Part D Prescription Drugs

Our List of Covered Drugs (Formulary) or “Drug List” tells you:

• Which drugs we pay for
• Which of the 5 cost-sharing tiers each drug is in
• Whether there are any limits on the drugs
• The drugs on this list are selected by the Plan with the help of a team of doctors and pharmacists.

If you need a copy of the Drug List, call Member Services or you can find the most current Drug List (Formulary) on the Member Materials section of this website.

The Drug List can change during the year. Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the Plan might make many kinds of changes to the Drug List. For example, the Plan might:

• Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.
• Move a drug to a higher or lower cost-sharing tier.
• Add or remove a restriction on coverage for a drug
• Replace a brand-name drug with a generic drug

Related documents:

Formulary Updates November 2024

Formulary Updates October 2024

Formulary Updates September 2024

Formulary Updates August 2024

Formulary Updates July 2024

Formulary Updates June 2024

Formulary Updates May 2024

Formulary Updates April 2024

Formulary Updates March 2024

Formulary Updates February 2024

February - December 2023 Formulary Updates

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 get a drug that works for your medical condition and is safe. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing. L.A. Care Medicare Plus Plan uses different types of restrictions to help our members use drugs in the most effective ways:

Using generic drugs whenever you can.
A “generic” drug works the same as a brand-name drug, but 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 doctor has told us the medical reason that the generic drug will not 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).

Getting L.A. Care Medicare Plus approval in advance.
For certain drugs, you or your doctor need to get approval from us before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes our approval is required so we can be sure that your drug is covered by Medicare rules. Sometimes the requirement for getting approval in advance helps guide correct use of certain drugs. If you do not get this approval, your drug might not be covered by us.  For a list of drugs that need Prior Authorization see the document entitled Drugs Requiring Prior Authorization.

Trying a different drug first.
This requirement encourages you to try safer or more effective drugs before we cover another drug. For example, if Drug A and Drug B treat the same medical condition, we may require you to try Drug A first. If Drug A does not work for you, the we will then cover Drug B. This requirement to try a different drug first is called “Step Therapy.” For a list of drugs that need Step Therapy see the document entitled Drugs Requiring Step Therapy.

Quantity limits.
For certain drugs, we limit the amount of the drug that you can have. For example, we might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. To see the Quantity Limits for drugs, see the most current Drug List (Formulary) on the Member Materials section of this website.

Tier increase\decrease
The amount you will pay for the drugs listed above that have tier changes depends on which coverage period you are in. Call our Member Services number to find out how much you will pay for these drugs.
 
Part B vs. D Determinations
A drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

You can get this information for free in other languages. Call 1-833-522-3767 (TTY 711), 24 hours a day, 7 days a week, including holidays. The call is free.

Copay for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.

Medicare Part B Coverage of Pre-exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) Prevention

HIV PrEP drugs were previously covered under Medicare Part D and were typically subject to a deductible and coinsurance or co-pay. CMS transitioned coverage of PrEP drugs to Medicare Part B, and beneficiaries have no Part B cost sharing obligations (i.e., deductibles or co-pays). Antiretroviral drugs used for the treatment of HIV continue to be covered under Medicare Part D, even though these may be the same drugs that are used for HIV PrEP.

For questions, you can contact Member Services at 1-833-522-3767 (TTY 711), 24 hours a day, 7 days a week, including holidays.

Related documents:

2025 Drugs Requiring Prior Authorization
2025 Drugs Requiring Step Therapy
2024 Drugs Requiring Prior Authorization
2024 Drugs Requiring Step Therapy
Preferred Diabetes Test Strip Program

One of the benefits of being a member of L.A. Care Medicare Plus (HMO D-SNP) is the chance to have your medications delivered to your home for free through our mail order pharmacy service. This convenient service can save you many trips to the pharmacy. 

Our preferred mail order pharmacy is Quality Drug Clinical Care (Quality Drug). They offer up to a 100-day supply of your chronic medications. They also offer automatic refill and automatic shipments to help you keep track of your refills. This means you do not have to call the pharmacy before every refill. The pharmacy will refill medications when they are due and ship them to you. To learn more about mail order pharmacy, see frequently asked questions (FAQs).

To Get Prescription Drugs by Mail Order

Call L.A. Care Member Services at 1-833-522-3767 (TTY 711) and ask to sign up for mail order. An L.A. Care pharmacy staff member will call you within 2 business days to help you sign up. The mail order pharmacy Quality Drug will reach out to you to complete the sign-up process. 
 
