationwide, including retail, mail order, long-term care, home infusion and Indian Health and Indian Tribal pharmacies. To find a network pharmacy near where you live or travel:
SilverScript has preferred network retail pharmacies where you can get up to a 90-day supply of your maintenance medications for the same copayment as mail-order, similar to Maintenance Choice in your current CVS Caremark plan. You will also be able to get up to a 90-day supply of your maintenance medication at non-preferred network retail pharmacies, but the minimum and maximum copayments will be three times the retail 30-day supply minimum and maximum copayments.
Please note: After the mail order pharmacy receives an order, it takes up to 10 days for you to receive the shipment of your prescription drug. You have the option to sign up for automated mail-order delivery.
You must use a network pharmacy to have your copayment or coinsurance count toward your Medicare total drug costs and Medicare out-of-pocket cost, unless it is an emergency or non-routine circumstance.
If you use an out-of-network pharmacy, you may have to pay the full cost of the drug at the pharmacy. In this case, you must complete a paper claim form and send it to the plan to request reimbursement. You will be reimbursed:
- The cost of your drug minus your deductible, coinsurance or copayment, if the drug is on the SilverScript formulary
- The amount that the City of Mesa would have paid at a network pharmacy minus your deductible, coinsurance or copayment, if the drug is paid through the additional coverage provided by the City of Mesa.
If you may need to get your prescription filled while you are traveling outside the country, contact SilverScript Customer Care before you leave the U.S. You can request a vacation override for up to a 90-day supply of your medication.
Veterans Affairs (VA) pharmacies are not permitted to be included in Medicare Part D pharmacy networks. The federal government does not allow you to receive benefits from more than one government program at the same time.
If you are eligible for VA benefits, you may still use VA pharmacies under your VA benefits. However, the cost of those medications and what you pay out-of-pocket will not count toward your Medicare out-of-pocket costs or Medicare total drug costs. Each time you get a prescription filled, you can compare your City of Mesa benefit through SilverScript to your VA benefit to determine the best option for you.
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