2023 Formulary Restrictions

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization: The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Care N’ Care before you fill your prescriptions.  If you don’t get approval, we may not cover the drug.   These drugs are listed in the drug formulary with the symbol “PA”.
    • Download the Prior Authorization Criteria document: English
    • Download the blank Prior Authorization request form document: English (Coming Soon)
  • Quantity Limits: For certain drugs, the Plan limits the amount of the drug that we will cover. For example, Care N’ Care provides 30 tablets per prescription for Januvia 100mg tablets.  This may be in addition to a standard one-month or three-month supply.  These drugs are listed in the drug formulary with the symbol “QL” followed by the quantity and day supply limitation.  To find out if your medication has a Quantity Limit, please search for the medication on the Medication Look Up page or download the Comprehensive Formulary under the Plan Documents.
    • Download the blank Quantity Limit Exception request form: English
  • Nonformulary Exception Request: You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. For more information, please see your Evidence of Coverage document located on the Plan Documents
    • Download the blank Nonformulary Exception request form: English
  • Tier Exception Request: You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. For more details on which drugs you can request this type of exception, please see your Evidence of Coverage document located on the Plan Documents
    • Download the blank Tier Exception request form: English

If you are not sure which form to use, you can complete a general request form called the Request for Medicare Prescription Drug Coverage Determination Form.

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