Commonwealth Care Alliance may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug (and/or move a drug to a higher cost-sharing tier), we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market we will immediately remove the drug from our formulary.
2013 Formulary Information
The formulary is updated during the year. Below is a list of changes that have been made to the 2013 Formulary:
What if my drug is not in the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that Commonwealth Care Alliance does not cover your drug, you have two options:
How do I request an exception to the Formulary?
You can ask Commonwealth Care Alliance to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
Generally, Commonwealth Care Alliance will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
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Last Updated 4/20/13