Part D prescription drug benefits

If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” This may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative or other person to be your representative, you must provide a completed Appointment of Representative (AOR) form. A copy of the AOR form is available below for download and printing or you can contact Member Services and ask for the Appointment of Representative form to be mailed to you. You can reach us at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). 

AOR form - English (PDF)

AOR form - Español (PDF)

The form must be completed and signed by you and by the person who you would like to act on your behalf. The completed and signed form is valid for one year. You are not required to use the AOR, you can also provide a written notice that contains the information below: 

1. Enrollee’s name, address, and telephone number 
2. Enrollee’s Medicare Identifier Number 
3. The name, address, and telephone number of the individual being appointed 
4. A statement that authorizes the representative to act on your behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to your representative 
5. Must be signed and dated by the enrollee making the appointment  
6. Must be signed and dated by the individual being appointed as your representative, and is accompanied by a statement that the individual accepts the appointment 

For medical care, your doctor can request a coverage decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it will automatically be forwarded to Level 2. To request any appeal after Level 2, your doctor must be appointed as your representative. 

For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or Level 1 or Level 2 appeal on your behalf. To request an appeal after Level 2, your doctor or other prescriber must be appointed as your representative. 

Formulary (list of covered drugs) 

2025 Formulary (PDF)  Updated 10/2024 

2024 Formulary (PDF)  Updated 11/2024 

2024 Formulary changes (PDF) Updated 11/2024

Search our 2024 0nline Formulary

Search our 2025 Online Formulary

You can register on the Caremark.com member portal to use the “Real-Time Benefit Tool”.  With this tool you can search for drugs on the “Drug List” to see an estimate of what you will pay and if there are alternative drugs on the “Drug List” that could treat the same condition.  Once registered, you can access the tool under the Plan & Benefits section and then clicking on the “Check Drug Cost & Coverage” option.

Are there any restrictions on my drug coverage?  

Yes, some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include the 2024 prior authorization criteria (PDF) Updated 11/2024  

2025 prior authoriation criteria (PDF) Updated 10/2024

Mercy Care Advantage requires you (or your physician) to get prior authorization for some drugs. This means that you need to get approval from Mercy Care Advantage before you fill your prescriptions. If you don’t, Mercy Care Advantage may not cover the drug.  

2024 step therapy criteria (PDF) No changes since 10/2023 

2025 step therapy criteria (PDF) No changes since 10/2024

Sometimes Mercy Care Advantage needs you first to try certain drugs to treat your medical condition before it covers another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Mercy Care Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work, you can ask Mercy Care Advantage to cover Drug B. 

As a Medicare beneficiary, you have rights under your Part D prescription drug benefits. The information in the options below will explain the Part D prescription drug benefits available to you and your rights as a Mercy Care Advantage plan member. You, your authorized representative or your doctor has the right to request a coverage determination or exception for a drug that you feel should be covered for you or to request we pay for a prescription drug you already bought. For complete information about the coverage determination process or appeal process, view Part D coverage determinations later on this page or refer to the Evidence of Coverage on this page. 

Safe use of opioid pain medication — information for Medicare Part D patients

Prescription opioid pain medications — like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine — can help treat pain after surgery or after an injury, but they carry serious risks, like addiction, overdose, and death. These risks increase with the higher the dose you take, or the longer you use these pain medications, even if you take them as prescribed. Your risks also increase if you take certain other medications, like benzodiazepines (commonly used for anxiety and sleep), or get opioids from many doctors and pharmacies.

Medicare is dedicated to helping you use prescription opioid pain medications more safely, and they have introduced new policies for opioid prescriptions in the Medicare Part D prescription drug program beginning in January 2019. 

Safety reviews when opioid prescriptions are filled at the pharmacy

Your Medicare drug plan and pharmacist will do safety reviews of your opioid pain medications when you fill a prescription. These reviews are especially important if you have more than one doctor who prescribes these drugs. In some cases, the Medicare drug plan or pharmacist may need to first talk to your doctor. 
 
Your drug plan or pharmacist may do a safety review for:

• Potentially unsafe opioid amounts

• If you take opioids with benzodiazepines like Xanax®, Valium®, and Klonopin®

• New opioid use — you may be limited to a 7-day supply or less; this does not apply to you if you already take opioids

If your pharmacy can’t fill your prescription as written, including the full amount on the prescription, the pharmacist will give you a notice explaining how you or your doctor can contact the plan to ask for a coverage decision. If your health requires it, you can ask the plan for a fast coverage decision. You may also ask your plan for an exception to its rules before you go to the pharmacy, so you’ll know if your plan will cover the medication.

