VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP) members who receive full extra help pay $0 or low co-pays for their prescription drugs. Please see Low Income Subsidy Chart in the Resources Section of our website.
Premium, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Formulary
VillageCareMAX Medicare Health Advantage FLEX Plan has a list of covered drugs called the formulary. The formulary lists which Part D prescription drugs are covered by the plan. The formulary also tells you if there are any restrictions in coverage for certain drugs.
2024 VillageCareMAX Medicare Health Advantage FLEX Plan Formulary
Use our online search tool to find out if your prescription drug is on the Formulary
Changes in the Formulary
The Formulary is updated throughout the year. If you are taking a prescription that is affected by a change in the Formulary, you will receive information about this in your monthly Explanation of Benefits (EOB) that we will send you. Below is a list of changes made to the Formulary this year.
2024 Formulary Changes (updated 10/2024)
Prior Authorization
The VillageCareMAX Medicare Health Advantage FLEX Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug.
2024 List of drugs that require prior authorization (updated 12/2024)
Quantity Limits
Certain drugs have limits on the amount of the drug that VillageCareMAX Medicare Health Advantage FLEX Plan will cover. For example, the Plan provides 60 capsules for 30 days per prescription for Celebrex.
Step Therapy
In some instances, VillageCareMAX Medicare Health Advantage FLEX Plan may require you to try certain drugs to treat your medical condition before we will cover another drug for that same condition. This is called Step Therapy. For example, if Drug A and Drug B both treat your medical condition, VillageCareMAX Medicare Health Advantage FLEX Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.
2024 List of drugs that require step therapy (updated 12/2024)
Coverage Determination
If your drug is not listed in the Formulary, you should call VillageCareMAX Member Services to confirm that the drug is not covered. If it’s not covered, you have two options:
- Ask Member Services for a list of similar drugs that are covered. Show the list to your doctor and ask him/her to prescribe a similar drug that is covered by VillageCareMAX Medicare Health Advantage FLEX Plan
- Ask the Plan to make a coverage determination and cover your drug.
There are several types of coverage determinations that you can ask us to make, including:
- Cover your drug even if it’s not on our Formulary. This is also called an exception.
- Waive coverage restrictions or limits on your drug.
When you are requesting an exception you should submit a statement from your physician supporting your request. We must make a decision within 72 hours of getting your physician’s supporting statement.
You can request an expedited exception if you or your doctor believes your health could be seriously harmed by waiting up to 72 hours. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your physician’s supporting statement
How to request a coverage determination for a prescription drug?
- Call Member Services at 1-888 807-6806 (TTY 711), 7 days a week, 8 am to 8 pm.
- Mail your request to: MedImpact Healthcare Systems, Inc., Attention: PA Department, 10181 Scripps Gateway Ct, San Diego, CA 92131.
- Fax your request to: 1-858-790-7100
- Submit your request online (Coverage Determination Request)
Learn more about Coverage Determinations and Exceptions
Part D Coverage Determination Form (Updated 4/2024)
Prescription Drug Transition Policy
New to Plan and do not live in a long-term care facility
As a new member in VillageCareMAX Medicare Health Advantage FLEX Plan, you may be taking drugs that are not on our Formulary or that are subject to certain restrictions such as prior authorization or step therapy. You should talk to you doctor right away to decide if s/he can switch you to another drug that is covered or request a Formulary exception. While you talk to your doctor, we will cover your drug during the first 90-days of membership in our plan.
Changes in drug coverage – current member
If you are a current member affected by a Formulary change from one year to the next, VillageCareMAX Medicare Health Advantage FLEX Plan may provide up to 30 days temporary supply of the non-formulary drug unless the drug was recalled for unsafe reasons. If you need a refill for the drug during the first 90 days of the new plan year, we will provide you with the opportunity to request a Formulary exception in advance for the following year.
We will send you a letter in the mail whenever you receive a transitional fill on your prescription. It will provide you with more information and will explain the steps you can take to request an exception, if you and your doctor believe this is needed for you.
(See the section Coverage Determinations above)
New to Plan and living in a long-term care facility
If you are a resident of a long-term care facility, we will allow you to refill your prescription for up to 98-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs during the first 90-days of your membership in our plan.
More than 90 days in plan and living in a long-term care facility
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 one 31-day supply, or less if your prescription is written for fewer days.
When your transition period ends
For each of your drugs that is not on our Formulary or if your ability to get your drugs is limited – VillageCareMAX Medicare Health Advantage FLEX Plan will temporarily cover up to 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your 90-day transition period ends, we generally will not pay for these drugs. We will provide you with written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to switch to an appropriate drug that we cover. You will receive an approval letter if we approve the request from you and your doctor.
Change in your level of care (after the first 90-days of membership)
There are times when you may experience a change in your level of care, such as a discharge from a hospital to a home setting. In these cases, we will cover a one-time temporary supply for up to 30-days (or 31- days if you are a long-term care resident) when you go to a network pharmacy. During this period, you should use the plan’s exception process if you wish to have continued coverage of the drug after the temporary supply is finished.
Medication Therapy Management (MTM) Program
Our Medication Therapy Management (MTM) program focuses on improving therapeutic outcomes at no additional cost to participants who have multiple medical conditions, who are taking many prescription drugs and have high drug costs. Headed by licensed pharmacists, our team helps you manage the medications you are taking to stay healthy, and protects you from potentially harmful drug combinations.
You will be automatically enrolled if you:
- Take eight or more Medicare Part D covered drugs for maintenance of chronic conditions
- Have three or more chronic conditions such as diabetes, asthma, high cholesterol, high blood pressure, congestive heart failure or chronic obstructive pulmonary disease
- Your drugs cost more than $4,935 a year
If you qualify you will receive an invitation to have a phone call with one of our pharmacists. The pharmacist will review all the drugs, vitamins and over-the-counter products you are taking and discuss them with you. Any concerns will be identified and shared with you and your doctor. The pharmacist will be able to answer any questions and address any of the concerns that you have about your medications and will send you the reviews and other useful information by mail.
If you do not wish to participate, please call Member Services. This program is not a benefit.
MTM Program Description (pdf) (updated 1/2024)
