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 Resources 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 $3.60 per prescription. Copays for all other drugs are $0, $3.90 or $8.95 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:
- 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.
- 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
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:
To request prior authorization, download the Prior Authorization Request form here.
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.
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.
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.
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.
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.
Also known as MTM, this is our plan’s drug program for members who take multiple medicines. If you have at least three (3) chronic conditions and take at least seven (7) long-term drugs that cost more than $4,255 per year, 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.
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.
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.