Drug Management Programs (DMPs)

Starting January 1, 2019, some Medicare drug plans (Part D) will have a DMP. If you get opioids from multiple doctors or pharmacies, your plan may talk with your doctors to make sure you need these medications and that you’re using them safely.

If your Medicare drug plan decides your use of prescription opioids and benzodiazepines isn’t safe, the plan may limit your coverage of these drugs. For example, under its DMP your plan may require you to get these medications only from certain doctors or pharmacies to better coordinate your health care.

Before your Medicare drug plan places you in its DMP, it will notify you by letter. You’ll be able to tell the plan which doctors or pharmacies you prefer to use to get your prescription opioids and benzodiazepines. After you’ve had the opportunity to respond, if your plan decides to limit your coverage for these medications, it will send you another letter confirming its decision. You and your doctor can appeal if you disagree with your plan’s decision or think the plan made a mistake. The second letter will tell you how to contact your plan to make an appeal.

Note: The safety reviews and DMPs should not apply to you if you have cancer, get hospice, palliative, or end-of-life care, or if you live in a long-term care facility.

Talk with your doctor

Talk with your doctor about all your pain treatment options including whether taking an opioid medication is right for you. There might be other medications you can take or other things you can do to help manage your pain with less risk. What works best can be different for each patient. Treatment decisions to start, stop or reduce prescription opioids are individualized and should be made by you and your doctor. You can get more information about safe and effective pain management. 

Additional resources

Contact your Medicare drug plan for additional information. You can find contact information in your member materials or on your membership card. 
 
Your Guide to Medicare Drug Coverage (PDF)

How Medicare Drug Plans use Pharmacies, Formularies, & Common Coverage Rules (PDF)

National Opioid Crisis: Help and Resources

Understanding Drug Overdoses and Deaths  

Visit the State Health Insurance Assistance Program (SHIP) or call 1-800-MEDICARE for the phone number of your SHIP.

Visit Medicare.gov for more information on what Medicare covers and drug coverage rules. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Legal  Notices

All trademarks and logos are the intellectual property of their respective owners.

The Low-Income Subsidy (LIS) program, also called “Extra Help” helps cover the cost of prescription drugs for people with low incomes who are eligible for the Medicare Part D program. If you are enrolled in Mercy Care Advantage, you were sent a copy of the Low-Income Subsidy Rider that explains your Part D prescription drug cost sharing responsibilities.

2025 Low-Income Subsidy (LIS) Rider – Benefit increase - English (PDF)

2025 Low-Income Subsidy (LIS) Rider – Benefit increase - Español (PDF)

2025 Low-Income Subsidy (LIS) Rider – Benefit decrease - English (PDF)

2025 Low-Income Subsidy (LIS) Rider – Benefit decrease - Español (PDF)

2024 Low-Income Subsidy (LIS) Rider – Benefit increase - English (PDF)

2024 Low-Income Subsidy (LIS) Rider – Benefit increase - Español (PDF)

2024 Low-Income Subsidy (LIS) Rider – Benefit decrease - English (PDF)

2024 Low-Income Subsidy (LIS) Rider – Benefit decrease - Español (PDF)

Do I qualify for Extra Help? 
People with limited income and resources may qualify for Extra Help in one of two ways: automatically or by submitting an application. The amount of extra help you get depends on your income and resources. If you automatically qualify, you do not need to apply. Medicare will send you a letter. You automatically qualify for Extra Help if one of the following is true:

• You have full coverage from a state Medicaid program like AHCCCS

• You get help from Medicaid paying your Medicare Part B premiums

• You get Supplemental Security Income (SSI) benefits

Apply 
If you do not automatically qualify, but have limited income and resources, you may file an application with the Social Security Administration at 1-800-772-1213 or visit the Social Security website. You also may apply at your State Medical Assistance (Medicaid) office at 602-417-4000 or 1-800-654-8713. They will determine if you meet the eligibility criteria.

How much do you pay for drugs covered by this plan? 
If you qualify for extra help with your drug costs, the cost for your drugs would normally depend on certain factors. These factors include your income and coverage levels, the type of drug and whether you are filling your prescription at an in-network or out-of-network pharmacy.

