(Part D) Prescription Drug Benefits



University Care Advantage covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. 


Members must receive all routine care from plan providers except in emergent or urgent care situations or for out-of area renal dialysis

If members obtain routine care from out-of plan providers neither Medicare nor 
University Care Advantage will be responsible for the cost. 

Beneficiaries must use network pharmacies to access their prescription drug benefits, except in non-routine circumstances, and quantity limitations and restrictions may apply.

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. The benefit information provided is a brief summary, not a comprehensive description of benefits. For more information contact the plan.

Quality Assurance 

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work medically just as well as a higher cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and costsharing.

Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs.

Restricting brand name drugs when a generic version is available

Generally, a “generic” drug works the same as a brand name drug and usually costs less. When a generic version of a brand name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical that neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)
 

How do I request an exception to the University Care Advantage Formulary? 
You can ask 
University Care Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary. 

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Maricopa Care Advantage limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. 

• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred/highest tier subject to the tiering exceptions process tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred/lowest tier subject to the tiering exceptions process tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. 

Generally, 
University Care Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug 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, tiering or utilization restriction exception. 

When you are requesting a formulary, tiering 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.





Medicare Part D resources for enrolled and prospective members