Prescription Drugs

Pharmacy and Prescription Benefits

Magellan Complete Care of Virginia (HMO SNP) members get prescription drugs and other pharmacy benefits from the plan. Your drugs are covered when you show your member ID card at a network pharmacy whenever you get your prescriptions filled.

We use Magellan Rx to administer your pharmacy benefits. Log into the Magellan Rx Member Portal to:

  • Learn about potential drug-to-drug interactions
  • Understand your drugs’ common side effects or significant risks
  • Find out the availability of generic substitutions
  • Find the location of an in-network pharmacy based on a proximity search by zip code

What drugs does MCC of VA (HMO SNP) cover?

Magellan Complete Care of Virginia (HMO SNP) covers a comprehensive list of drugs chosen for their effectiveness by our plan along with a team of doctors and pharmacists. This drug list, called a formulary, lists brand name and prescription drugs and lists any rules or restrictions that apply. We also cover many over the counter (OTC) medications when you have a prescription from your doctor. Go to the Member Materials and Forms page to review the formulary.

How much do I pay for my prescriptions?

MCC of VA (HMO SNP) members have no annual deductible and no premiums. But you may have copays for some drugs. Individuals on Medicaid qualify for Extra Help to pay for those drugs. Depending on the level of Extra Help you get, your copays for generic and multisource drugs are $0, $1.30 or $3.70 per prescription. Copays for all other drugs are $0, $4.00 or $9.20 per prescription. This Extra Help also counts toward your out-of-pocket costs.

Where can I get my prescriptions filled?

To find a network pharmacy near you, use our Pharmacy Locator Tool. Our network includes many types of pharmacies and drugstores, including mail-order and specialty pharmacies.

To order refills for existing and unexpired mail-order prescriptions, please visit the MRx Mail Order Pharmacy.

How do I use the formulary?

There are two (2) ways to find your drug in the formulary:

  1. Search by medical condition: Drugs are grouped by the medical conditions they are used to treat. If you know what the drug is used for, look for the category name, then the drug name. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Medications.
  2. Search by drug name: Use the index at the back of the book to search by drug name. Drugs in the Index are listed alphabetically. Then, go to the page number listed beside the drug name to get information about the drug. You may also use the Drug Name Search Tool found on the formulary page.

When you find your drug, any rules or special requirements are listed under the column titled Requirements/Limits. There are generally three (3) types of requirements your drug may have:

  • Prior Authorization: indicated by PA in the Requirements/Limits column
  • Quantity Limits: indicated by QL in the Requirements/Limits column.
  • Step Therapy: indicated by ST in the Requirements/Limits column

You or your doctor can ask for an exception to these rules. Learn more here.

 

Questions & Answers

What is prior authorization?

For certain drugs, you or your provider need to get preapproval (or prior authorization) from MCC of VA (HMO SNP) before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

These drugs will need prior authorization for our plan:

What are quantity limits?

MCC of VA (HMO SNP) limits the amount of certain medications you can receive within a certain time period. We do this to help ensure safe, cost-effective use of these drugs. For example, if it’s considered safe to take only one pill per day of a drug, we may limit the quantity you’re able to receive to 30 pills in a 30-day period.

What is step therapy?

In some cases, we require that you first try certain drugs to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat the condition but Drug A costs less, you may need to try Drug A first. If Drug A doesn’t work for you, we’ll then cover Drug B.

Your provider can learn more about how we determine whether step therapy is needed here.

What if I need a drug that’s not on the formulary?

There may be times when you need a drug that’s not on our formulary or that is on our formulary but has restrictions. When this happens, you can:

  • Talk to your doctor to decide if you should switch to another drug on our formulary
  • Request a formulary exception
  • You may be able to get a transition supply of the drug

Transition (temporary) supply

In certain situations, we can provide a temporary, or transition, supply of your drug. You can read our policy here. It applies to:

  • New MCC of VA (HMO SNP) members within the first 90 days of membership
  • Current members affected by an annual formulary change during the first 90 days of the new year

During the transition period, we will automatically process a 30-day supply refill of your drug. The quantity may be less if your prescription is written for less than a 30-day supply. Once we cover the temporary supply, we generally won’t cover the drug again under our transition policy. You’ll receive a written notice explaining the steps you can take to request an exception or to work with your doctor on finding another drug on our formulary.

Learn more about requesting a formulary exception.

For new members residing in long-term care facilities, we’ll cover more than one refill during the first 90 days of membership. If you’ve been enrolled for more than 90 days, we’ll cover a temporary 31-day emergency supply (unless the prescription is for fewer days) while you’re pursuing the formulary exception.

Can I get help managing my prescriptions?