2024 Low-Income Subsidy eligibility and benefits information:

Your monthly plan premium is: $0 
Your yearly deductible is: $0

Your cost sharing amount for generic/preferred multi-source drugs is no more than: 
$0 / $1.55 / $4.50 (each prescription)

Your cost sharing amount for all other drugs is no more than: 
$0 / $4.60 / $11.20 (each prescription)

2025 Low-Income Subsidy eligibility and benefits information: 

Your monthly plan premium is: $0 
Your yearly deductible is: $0

Your cost sharing amount for generic/preferred multi-source drugs is no more than: 
$0 / $1.60 / $4.90 (each prescription)

Your cost sharing amount for all other drugs is no more than: 
$0 / $4.80 / $12.15 (each prescription)

There is $0 cost share required for members in a long-term care facility or who have reached the catastrophic coverage stage of your Part D prescription benefit coverage in the current calendar year.

Please note: Mercy Care Advantage does not have a monthly plan premium. You must continue to pay your Medicare Part B premium. If you are a full dual-eligible member, your monthly Part B premium is paid by the State.

The Mercy Care Advantage Medication Therapy Management (MTM) Program is all about you and your health. The MTM Program helps you get the most out of your medications by:

• Preventing or reducing drug-related risks
• Supporting good lifestyle habits
• Providing information for safe medication disposal options

Who qualifies for the MTM Program?

You will be enrolled in the Mercy Care Advantage MTM Program if you meet one of the following:

Have coverage limitation(s) in place for medication(s) with a high risk for dependence and/or abuse, or meet the following criteria:

 You have three or more of these conditions

• Asthma
• Chronic heart failure (CHF)
• Chronic obstructive pulmonary disease (COPD)
• Diabetes
• Dyslipidemia
• Hypertension
• Chronic alcohol & drug dependence
• HIV/AIDS

You take eight or more routine medications covered by your plan

You are likely to spend more than $5,330 in Part D prescription drug costs in 2024

Your participation in the MTM Program is voluntary and does not affect your coverage. This is not a plan benefit and is open only to those who qualify. There is no extra cost to you for the MTM Program.

How will I know if I qualify for the MTM Program?

If you qualify, we will mail you a letter. You may also receive a call to set up your one-on-one medication review.  

What services are included in the MTM Program?

In the MTM Program, you will receive the following services from a health care provider:

• Comprehensive medication review
• Targeted medication review

What is a comprehensive medication review?

The comprehensive medication review is completed with a health care provider in person or over the phone. This review is a discussion that includes all your medications:

• Prescriptions
• Over-the-counter (OTC)
• Herbal therapies
• Dietary supplements

This review usually takes 20 minutes or less to complete. During the review, you may ask any questions about your medications or health conditions. The health care provider may offer ways to help you manage your health and get the most out of your medications. If more information is needed, the health care provider may contact your prescriber.

After your review, you will receive a summary of what was discussed. The summary will include the following:

• Recommended To-Do List. Your to-do list may include suggestions for you and your prescriber to discuss during your next visit.
• Medication List. This is a list of all the medications discussed during your review. You can keep this list and share it with your prescribers and/or caregivers.

Here is a blank copy of the Medication List (PDF) for tracking your medications.

Who will contact me about completing the review?

You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You can choose to complete the review in person or over the phone.

A health care provider may also call you to complete your review over the phone. When they call, you can schedule your review at a time that is best for you.

Trusted MTM Program partners: You may receive a call from the CVS Caremark Pharmacist Review Team or the Outcomes Patient Engagement Team to complete this service. 

Why is this review important?

Different prescribers may write prescriptions for you without knowing all the medications you take. For that reason, the MTM Program health care provider will:

• Review all your medications
• Discuss how your medications may affect each other
• Identify any side effects from your medications
• Help you reduce your prescription drug costs

How do I benefit from talking with a health care provider?

By completing the medication review with a health care provider, you will:

• Understand how to safely take your medications
• Get answers to any questions you may have about your medications or health conditions
• Review ways to help you save money on your drug costs
• Receive a Recommended To-Do List and Medication List for your records and to share with your prescribers and/or caregivers

What is a targeted medication review?

The targeted medication review is completed by a health care provider who reviews your medications at least once every three months. With this review, we mail, fax, or call your prescriber with suggestions about prescription drugs that may be safer or work better for you. As always, your prescriber will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your prescriber decide to change them. We may also contact you by mail or phone with suggestions about your medications.

How can I get more information about the MTM Program?

Please contact us if you would like more information about the Mercy Care Advantage MTM Program or if you do not want to participate. Our number is 602-586-1730 or 1-877-436-5288 (TTY 711). We’re here for you 8 a.m. to 8 p.m., 7 days a week.

How do I safely dispose of medications I don’t need?

The Mercy Care Advantage MTM Program is dedicated to providing you with information about safe medication disposal. Medications that are safe for you may not be safe for someone else. Unneeded medications should be disposed of as soon as possible. You can discard your unneeded medications through a local safe disposal program or at home for some medications. 