Usually, a mail order pharmacy order will get shipped to you in no more than 1 to 3 business days. However, sometimes your mail order may be delayed. If your mail order does not arrive in the time estimated, please call Quality Drug at 949-471-0223. If you need to start your medication right away or do not have enough to last you at least 10 days, Quality Drug may be able to transfer your prescription to a local pharmacy to be filled right away or you can pay for fast shipping. You can also ask your doctor for two prescriptions whenever you start a new chronic medication: one for a short supply that your local retail pharmacy can fill right away, and a second for a 100-day supply that can be sent to Quality Drug
 
If you have questions or want to learn more about filling your prescriptions by mail, call L.A. Care Member Services at 1-833-522-3767 (TTY 711).

L.A. Care Medicare Plus members can receive a flu, pneumococcal and/or shingles vaccine at no cost or a low cost. You can get vaccinated at your local pharmacy or doctor's office. Talk to your doctor or pharmacist to find out if these shots are right for you.

How much will it cost?

For 2024, if you decide to get one of these vaccines at your local pharmacy, this is how much it will cost:

• Influenza (flu) - $0 under Part B
• Pneumococcal - $0 under Part B
• Shingles - $0 

To learn more about these vaccines and who should receive them, go to L.A. Care's Vaccines page.

Programs to Help Members Use Drugs Safely

L.A. Care Medicare Plus (HMO D-SNP) conducts drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

• Possible medication errors.
• Drugs that may not be necessary because you are taking another drug to treat the same medical condition.
• Drugs that may not be safe or appropriate because of your age or gender.
• Certain combinations of drugs that could harm you if taken at the same time.
• Prescriptions written for drugs that have ingredients you are allergic to.
• Possible errors in the amount (dosage) of a drug you are taking.
• If we see a possible problem in your use of medications, we will work with your doctor to correct the problem.

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program. MTM helps you and your prescriber make sure that your medications are working. It also helps identify and reduce possible medication problems.

What is the Medication Therapy Management (MTM) program?

The MTM program is a service offered by L.A. Care Health Plan at no additional cost to you. This program is required by the Centers for Medicare and Medicaid Services (CMS) and is not part of your pharmacy benefit.
 
How do I participate in this program?

To participate, you must meet certain criteria set by CMS. These criteria are used to identify people who have many chronic diseases and are at risk for medication-related problems. If you qualify for MTM, we will send you a letter inviting you to take part in the program. We will also send you information and provide instructions to access the program. Your enrollment in MTM is voluntary. It does not affect Medicare coverage for drugs covered under Medicare.
 
To qualify for L.A. Care Health Plan MTM program, you must meet the requirements for at least one of the following two groups:
 
1. Have at least 3 of the following conditions or diseases:

• Bone Disease: Arthritis, Osteoporosis
• Chronic Heart Failure (CHF)
• Diabetes
• Dyslipidemia
• Hypertension

AND

• Take at least 8 covered Part D medications

AND

• Are likely to have greater than $5,330 per year in covered Medicare Part D medication costs.

OR
 
2. Are enrolled in the L.A. Care Health Plan Drug Management Program, also known as the Opioid Home Program. This program helps our members safely use their prescription opioid medications, and other medications that are frequently abused.

What services does the MTM program offer?

To help reduce the risk of possible problems, our MTM program offers two types of clinical review: 

• Targeted medication review: At least every three months, we will review all of your prescription medications and may contact your doctor if we detect a potential problem.
   
• Comprehensive medication review (CMR): At least once a year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This service is provided to you telephonically by Navitus Clinical Engagement Center on behalf of L.A. Care Health Plan. The CMR may also be provided in person at your provider's office, pharmacy, or long-term care facility.
  • Recommended To-Do-List (TDL), also known as Medication Action Plan (MAP): The TDL has steps you should take to help you get the best results from your medications. Access a blank version of the form.
  • Medication List, also known as Personal Medication List (PML): The Medication List will help you and your health care providers keep track of your medications. It explains how to use your medications the right way. Access a blank version of the form.

Next Steps

If you take many medications and have three or more chronic health conditions, please contact us to see if you're eligible. You can call the Navitus Medication Therapy Management (MTM) program team at 1-213-584-2028 or toll-free at 1-866-718-9545, Monday through Thursday 6:00 a.m. to 5:00 p.m. Pacific Time and on Friday 6:00 a.m. to 3:00 p.m. Pacific Time. TTY users can reach our program team through the National Relay Service 711, during the same hours as shown above.

How do I Opt Out of this program?

