Pharmacy Access Information

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage.

These requirements and limits may include:

• Prior Authorization: MD Care Inc. requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from MD Care Inc. before you fill your prescriptions. If you don't get approval, MD Care Inc. may not cover the drug.
• Quantity Limits: For certain drugs, MD Care Inc. limits the amount of the drug that MD Care will cover. For example, MD Care Inc. provides 30 tablets per prescription for LIPITOR. This may be in addition to a standard one month or three month supply.
• Step Therapy: In some cases, MD Care Inc. requires you to first try certain drugs 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, MD Care may not cover drug B unless you try Drug A first. If Drug A does not work for you, MD Care will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7.

You can ask MD Care Inc. to make an exception to these restrictions or limits. See the section, “How do I request an exception to the MD Care Inc. formulary?” on page 3 for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Member Service and ask if your drug is covered. If you learn that MD Care Inc. does not cover your drug, you have two options:

• You can ask Member Service for a list of similar drugs that are covered by MD Care Inc.. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by MD Care Inc.
• You can ask MD Care Inc. to make an exception and cover your drug. See below for information about how to request an exception.

NOTE: Due to a change in Medicare, most Medicare Drug Plans no longer cover erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra, and Caverject. For more information, you can contact Member Service.

How do I request an exception to the MD Care Inc. Formulary?

You can ask MD Care Inc. 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, MD Care Inc. limits 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 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, MD Care Inc. 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 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 prescribing physician's supporting statement.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31 day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Filling prescriptions outside the network

We have network pharmacies outside of the service area where you can get your drugs covered as a member of our Plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill your prescription in these situations, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your copay) when you fill your prescription. You may ask us to reimburse you for our share of the cost by submitting a claim form. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay will help you qualify for catastrophic coverage.

If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

Out of Area Prescription Refill

If you are away from home and have an urgent or emergency situation that requires a prescription, and you do not have access to a Network Pharmacy, you may have your prescription filled at any pharmacy. You may also have your prescriptions filled at an out of Network Pharmacy in the following situations: 1) if you are unable to get a Covered Drug in a timely manner because there are no 24-hour Network Pharmacies within a reasonable driving distance; 2) if your Covered Drug is not carried at a Network Pharmacy or through mail service (for example, high cost or unique drugs); 3) if you need a prescription while traveling in the United States because you become ill, lose or run out of you prescription drug; 4) if you are getting a vaccine that is medically necessary but not covered by Medicare Part B; 5) if you receive certain Covered Drugs Administered in your doctor's office.

The supply of medication that you can obtain from an out of network pharmacy is limited to a 30 day supply. Supply of medications in excess of 30 days will not be covered at an out of network pharmacy. All medications you obtain at an out of network pharmacy are subject to the same limitation and rules on coverage for medications including prior authorizations, dosage limits, quantity limits, or step requirements. Any prescriptions obtained at an out of network pharmacy that does not meet these limitations and rules on coverage may not be reimbursed by MD Care.