FormulariesCommonwealth 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 InformationDownload the 2013 Over the Counter Drug List (pdf) Download the 2013 Formulary (pdf) Download the 2013 Formulary for MassHealth Only Members (pdf) Formulary changesThe 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. To download these documents, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here* to download and install a free version of Adobe Acrobat Reader. To search an Adobe PDF file using Adobe Acrobat Reader, click on the "Search" icon (the button with the binoculars) on the Acrobat file toolbar or choose "Edit > Search" from the Acrobat menu. In the "Search PDF" window that opens, type in the word or phrase you are looking for and click on "Search". The cursor will jump to the first place in the document that word or phrase appears and a search results box will appear listing all the occurrences of that word or phrase. You can jump to any particular instance of the word or phrase by clicking on that item in the results box. You can also use the "Edit > Search Results > Next Result" or "Edit > Search Results > Previous Result" in the Acrobat menu to navigate forwards or backwards to the next item. *When you click this link, you will leave Commonwealth Care Alliance's web site Last Updated 4/20/13 |
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