Although we encourage members to take advantage of this valuable program, your enrollment in MTM is voluntary. You may choose to opt out by calling and requesting to be removed from the program and you will not be contacted about the MTM program again during the calendar year. If you do not want to take part in the program, or if you have questions, please call the Navitus Medication Therapy Management (MTM) program team at 1-213-584-2028 or toll-free at 1-866-718-9545, Monday through Thursday 6:00 a.m. to 5:00 p.m. Pacific Time and on Friday 6:00 a.m. to 3:00 p.m. Pacific Time. TTY users can reach our program team through the National Relay Service 711, during the same hours as shown above.

New and Expanded Opioid Safety Efforts
 
Opioids are drugs that are used to treat severe pain. However, with wrong use, it may put members at risk for serious health concerns. As a health plan, L.A. Care will implement various safety edits to help manage opioid use. When taking your prescription to the pharmacy, these opioid safety edits will prompt the pharmacy team to follow up with your provider in order to ensure proper utilization and safety. Remember to talk to your doctor about these safety measures in order to decrease any delay in obtaining your medications.
 
The following is a summary of the new and expanded opioid safety measures:

• Opioid and Benzodiazepine use: will tell the pharmacy when there is a fill for an opioid as well as for a benzodiazepine.
• Duplicate Long-Acting Opioid Therapy: will tell the pharmacy when there are multiple prescriptions for long-acting opioids.
• Morphine Milligram Equivalent (MME): will tell the pharmacy when members are filling at more than 2 pharmacies from more than 2 prescribers and when the total opioid dose is bigger than a certain amount.
• 7-Day Initial Fill Limit: members new to opioids will only be allowed a 7-day supply limit for his or her first fill. 
• Refill Tolerance: opioid prescriptions may only be refilled when 90% of the medication has been used (based on the prescribed day supply).
   

Drug Management Program (DMP)

L.A. Care’s Medicare Plus Plan has a new Drug Management Program (DMP) that can help members safely use their prescription opioid medications or other medications that are frequently abused. This program is called the Opioid Home Program and it launched on January 1, 2019. 
 
If you use opioid medications that you get from several doctors or pharmacies, or if you had a recent opioid overdose, we may talk to your doctors to make sure your use is appropriate and medically necessary. Working with your doctors, if we decide your use of prescription opioid or benzodiazepine medications is not safe, we may limit how you can get those medications. Limitations may include:

• Requiring you to get all prescriptions for those medications from one pharmacy and/or from one doctor
• Limiting the amount of those medications we will cover for you

If we decide that one or more limitations should apply to you, we will send you a letter in advance. The letter will explain the limitations we think should apply. You will have a chance to tell us which doctors or pharmacies you prefer to use. If you think we made a mistake, you disagree that you are at risk for prescription drug abuse, or you disagree with the limitation, you and your doctor can file an appeal. 
 
The DMP may not apply to you if you:

• have certain medical conditions, such as cancer or sickle cell disease, or
• are getting hospice, non-hospice palliative, or end-of-life care, or
• live in a long-term care facility.

 
For questions, you can contact Member Services at 1-833-522-3767 (TTY 711), 24 hours a day, 7 days a week, including holidays.
 

New members in L.A. Care Medicare Plus may be taking drugs that aren't in our Drug List (Formulary) or that are subject to certain restrictions, such as prior authorization or step therapy.

Current members may also be affected by changes in our formulary from one year to the next.

Drug Transition Policy

In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

To get a temporary supply of a drug, you must meet the two rules below:

1. The drug you have been taking:

• is no longer on our Drug List, or
• was never on our Drug List, or
• is now limited in some way.

2. You must be in one of these situations:

You were in the plan last year

• We will cover a temporary supply of your drug during the first 90 days of the calendar year.
• This temporary supply will be for up to an approved month’s supply.
• If your prescription is written for fewer days, we will allow multiple fills to provide up to a total month’s supply of medication. You must fill the prescription at a network pharmacy.
• Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.

You are new to our plan

• We will cover a temporary supply of your drug during the first 90 days of the calendar year.
• This temporary supply will be for up to an approved month’s supply.
• If your prescription is written for fewer days, we will allow multiple fills to provide up to a total month’s supply of medication. You must fill the prescription at a network pharmacy.
• Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.

You have been in the plan for more than 90 days and live in a long-term facility and need a supply right away.

• We will cover to up to an approved month’s supply, or less if your prescription is written for fewer days. This is in addition to the above temporary supply.
• You may experience a change in the level of care received and/or may be required to transition (move) from one facility or treatment site to another. Exceptions (special cases) are available to you if you experience a change in the level of care being received. If you experience a change in level of care, L.A. Care Medicare Plus will cover a temporary month supply (unless you have a prescription written for fewer days).
• To ask for a temporary supply of a drug, call Member Services at 1.833.522.3767 (TTY 711), 24 hours a day, 7 days a week, including holidays.