• Locating a community safe drug disposal site. A drug take back site is the best way to safely dispose of medications. To find drug take back sites near you, visit the website below and enter your location Visit the U.S. Department of Justice website and enter your location. Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs, and other ways for safe disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you.
• Mailing medications to accepting drug disposal sites. Medications may be mailed to authorized sites using approved packages. Find information on mail-back sites at the Drug Enforcement Administration (DEA) website.
• Safe at-home medication disposal. You can safely dispose of many medications through the trash or by flushing them down the toilet. Visit the U.S. Department of Health and Human Services website first to learn what medications are safe to dispose of at home.

1. Remove medication labels to protect your personal information
   
2. Mix medications with undesirable substances, such as dirt or used coffee grounds
3. Place mixture in a sealed container, such as an empty margarine tub

When you join Mercy Care Advantage (HMO SNP) and you learn that we do not cover a prescription drug you were taking before you joined our Plan, you may be able to get a one-time temporary fill of a 31-day supply of that prescription drug (or less, as prescribed, up to a 31-day supply) at a retail pharmacy. This gives you the opportunity to work with your doctor to complete a successful transition to your new coverage year and avoid disruption in your treatment. This is called the Transition of Coverage (TOC) process. If you receive a transition fill for a drug, we will send you a letter explaining that the drug was filled under the Transition of Coverage process. The letter will explain the action you can take to get approval for the drug or how to switch to another drug on the plan formulary.

Right to transition fill 
If you are a new member and are taking a Part D drug that is not on the Mercy Care Advantage formulary or is subject to a utilization management requirement or limitation (such as step therapy, prior authorization, or a quantity limit), you are entitled to receive a 31-day supply of the drug within the first 90-days of your enrollment. This period of time is called your “transition period”. If your prescription is written for less than a 31-day supply, you can get it refilled until you reach the 31-day supply.

If you are an existing member and are taking a Part D drug that is not on the Mercy Care Advantage formulary, or is subject to a new utilization management requirement or limitation (such as step therapy, prior authorization, or a quantity limit), you are entitled to receive a 31-day supply of the drug within the first 90-days of the new plan year. This period of time is called your “transition period”. If your prescription is written for less than a 31-day supply, you can get it refilled until you reach the 31-day supply.

Existing members who are taking a Part D drug that was removed from the formulary, or a drug that now has a new utilization requirement or limitation at the beginning of the new plan year, may ask Mercy Care Advantage to make a coverage determination and exception request for your drug.

In general, we will determine your right to a 31-day fill at the pharmacy when you go to fill your prescription. In some situations, we will need to get additional information from your doctor before we can determine if you are entitled to a transition 31-day fill.

If you live in a Long-Term Care facility and are entitled to a transition supply, we will allow you to refill your prescription until we have provided you with up to a 31-day supply (unless the prescription is written for less) during your transition period.  If your prescription is written for less than a 31-day supply, we will allow multiple fills to provide up to a maximum of 31-days of medication.

You may also be eligible to receive a transition fill outside of your 90-day transition period. For example, you may be eligible to receive a temporary supply of a drug if you experience a change in your “level of care” (i.e., if you have returned home from a stay in the hospital with a prescription for a drug that isn’t on the formulary). There are other situations where you may be entitled to receive a temporary supply of a prescription drug.

It is important that you understand that the transition fill is a temporary supply of this drug. Before this supply ends, you should speak to our Plan and/or your physician regarding whether you should change the drug(s) you are currently taking or request an exception from our Plan to continue coverage of the drug. You, your authorized representative or your provider can ask for an exception request.

Coverage Determination forms

Online Coverage Determination form - English 

Online Coverage Determination form - Español 

Print Coverage Determination form (PDF)

If you have questions about whether you are entitled to a temporary supply of a drug in a particular situation or you want to request for Mercy Care Advantage to make a coverage determination and exception for your drug, please call Mercy Care Advantage Member Services. 

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative. 

For certain kinds of drugs, you can use the plan’s network mail-order services to get prescriptions drugs shipped to your home. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs that are not available through the plan’s mail-order service are marked as “non-maintenance” drugs in our 2024 online formulary or 2025 online formulary.

When you order prescription drugs through the network mail-order pharmacy service, you must order at least a 75-day supply, and no more than a 90-day supply of the drug. Take the mail-order drug form to your doctor and ask your doctor to write a new prescription(s) for up to the maximum mail-order day supply. Fill out the order form completely, including your member ID number, your doctor's name, and any allergies, illnesses or medical conditions you may have.

