Presbyterian Medicare Advantage Formularies
This formulary is a list of covered drugs selected by Presbyterian Senior Care (HMO), Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Presbyterian Senior Care (HMO), Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Presbyterian Senior Care (HMO), Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO network pharmacy and other plan rules are followed.
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Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization
Presbyterian Senior Care (HMO), Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO requires you or your provider to get prior authorization for certain drugs
Quantity Limits
For certain drugs, Presbyterian Senior Care (HMO), Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO limits the amount of the drug that Presbyterian Senior Care (HMO), Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO will cover.
Step Therapy
In some cases, Presbyterian Senior Care (HMO), Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
Can the formulary (drug list) change?
Presbyterian Medicare Advantage Formulary may change during the year. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except when a drug has been found to be unsafe, ineffective, or you can save additional money. All changes will be listed in the Notification of Formulary Changes
What if my drug is not on the formulary?
If your drug is not included in this formulary (list of covered drugs), you should contact the Presbyterian Customer Service Center and ask if your drug is covered.
or (TTY ) Hours: 8 a.m. to 8 p.m., Sunday - SaturdayIf you learn that our plan does not cover your drug, you have two options:
You can ask customer service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.
You can ask Presbyterian Senior Care (HMO), Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), or Presbyterian MediCare PPO to make an exception and cover your drug. Drug formulary exception can be requested by phone, fax, mail, or online.