Pharmacy

McLaren Advantage Pharmacy

With McLaren Advantage® (HMO), we offer more of the prescription drugs you need. We provide access to more than 63,000 pharmacies, which are listed in the Pharmacy Directory.

McLaren Advantage uses a Preferred Drug List (formulary) to show the drugs we prefer that your doctor prescribe. Some drugs are not covered by Medicare prescription drug coverage. Some drugs may also have amount limits or require step therapy. For a list of prescription drugs requiring Prior Authorization, please select the Drugs requiring Prior Authorization. Also for a list of the drugs that require step therapy, please select the Drugs requiring Step Therapy.  Click here for the Transition Fill Policy.

McLaren will coordinate your medical care and your prescription drug needs so you can focus on other things in your life. McLaren's Medicare Prescription Drug Benefit is only available to members of the McLaren Advantage plan.

We know you have a lot of questions about prescription drug benefits. Here are some questions we are often asked:


How do I find out if my drug is covered?

You may view our online Preferred Drug List (formulary) to see if a drug is covered or can call our Customer Service Department at (888) 327-0671, Monday through Friday, 8 a.m. to 8 p.m. (TTY users should call 711).

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How do I find a pharmacy?

You may look in the Pharmacy Directory

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Does McLaren Advantage offer mail order services?

For your convenience, McLaren Advantage partners with 4D Pharmacy Services, our Pharmacy Benefits Manager to offer mail order services. When you use these services, your Medicare prescriptions are delivered to you free of charge for regular delivery.

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Will the Preferred Drug List (formulary) change?

We may add or remove drugs from the formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. If we remove drugs from the formulary, or add Prior Authorizations, quantity limits and/or step therapy restrictions on a drug, and you are taking the drug affected by the change, we will notify you of the change at least 60 days before the date that the change becomes effective. If we don’t notify you of the change in advance, you will get a 60-day supply of the drug when you request a refill of the drug. However, if a drug is removed from our formulary because the drug has been recalled from the market, we will not give 60 days notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members about the change as soon as possible.

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Do you offer generic drugs?

McLaren Advantage covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a 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.

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Will I have a co-pay for my prescription drugs?

Yes, co-pays may vary by drug. See your 2017 Summary of Benefits for more information.

If you think you are being charged an incorrect co-payment for your prescription drugs, please contact our Customer Service Department at (888) 327-0671, Monday through Friday, 8 a.m. to 8 p.m. (TTY users should call 711). You may also read the Centers for Medicare and Medicaid Services’ (CMS) Best Available Evidence Process to get information.

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How do I find out if I am eligible to receive additional help to pay for my prescription drug costs?

You may be able to get extra help to pay for your prescription drug premium and costs. To see if you qualify for getting extra help, call:

  • 1-800-MEDICARE ((800) 633-4227). TTY/TDD users should call (877) 486-2048, 24 hours a day/7 days a week);
  • The Social Security Administration at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778;
  • Your State Medicaid Office

    *For more premium information, see LIS Premium Summary Chart.   

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What is a network pharmacy?

We call the pharmacies listed in the Pharmacy Directory our “network pharmacies” because we have agreements with them to provide prescription drugs to our members. A network pharmacy is a pharmacy where members can get prescription drug benefits provided by McLaren.

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What is Step Therapy?

In Step Therapy, certain drugs are put into groups to help your doctor decide which drugs to prescribe. The steps in the process are:

  • Step 1: Front-line drugs are generic drugs proven safe, effective and affordable. These drugs should be tried first because they can provide the same health benefit as more expensive drugs, at a lower cost.
  • Step 2: Back-up drugs are lower-cost brand-name drugs such as those you see advertised on TV.
  • Step 3: Back-up drugs that are higher-cost brand drugs. Back-up drugs may be used when lower cost alternatives do not meet a member’s needs.

For a list of the drugs that require step therapy, please select the Plan Step Therapy List.

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What are Quantity Limits?

For certain drugs, McLaren Advantage® (HMO) limits the amount of the drug that McLaren Advantage will cover. For example, McLaren Advantage provides 30 tablets per 30 days per prescription for Atorvastatin 80mg. This may be in addition to a standard one-month or three-month supply.

You can find out if your drug has any additional requirements or limits by looking in the Preferred Drug List (formulary).
 
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How will the Transition Period requirement be handled?

For those members who are new to the plan and aren’t in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.

For those who are a new member and a resident in a long-term care facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31 days, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.

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Do you require Prior Authorization?

If your doctor feels it is medically necessary for you to have a drug that is not on the list, he or she will need to ask for a Prior Authorization. Providers can use the Pharmacy Coverage Determination Form to make a Prior Authorization Request. For a list of prescription drugs requiring Prior Authorization, please select the Drugs requiring Prior Authorization

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Are the doctors in your network aware of your prescription drug benefits?

Yes, participating McLaren physicians have been notified in writing of the drugs included on the Preferred Drug List (formulary)

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What if I have to use an out-of-network pharmacy?

In most cases, your prescriptions are covered under McLaren Advantage only if they are filled at a network pharmacy. Please see the Pharmacy Directory for more information. Please contact the plan for details regarding out-of-network prescription drug fills.

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How do I file a grievance or appeal a decision about my prescription drug benefits?

A grievance is a complaint that shows you are not satisfied with the plan or pharmacy’s service. To find out how to file a grievance, appeal a decision, request an exception, or redetermination please call our Customer Service Department at (888) 327-0671, Monday through Friday, 8 a.m. to 8 p.m. (TTY users should call 711).

Click this link for the Redetermination Form

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How do I find out about McLaren Advantage’s programs for drug safety and managing my medications?

McLaren has established Quality Assurance programs to ensure that medications are safely and appropriately provided to our members. To find out more, please view the Evidence of Coverage.

Through our Medication Therapy Management program, we assist members with complex medical conditions, who take several medications, and who meet certain eligibility criteria to ensure that the medications they take work best for them and that they understand how they work. This program is free to members. To learn more about the Medication Therapy Management program, please visit our Medication Therapy Management page or the or the Evidence of Coverage.

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How do I request a Coverage Determination?

Please complete the Online Rx Coverage Determination Form

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H0141_MIMHMO240
Pending CMS Approval
Last Updated 12/29/2016

Please Note: There may be links on the McLaren Advantage website that takes you to non-McLaren Advantage information. By clicking these links you will be leaving the McLaren Advantage web pages.