Download the Prescription Drug Mail-order Form:

Prescription Drug Mail-order Form - English (PDF)

Prescription Drug Mail-order Form - Español (PDF)

To request order forms and information about filling your prescriptions by mail, call Member Services ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). You can also register online with CVS Caremark. Once registered, you will be able to order refills, renew your prescriptions and check the status of your order. 

Mail the order form and the prescription(s) to:
CVS Caremark 
PO Box 659541 
San Antonio, TX  78265-9541

Usually, a mail-order pharmacy order will get to you in no more than 10 to15 days. In the unlikely event that there is a significant delay with your mail-order prescription drugs, our mail-order service will work with you and a network pharmacy to provide you with a temporary supply of your mail-order prescription drugs. If you have not received an order within 10 to15 calendar days of when you sent the order, call CVS Caremark Customer Care at 1-844-843-6264 (TTY 1-800-231-4403) for assistance. Calls to these numbers are free.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Limitations, copayments and restrictions may apply. This information is not a complete description of benefits. Contact the plan for more information.

We cover specialty drugs under your Part D and Part B benefits. Specialty drugs need prior authorization (PA). 

PA for Part D specialty drugs

Your provider can ask for PA under your Part D benefit:  

• By fax: Print and complete the Coverage Determination form (PDF). Then, fax it with any supporting documentation to 1-855-230-5544.  

• By phone: Call us at 602-586-1730 or 1-877-436-5288 (TTY 711). Choose option 2 for providers. Then, choose option 1 to initiate a coverage determination request. 

PA for Part B specialty drugs

Your provider can ask for PA under your Part B benefit:   

• By fax: Fax your PA request with supporting documentation to 1-800-217-9345.  

• By phone: Call 602-586-1730 or 1-877-436-5288 to initiate an organization determination (PA) for the specialty drug.   

Part B versus Part D coverage rules 

You can learn more about Part B versus Part D coverage rules. Check Appendix C, Chapter 6 of the Medicare Prescription Drug Manual (PDF). 

TrOOP or True Out-Of-Pocket costs includes all payments for medications listed on the plan's formulary and purchased at a network or participating pharmacy. This includes payments made by the member and payments that were made by others on a member’s behalf. TrOOP is the spending that determines when a member enters the initial coverage phase, becomes eligible for the Drug Discount Program, reaches the annual OOP threshold, and enters the catastrophic coverage phase of their Part D prescription drug benefit.

Effective January 1, 2025, the TrOOP amount is $2,000.  If a member changes Medicare health plans during the calendar year, their TrOOP balance will be transferred to their new Medicare health plan as long as it includes Part D prescription drug coverage.

The following do not apply to TrOOP: plan premium payments; money spent on drugs not covered by Medicare Part D (excluded drugs); and payments made by non-qualified third parties.

Effective January 1, 2025, payments made by the following will count towards TrOOP:

• Supplemental commercial health insurance;
• Qualified State Pharmacy Assistance Programs (SPAPs)
• Indian Health Service and certain other Native American organizations;
• AIDS Drug Assistance Programs; and
• Legitimate charities.

Members enrolled in Mercy Care Advantage (MCA) qualify for “Extra Help” and do not have to pay a Medicare Part D deductible. MCA members will remain in the Part D Initial Coverage Stage, until the member and health plan have met the $2,000 in out-of-pocket costs. Once this amount has been met, MCA members will automatically move into the Catastrophic Coverage stage of their Medicare Part D coverage. Once in the Catastrophic Coverage stage, Mercy Care Advantage will pay all the costs of the members drugs for the remainder of the calendar year. 

TrOOP or True Out-Of-Pocket costs includes all payments for medications listed on the plan's formulary and purchased at a network or participating pharmacy. This includes payments made by the member and payments that were made by others on a member’s behalf. The TrOOP amount for 2024 is $8,000.  If a member changes Medicare health plans during the calendar year, their TrOOP balance will be transferred to their new Medicare health plan as long as it includes Part D prescription drug coverage. The following do not apply to TrOOP: plan premium payments; money spent on drugs not covered by Medicare Part D (excluded drugs); and payments made by non-qualified third parties, including group health plans, insurers, government funded health programs or similar third parties.

Members enrolled in Mercy Care Advantage (MCA) qualify for “Extra Help” and do not have to pay a Medicare Part D deductible. MCA members will remain in the Part D Initial Coverage Stage, until the member and health plan have met the $8,000 in out-of-pocket costs. Once this amount has been met, MCA members will automatically move into the Catastrophic Coverage stage of their Medicare Part D coverage. Once in the Catastrophic Coverage stage, Mercy Care Advantage will pay all of the costs of the members drugs for the remainder of the calendar year. 