Yes, we can help you with that. MCC of VA (HMO SNP) offers a Medication Therapy Management (MTM) program. It’s for members with complex medical conditions who take multiple drugs. During a medication review session, a pharmacist can help you to safely manage your multiple prescriptions.

Always carry a list of your current medications. Click here for a personal medication form that will help you keep track of them and help your pharmacist, too.

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How do I appeal a decision you made about my prescription drug?

Our members have the right to appeal any decision we make that terminates, suspends, delays, reduces or denies a prescription drug or service. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made. This is called a Level 1 appeal.

A provider or family member may file an appeal on your behalf if they have the member’s written consent to do so. If you want someone other than your provider to act on your behalf, please complete this CMS Appointment of Representative Form, along with your appeal form.
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To appeal our decision that denied your Medicare Part D prescription drug request, you may: 

1.    Phone: Call Member Services at 1-800-424-4495 (TTY 711)

2.     Write: Write to us or download and complete the Request for Redetermination Form  English    Spanish and send it to:

MCC of VA (HMO SNP)
Attn: Appeals
58 Charles Street
Cambridge, MA 02141

3.    Fax: You can fax your letter and/or the request form to us at 1-888-251-7823

4.    Online: You may complete this online form and submit it here:  Medicare Part D Request for Redetermination after Denial Form.

  • If you ask for a standard appeal, we must give you our answer within 7 calendar days after we receive it. You may appeal by phone or in writing.
  • If you request a “fast appeal,we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.

See Chapter 9 of the Evidence of Coverage for more details.
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If the plan denies my appeal for a prescription drug, is there anything else I can do?

If your appeal is denied, you have the right to make additional appeals. If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process. Learn more about your rights by visiting the CMS web page on making appeals. You may also see Chapter 9 of the Evidence of Coverage for more details.
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For a Level 2 Medicare Part D drug appeal, you must use the Medicare Request for Reconsideration Form– Second Level of Appeal. Your appeal will not be decided by MCC of VA (HMO SNP). It will be reviewed by a qualified independent contractor of CMS, called C2C Innovative Solutions. They decide whether the decision we made should be changed. You may send your Level 2 appeal request to:

Standard Mail:                                                           Courier or Tracked Mail (e.g. FedEx or UPS):
C2C Innovative Solutions, Inc.                                   C2C Innovative Solutions, Inc.
Part D Drug Reconsiderations                                    Part D Drug Reconsiderations
P.O. Box 44166                                                           301 W. Bay St., Suite 600
Jacksonville, FL 32231-4166                                      Jacksonville, FL  32202

Or use their toll free fax: 1-833-710-0580
Learn more about C2C Innovative Solutions at https://www.c2cinc.com//Appellant-Signup.

You may request a standard or fast Level 2 appeal of your Medicare Part D prescription drug(s):

  • Standard Level 2 appeal:

    – For a drug you have not received yet, the independent contractor will answer your appeal within 7 calendar days after it receives your appeal.

    – For a drug you already bought and want to be repaid, the independent contractor must answer your appeal within 14 calendar days after it receives your request.

  • Fast Level 2 appeal:

    – Your health must require it.

    – If the independent contractor agrees to give you a “fast appeal,” they must answer your Level 2 Appeal within 72 hours after they receive it.

    – If they say yes to your request, we must provide the drug coverage that they approved within 24 hours after we receive their decision.

See Chapter 9 of the Evidence of Coverage for more details.
English             Spanish

 For information on how to appeal a denial of Medicare Medical Services, please visit our How Do I page. 

What is the Medication Therapy Management program?

Also known as MTM, this is our plan’s drug program for members who take multiple medicines. If you have several chronic conditions and take multiple long-term drugs, you may be eligible. The program is not considered a benefit and is free to all members. You’re not required to participate, but we encourage you to.

If you qualify for the program, we’ll send you a letter with more information about the program. This program is free of charge.You can read more about it here:

What is Medicare’s Best Available Evidence policy?

Individuals with Medicare who are also enrolled in Medicaid qualify for Extra Help paying for prescription drugs. This Extra Help is also called the Low-Income Subsidy (LIS). We use Medicare’s Best Available Evidence policy to determine the amount our dual-eligible members pay for prescription drugs. You may review the entire policy here.

If you believe you qualify for Extra Help or the LIS and are paying an incorrect copay amount for your prescriptions, please contact Member Services.

Contract Termination:
If your prescription drug coverage is provided under a contract with Medicare, your coverage is not guaranteed beyond the end of the current contract year. In the event that Medicare or MCC of VA (HMO SNP) terminates or chooses not to renew this contract, as is allowed by law, your coverage may end. If this occurs, you will be able to choose another plan without having to pay a late enrollment penalty, as long as you’re within the time period required by Medicare.