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Your Prescription Drug Coverage

Here’s some important information about your pharmacy and drug coverage under the Commonwealth Care Alliance Senior Care Options and One Care programs.

  • Cost

    As a Commonwealth Care Alliance member, you have no costs for your prescription drug coverage.

  • Formulary (List of Covered Drugs)

    We'll cover the drugs listed in our formularies as long as they are medically necessary. Drugs in the Commonwealth Care Alliance formularies are selected with the help of a team of healthcare providers. For a complete list of covered drugs review the plan's formulary:

    Senior Care Options List of Covered Drugs
    Senior Care Options MassHealth-Only List of Covered Drugs
    One Care List of Covered Drugs

  • Mail-order options

    Our Senior Care Options and One Care programs offer the option of a mail-order pharmacy service. The drugs available for mail-order service are generally drugs that you take on a regular basis for a chronic or long-term medical condition. Many of our network pharmacies offer home delivery service.

  • Out-of-network coverage

    In limited circumstances, we will cover prescriptions filled at an out-of-network pharmacy. These circumstances may relate to when you travel or need urgent or emergency care, or if a network pharmacy or particular drug is not available.

  • How to fill a prescription

    To fill a prescription for a covered drug at a network pharmacy, all you have to do is show your Commonwealth Care Alliance Member ID card. If you do not have the card with you at the pharmacy, you may have to pay the full cost of the prescription. If this happens, you can submit a claim for reimbursement to us. To find out how to submit a claim, look in your Evidence of Coverage (Member Handbook) or call our Member Services team at 866-610-2273 (TTY 711).

  • Medicare

    Commonwealth Care Alliance is a Medicare and MassHealth contractor offering prescription and over-the-counter drug benefits. Enrollment entitles you to coverage of those drugs and over-the-counter items that you would normally receive under Medicare and MassHealth.

    Please keep in mind:

    • Medicare Part A covers hospital care drugs
    • Medicare Part B covers drugs you get at a doctor’s office
    • Medicare Part D covers outpatient prescription drugs
  • Hospital stays

    If you're admitted to a hospital, we will cover your prescription drugs under your medical benefit. When you are released from the hospital, we will cover your prescription drugs under your outpatient drug benefit.

  • Generics and brand-name drugs

    A generic drug has the same active ingredient formula as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

  • Explanation of Benefits

    When you use your prescription drug benefits at a pharmacy, we will send you an Explanation of Benefits statement, containing information about:

    • The prescription drugs that you get from our programs
    • The amount of money that our programs pay for your drugs
    • How to request an exception and how to appeal our coverage decisions
    • Changes that will occur to the drug formulary (covered drug list) at least 60 days in the future


Changing a prescription


If you’d like to change a prescription, you can ask us if we cover another drug used to treat your condition. If we do cover other drugs, talk to your doctor about whether any of these drugs is an option for you. If your doctor tells you that none of the drugs we cover for your condition is medically appropriate, you have the right to request a formulary exception from us.


Best Available Evidence policy


Commonwealth Care Alliance works with the Centers for Medicare & Medicaid Services (CMS) to ensure that your Low-Income Subsidy status is accurate. We achieve this with the Best Available Evidence policy. However, because all members pay $0 copayments for medications, this Low-Income Subsidy status and Best Available Evidence policy do not have an effect on how much you pay for medications. All members pay $0 for medications regardless of your Low-Income Subsidy status. For more information, click here* to visit the CMS website.



To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader* software on your computer.

*When you click this link, you will leave Commonwealth Care Alliance’s website.



 
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Formulary Exception