As a member of Mercy Care Advantage, you, your authorized representative or your doctor has the right to request a coverage determination or exception for a drug that you feel should be covered for you or to pay for a prescription drug you already bought. If your pharmacist tells you that your prescription drug claim was rejected, you will be given a written notice that explains how you can request a coverage determination or exception. This information is also explained in Chapter 9 of the Evidence of Coverage (PDF). 

Mercy Care Advantage has a list of covered Part D prescription drugs called a “formulary.” Your network doctor will refer to the formulary and typically prescribe a drug from the formulary that will meet your medical needs. Not all prescription drugs are included on the Mercy Care Advantage formulary, and some drugs covered under our formulary may require prior authorization, step therapy or have quantity limits that apply. You can view the formulary, prior authorization criteria and step therapy criteria in the Formulary topic on this page. 

A coverage determination is any determination (e.g., an approval or denial) made by Mercy Care Advantage for the following reasons: 

1. A decision about whether to provide or pay for a Part D drug (including a decision not to pay) because: 
   
   
   • The drug is not on the plan’s formulary 
   • The drug is determined not to be medically necessary 
   • The drug is furnished by an out-of-network pharmacy 
   • Mercy Care Advantage determines that the drug is otherwise excluded under section 1862(a) of the Act (if applied to Medicare Part D) that the enrollee believes may be covered by the plan 
2. Failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the enrollee; 
3. A decision concerning a tiering exceptions request; 
4. A decision concerning a formulary exceptions request; 
5. A decision on the amount of cost sharing for a drug; or 
6. A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement. 

There may be times that you, your authorized representative, or your doctor will want to ask for a coverage determination or exception. Mercy Care Advantage must review and process the request within the expedited (24 hours) or standard (72 hours) time frames required by Medicare. 

In order for us to cover a formulary exception, your doctor must provide a statement that says you have tried formulary alternatives in the same drug class and they didn’t work for you, or a medical reason why you can’t try the formulary alternatives in the same drug class. 

If we approve the request, you will be notified and the drug or payment will be provided. 

If we deny the request, you will be notified and receive a written notice explaining why it was denied and how you can appeal this decision. An unfavorable decision could be because the drug is not on the formulary, excluded from Part D coverage, or determined not to be medically necessary, or you have not tried a similar drug listed on the formulary. It could also be based on whether or not you have satisfied the prior authorization requirement. In most situations, this process cannot be applied to any medications excluded from Part D under federal law (e.g., over-the-counter medications). 

Coverage determination requests can be made in writing, by phone or by fax. Members can call Mercy Care Advantage Member Services at the numbers provided below to request a coverage determination or exception. You may also use the coverage determination form to submit your request. 

Coverage Determination forms

Online Coverage Determination form - English

Online Coverage Determination form - Español

Print Coverage Determination form (PDF)

Multi-language interpreter services (PDF)

Providers can call or fax a coverage determination or exception request to Mercy Care Advantage at the numbers below. A request for an exception needs to include a supporting statement from your doctor to provide the medical reasons for the drug requested. 

Coverage decisions for Part D prescription drugs 

Mercy Care Advantage members can ask us for a coverage determination by: 

• Phone: ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). 

• Fax: 1-855-230-5544  

• Mail: Mercy Care Advantage   
  Part D Coverage Determination Pharmacy Department   
  4750 44th Place, Suite 150   
  Phoenix, AZ 85040 

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative. 

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). 

Requests 

1. Request to Satisfy a Prior Authorization (PA) or other utilization management (UM) requirement 
   
   Standard coverage determination time frame 
   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but not later than 72 hours from the receipt of the request. 
   
   Expedited coverage determination time frame 
   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the request. 

2. Request to Waive a Prior Authorization (PA) or other utilization management (UM) requirement — Formulary Exception Request 
   
   Standard coverage determination time frame 
   If an enrollee or an enrollee's prescribing physician or other prescriber is asking MCA to waive a PA or other UM requirement because the physician or other prescriber feel that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support this type of request.
   
   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 72 hours after receiving the physician's or other prescriber's supporting statement for standard cases. 
   
   Expedited coverage determination time frame 
   If an enrollee or an enrollee's prescribing physician or other prescriber is asking MCA to waive a PA or other UM requirement because the physician or other prescriber feels that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support this type of request.  
   
   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the physician's or other prescriber's supporting statement for standard cases. 

3. Request for Reimbursement for drug already received that involves waiving a Prior Authorization (PA) or other utilization management (UM) requirement — Exception Request 
   
   Standard coverage determination time frame 
   If an enrollee is asking to be reimbursed for a drug purchased that requires MCA to waive a PA or other UM requirement because the physician or other prescriber feels that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support the request. 
   