Within three business days after you receive your temporary supply, you will receive a letter that explains what to do next.
You should talk with your doctor to decide what to do before your supply runs out.

Here are your choices:

You can change to another drug.

There may be a different drug covered by our plan that works for you. You can call Member Services at 1.833.522.3767 (TTY 711), 24 hours a day, 7 days a week, including holidays, to ask for a list of covered drugs that treat the same medical condition. The list can help your provider find a covered drug that might work for you. 

OR

You can ask for an exception.

You and your provider can ask us to make an exception. For example, you can ask us to cover a drug even though it is not on the Drug List. Or you can ask us to cover the drug without limits.
If your provider says you have a good medical reason for an exception, he or she can help you ask for one.

To learn more about how to ask for an exception or if you disagree with our coverage or exception request decision and want to request an appeal, see Chapter 9 of the Member Handbook.

If you need help asking for an exception, you can contact Member Services at 1.833.522.3767 (TTY 711), 24 hours a day, 7 days a week, including holidays.

You can also file an Appeal or Grievance.  

Best Available Evidence Policy

To learn more about how we must establish cost-sharing for low-income subsidy beneficiaries, see the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence policy.
 

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits.  For more information contact the plan or read the Member Handbook.

Limitations, copays, and restrictions may apply. For more information, call L.A. Care Medicare Plus Plan Member Services or read the L.A. Care Medicare Plus Plan Member Handbook.

Benefits and/or copayments may change on January 1 of each year

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

You can get this information for free in other languages. Call Member Services at 1.833.522.3767 (TTY 711), 24 hours a day, 7 days a week, including holidays. The call is free.
 

Related Documents

Drug Transition Policy

What is the Medicare Prescription Payment Plan?

The Medicare Prescription Payment Plan (M3P) is a new program created under the Inflation Reduction Act that requires Part D plan sponsors to provide their enrollees with the option to pay out-of-pocket prescription drug costs in the form of monthly payments over the course of the plan year instead of all at once to the pharmacy. The program begins January 1, 2025. Program participants will pay $0 to the pharmacy for covered Part D drugs, and Part D plan sponsors will then bill program participants monthly for any cost sharing they incur while in the program. 

What does this mean for you?

Starting on January 1, 2025, L.A. Care Health Plan will offer the Medicare Prescription Payment Plan (M3P). The M3P is a new payment option that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year 
(January – December). Anyone can use this payment option for drugs covered by Part D and participation is voluntary.

If you select this payment option, each month you will continue to pay your plan premium (if you have one), and you will get a bill from your health plan to pay for your prescription drugs (instead of paying the pharmacy). There is no cost to participate in the M3P, and you won’t pay any interest or fees on the amount you owe, even if your payment is late.

This payment option will help you if you have high out-of-pocket drug costs earlier in the calendar year since this payment option will spread out what you will pay each month across the calendar year 
(January – December), so you don’t have to pay out-of-pocket costs to the pharmacy. This option will help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs.

This payment option might not be the best choice for you if:

• Your yearly drug costs are low or you have no co-pay.
• Your drug costs are the same each month.
• You’re considering signing up for the payment plan option late in the calendar year (after September).
• You don’t want to change how you pay for your drugs.
• You get or are eligible for Extra Help from Medicare.
• You are eligible for a Medicare Savings Program.
• You get help paying for your drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.

For more information:

• Contact SimplicityRx at 1-833-696-2087
• Visit activate.rxpayments.com to elect into the M3P Program
• Visit rxpayments.com if you are already enrolled and want to make payments

• Request for Medicare Prescription Drug Determination Request Form
• Request for Medicare Redetermination Request Form 1st Level of Appeal

The Medicare Prescription Drug Determination Request Form is not required to request a coverage decision. L.A. Care is required to accept any request that is made in writing when made by a Member, a Member’s prescribing physician, or other prescriber, or a Member’s appointed representative. L.A. Care is prohibited from requiring a member, physician or other prescriber to make a written request on a specific form. You or your physician can attach any “supporting documents” to this form. The written request can be mailed, delivered in person, or faxed to:

Navitus Health Solutions

P.O. Box 1039
Appleton, WI 54912
Fax: 1-855-668-8552 

To ask for a redetermination (appeal), you can use the “Request for Medicare Redetermination Request Form – 1st Level of Appeal” form linked above.  You are not required to use this form.   For more information on L.A. Care Medicare Plus Plan’s Coverage Determinations, Redeterminations, Appeals & Grievances process, please visit our Appeals & Grievances page.