Formulary
Formulary is a list of all the drugs that are covered by an insurance plan. In general, the drugs listed in the formulary are covered as long as the drug is medically necessary, the prescription is filled through a network pharmacy or network mail order facility (when applicable), and other coverage rules are followed. For some drugs, there are additional requirements or limits to coverage.
The drugs on formulary are selected by drug plan and health professionals. The formulary drugs are then verified by a Pharmacy and Therapeutics Committee, consisting of independent physicians and pharmacists.
Not all drugs are included on the plan formulary. In some cases, drugs are excluded from benefit coverage. In other instances, a combination of clinical and economic criteria was used to decide not to include a particular drug on the plan formulary.
Managed Health Services (MHS) has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.
Please click here for the Medicare Prescription Drug Coverage Determination Request Form. Or if you are a provider requesting on behalf of the member, you can use the MHS prior authorization request form, click here.
You cannot use this form for Medicare non-covered drugs including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). (Please note: By clicking on this link you will be leaving the Advantage by Managed Health Services HMO SNP (Advantage by MHS) website.)