   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision (and make payment when appropriate) no later than 14 calendar days after receiving the request. 
   
   Expedited coverage determination time frame 
   Reimbursement requests do not qualify for expedited processing. 

4. Request for Tiering Exception — drug not yet received
   
   Standard coverage determination time frame  
   If an enrollee wishes to obtain a tiering exception for a drug not yet received, his or her prescribing physician or other prescriber must provide the plan sponsor with a statement to support the request. 
   
   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 72 hours after receiving the physician’s or other prescriber's supporting statement. 
   
   Expedited coverage determination time frame
   If an enrollee wishes to obtain a tiering exception for a drug not yet received, his or her prescribing physician or other prescriber must provide the plan sponsor with a statement to support the request. 
   
   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but no later than 24 hours after receiving the physician’s or other prescriber's supporting statement. 

5. Request for Tiering Exception Reimbursement 
   
   Standard coverage determination time frame 
   If an enrollee is asking for a reimbursement related to a tiering exception, the prescribing physician or other prescriber must submit a statement to support the request. 
   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision (and make payment when appropriate) no later than 14 calendar days after receiving the request. 
   
   Expedited coverage determination time frame  
   Reimbursement requests do not qualify for expedited processing. 

How to file a grievance  

You have the right to file a complaint (also called a “grievance”) if you have a problem or concern. A grievance is any complaint or dispute, other than one that involves a coverage determination or an LIS (Low-Income Subsidy) or LEP (Late Enrollment Penalty) determination, expressing dissatisfaction with any aspect of the operations, activities or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times and the customer service you receive.  
  
You may file a grievance if you have a problem with Mercy Care Advantage or one of our network providers or pharmacies. Some examples of why you might file a complaint/grievance include: 

• You believe your plan's customer service hours of operation should be different. 

• You have to wait too long for your prescription. 

• The plan is sending you materials that you didn’t ask to get and aren’t related to the drug plan. 

• The plan didn’t make a timely decision about a coverage determination in level 1 and didn’t send your case to the IRE. 

• You disagree with the plan’s decision not to grant your request for an expedited (fast) coverage determination or first-level appeal (called a “redetermination”). 

• The plan didn't provide the required notices. 

• The plan's notices don't follow Medicare rules. 

We may use your complaint type to track trends and identify service issues. Please see Chapter 9 of the Evidence of Coverage on this page for detailed information and timelines for filing a grievance.  
  
If you want to file a grievance, contact us promptly — either by phone or in writing. Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can reach Member Services at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711).  

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works: 

• If you ask for a written response, file a written grievance or your complaint is related to quality of care, we will respond to you in writing. 

• If we cannot resolve your complaint over the phone, we will respond to your complaint within 30 calendar days. 

Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 days after you had the problem you want to complain about. If you need an interpreter, one can be provided at no cost to you. Please submit written complaints by: 

• Fax: 1-602-351-2300

• Mail:  Mercy Care Advantage  
  Attn: Grievance Department  
  4750 44th Place, Suite 150  
  Phoenix, AZ 85040 

You may file a request for a "fast complaint" (expedited grievance) if you disagree with our decision not to process your request for a "fast response" to a coverage decision or appeal. If you request a fast complaint, we must give you an answer within 24 hours. 

If you have a complaint about your quality of care, you may file a grievance with the plan by calling Member Services and filing the complaint over the phone. The plan Quality Team will research the complaint and send a response to you. You may also file a grievance with Arizona's Quality Improvement Organization, Livanta by: 

• Phone: 1-877-588-1123 (TTY 1-855-887-6668) 

• Fax: 1-833-868-4063 

• Mail: Livanta LLC 
  BFCC-QIO 
  10820 Guilford Road, Suite 202 
  Annapolis Junction, MD 20701-1105 

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). 

Appeals 

If you are notified of a coverage determination denial by Mercy Care Advantage, you or your appointed representative may submit a redetermination request (1st level of appeal) within 60 calendar days from the date of the written notice. You may submit an appeal after this time frame if you have good cause.  

You may submit a redetermination request by calling Mercy Care Advantage or sending a request in writing. You or your physician may request a fast (expedited) appeal if it is believed that applying the standard time frame could seriously affect your health. If Mercy Care Advantage does not agree, you will be notified, and your redetermination will be automatically moved to the standard process.  

Because Mercy Care Advantage denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our "Notice of Denial of Medicare Prescription Drug Coverage" to ask us for a redetermination.  

