Prescription Coverage

A formulary is a list of the prescription drugs that we help pay for as part of your plan. We work with a team of healthcare providers to develop this list. These providers agree that these drug therapies are necessary for quality treatment.

Prescription drugs are available as brand-name drugs or generic drugs. Most drugs have a brand-name version and a generic version. Both versions have the same active ingredients. The difference is that you may not know the generic name. The generic is often cheaper than the brand-name version.

To get additional information about the drugs covered by KelseyCare Advantage, or to request a copy of the Formulary Addendum be mailed to your home, please call Member Services at 713-442-CARE (2273) or 1-866-535-8343, 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, and from 8 a.m. to 8 p.m., Monday through Friday from April 1 through September 30. TTY/TDD users should call 711.

If your drug is not on the approved list of drugs or is restricted:

• You can change to another drug.
• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.
• You may be able to get a temporary (transition) supply of the drug. This will give you and your doctor time to change to another drug or to file an exception. Note: Only members in certain situations can get a temporary supply.

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 supply of up to 30 days.

When you transfer from one treatment setting to another, such as moving from an inpatient hospital setting to home, it is called a level-of-care change. These types of changes often do not leave you enough time to determine if a new prescription contains a drug that is on the plan formulary. In these unexpected situations, KelseyCare Advantage will cover a temporary transition supply of up to 30 days. If your level-of-care change involves moving to a long-term care facility and a new drug is prescribed, the plan covers a temporary supply of up to 31 days.

If you take a lot of medications, you may qualify for a program that helps you manage your prescriptions.

Your participation is voluntary and doesn’t affect your coverage. This program is open to those invited to take part. The program isn’t a benefit for all members.

Learn more about our Medication Therapy Management program.