Coverage Redetermination forms 

Online Coverage Redetermination form - English

Online Coverage Redetermination form - Español

Print Coverage Redetermination form (PDF)

Multi-language interpreter services (PDF)

Who may make a request: Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative. 

You can submit a redetermination request by: 

• Phone: Call ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711).  

• Fax: 1-855-230-5544

• Mail: Mercy Care Advantage  
  Attn: Part D Appeals  
  Pharmacy Department  
  4750 44th Place, Suite 150  
  Phoenix, AZ 85040 

When you or your representative requests a redetermination, a special team will review your request, collect evidence and findings that the denial was based on and any additional evidence from you or your doctors. The case will then be reviewed by a different physician than the one who made the original determination. Mercy Care Advantage will notify you and your doctor of the redetermination decision, following the time frames below. 

If Mercy Care Advantage fails to make a redetermination decision and notify you within the time frame, Mercy Care Advantage must submit your redetermination case file to IRE for review. Mercy Care Advantage will notify you if this action should occur. You have the right to a timely redetermination (see table below) and may file an expedited grievance if we do not notify you of our decision within this time frame (see Grievances). 

If Mercy Care Advantage notifies you of an unfavorable decision, and you disagree, you may submit a reconsideration request (second-level appeal) to the Independent Review Entity. Additional instructions will be included in the written notice. 

Appeals  

1. Redetermination by Mercy Care Advantage  
   
   Standard appeal  
   Upon receipt of your appeal (redetermination), the Appeals Unit Coordinator will gather evidence on the basis of the denial of the Part D prescription drug, and additional evidence from you or your representative and prescribing doctor. Your appeal will be evaluated by a clinical expert. Mercy Care Advantage will notify you by telephone as fast as your health condition requires but not later than 7 calendar days from the receipt of the appeal.
   
   Expedited appeal 
   You or your doctor may request Mercy Care Advantage to expedite your appeal if it believes that waiting for the standard time frame will cause you serious harm. Mercy Care Advantage will notify you of the decision by telephone as fast as your health condition requires but not later than 72 hours after receipt of your appeal. If Mercy Care Advantage does not agree that your appeal requires a fast review, you will be notified that the standard time frame will be applied. 

2. Reconsideration by Independent Review Entity (IRE) 
   
   Standard appeal  
   If Mercy Care Advantage upholds the original denial for your prescription drug, you may send your appeal to the CMS-contracted IRE within 60 calendar days of the Mercy Care Advantage notice. The IRE will review your appeal and make a decision within 7 calendar days. 
   
   Expedited appeal 
   You may file a fast appeal with the IRE if you or your doctor believes that waiting for the standard time frame will cause you serious harm. The IRE will review your appeal and notify you if they do not agree that your appeal requires a fast review and will apply the standard time frame. If the IRE agrees, they will notify you of their decision within 72 hours from the time your appeal was received. 

3. Hearing with Administrative Law Judge (ALJ)
   
   Standard appeal  
   If the IRE decision is unfavorable and the amount in dispute meets the requirements, you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE. 
   
   Expedited appeal 
   Same as standard appeal.  

4. Review by Medicare Appeals Council (MAC)  
   
   Standard appeal  
   If the ALJ decision is unfavorable, you may appeal to the MAC, which is within the Department of Health and Human Services. The MAC oversees the ALJ decisions. 
   
   Expedited appeal 
   Same as standard appeal.  

5. Federal District Judge  
   
   Standard appeal   
   If you do not want to accept the decision, you might be able to continue to the next level of the review process. It depends on your situation. Whenever the reviewer says no to your appeal, the notice you get will tell you whether the rules allow you to go on to another level of appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. 
   
   Expedited appeal  
   Same as standard appeal.  

More information on appeals 

The prescription drug coverage expedited appeals (redetermination) process  
You may file a request for an expedited appeal for drug coverage if you believe that applying the standard appeals process could jeopardize your health. If Mercy Care Advantage decides that the time frame for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited. 

1. You, your appointed representative or your doctor or other prescriber can request an expedited appeal. An expedited request can be submitted orally or in writing to Mercy Care Advantage and your doctor or other prescriber may provide oral or written support for your request for an expedited appeal.  
2. Mercy Care Advantage must provide an expedited appeal if it determines that applying the standard time frame for making a determination may seriously jeopardize your life or health or your ability to regain maximum function. 
3. A request made or supported by your doctor or other prescriber will be expedited if he/she tells us that applying the standard time frame for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.  

Please see Chapter 9, Section 7 of the Evidence of Coverage on this page for more information about Part D prescription drug coverage determinations and appeals.  

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711).