Formulary & Prescription

Information provided for Community y Más (HMO C-SNP), a Medicare Plan, is for the current benefit year. It is intended to be a summary of the plan. If you need a complete explanation of benefits, services and costs associated with this plan please refer to your Member Handbook.

Community y Más Drug Lookup Tool

You can use the drug lookup tool to search our online formulary to see if your medications are covered and what pharmacies you can go to. Please click on the link below to access our Drug Lookup Tool. You will then have to select your income level (based on a family size of 1) to get the most precise drug cost detail.

Drug Lookup Tool

Certain pharmacies are not available to all members (Home Infusion, Long-Term Care, Indian Health and Specialty). This pharmacy listing does not guarantee that the pharmacy is still in the network. Please contact the Member Services Department at 1-800-232-3133 (TTY 1-855-266-4584 for more information about the pharmacies in our network.

Part D Program

In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies, these are pharmacies that contract with Community y Más to provide your covered prescription drugs. There are some retail pharmacies in Community y Más where you can obtain an extended supply of all medications.

To locate a retail pharmacy in Community y Más network, please call Member Services or review the pharmacy listing.

Community y Más has contracts with over 400 pharmacies that equal or exceed Medicare requirements for pharmacy access in the Plan's approved service area.

Filling prescriptions outside the network

In most cases Community y Más only covers drugs filled at an out-of-network pharmacy when a network pharmacy is not available or in case of an emergency.

If you fill your prescription at an out-of-network pharmacy, you may be responsible for paying the full cost of the prescription. You may request Community y Más to reimburse you for your share of the cost by submitting a claim form to the following address:

Community y Más
Attention: Pharmacy & Formulary
2420 Fenton Street, Suite 100
Chula Vista, CA 91914

Mail Order Pharmacy Service

You may obtain maintenance medications through Community y Más mail-order-pharmacy service. These are prescription drugs that you take on a regular basis for a chronic or long-term medical condition. Please note that these are the only drugs available through our mail-order service.

When you order prescription drugs through Community y Más mail-order-pharmacy service, you must order at least a 31-day supply, and no more than a 93-day supply of the drug. Generally, it takes the mail-order pharmacy 10 days to process your order and ship it to you.

Best Available Evidence

To access the CMS “Best Available Evidence Policy”, please click on the following link. You will be directed to the CMS Website.

Best Available Evidence (BAE)

2024 List of Covered Drugs (formulary)

Community y Más will cover the drugs listed in our formulary as long as the drug meets the following criteria:

• It is Medically necessary,

• it is filled at a network pharmacy, or

• filled through our network mail-order-pharmacy service, and

• all coverage rules are followed.

The list of covered drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

What drugs are on the 2024 List of Covered Drugs (Formulary)?

If you need a copy of the drug formulary, or for the most recent list of changes, please contact the Member Services Department at 1-800-232-3133 (TTY 1-855-266-4584).  Community y Más representatives are available 24 hours a day, 7 days a week, including holidays. To find out if your drug is on the formulary, please click on the 2024  List of Covered Drugs link to view the additional information regarding Community y Más Formulary. The first part of this formulary booklet tells you how to find a drug on our most recent formulary list.

Click on the following link to access the most recent Formulary/Medication Listing.

• List of Covered Drugs (Formulary) (English)
• List of Covered Drugs (Formulary) (Spanish)
• List of Covered Drugs (Formulary) (Arabic)
• List of Covered Drugs (Formulary) (Vietnamese)
• List of Covered Drugs (Formulary) (Tagalog)
• List of Covered Drugs (Formulary) (Chinese)
• List of Covered Drugs (Formulary) (Farsi)

Important Message About What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.

Important Message About What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.

Over-The-Counter Benefits Catalog

Community y Más members have a new OTC benefit for 2024. You will get $155 every quarter (three months), including tax, to spend on OTC items found in your OTC Catalog. Any unused amount will not carry over to the next quarter. Some limitations may apply. Please refer to the OTC catalog for more information or call the Member Services Department at 1-800-232-3133 (TTY 1-855-266-4584).

Over-The-Counter Benefits Catalog 

Over-The-Counter Benefits Catalog - Spanish

Over-The-Counter Benefits Catalog - Vietnamese

Utilization Management (UM) & Quality Assurance UM

There are certain prescription drugs that Community y Más may have additional requirements for coverage or limits. These requirements and limits ensure that Community y Más members use these drugs in the most effective way. These requirements and limits were developed for Community y Más by a team of doctors and/or pharmacists. These requirements were developed to assist us to provide quality coverage to our members.

The requirements for coverage or limits on certain drugs are listed as follows:

Generic Substitution: When there is a generic version of a brand-name drug available, Community y Más network pharmacies will automatically give you the generic version, unless your doctor has requested the brand name drug and we have approved this request. You also have the option to request an exception (coverage determination).

Prior Authorization: Community y Más you to obtain prior authorization for certain drugs. Authorized providers will need to obtain approval from Community y Más before filling your prescription. Your prescription drug may not be covered if prior approval is not obtained from the plan. Please click on the following link to access Community y Más Part D Prior Authorization Criteria:

• Pharmacy Prior Authorization Criteria

Step Therapy: In some cases, Community y Más requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Community y Más may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

• Pharmacy Step Therapy Criteria

Quantity Limits: Community y Más limits the amount of drug that is covered per prescription, or within a specific time frame. Quantity limits are noted within the formulary.

Please call Member Services if you need to find out if the drug you take is subject to these additional requirements or limits. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren't able to meet the additional restriction or limit for medical necessity reasons, you, your physician, or other prescriber may request an exception (coverage determination). See your Member Handbook for more information about how to request an exception.

Quality Assurance

Community y Más conducts drug utilization reviews for all of our members to determine you are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. These are conducted each time you fill a prescription and on a regular basis by reviewing Community y Más. During these reviews, Community y Más looks for the following medication red flags or problems:

• Possible medication errors.

• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.

• Drugs that are inappropriate because of your age or gender.

• Possible harmful interactions between drugs you are taking.

• Drug allergies.

• Drug dosage errors.

If Community y Más identifies a medication red flag or problem during our drug utilization review, we will work with your doctor, or other prescriber to correct it.

Medication Therapy Management (MTM) Program

Community y Más offers a medication therapy management (MTM) program to help you and your doctor(s) make sure that your medications are working to improve your health. This program is not a benefit. It is a voluntary program and is available free of charge to eligible members.

MTM Program Eligibility

Members who have three or more of the following chronic diseases, who take at least eight (8) Part D medications, and whose total 2024 drug cost for the year is expected to exceed $5,330, will be eligible for our program.

• Asthma

• Chronic Obstructive Pulmonary Disease (COPD)

• Congestive Heart Failure (CHF)

• Diabetes

• Hypertension

• Dyslipidemia

• Osteoporosis

• Cardiovascular disease (Anticoagulation, Atrial Fibrillation, Coronary Artery Disease, Peripheral Artery Disease)

Members who are determined to be at risk under the Drug Management Program (DMP), which is related to opioid utilization, will also be eligible for the MTM Program.

MTM Program Enrollment

All eligible members will be automatically enrolled into the MTM program. Eligible members will receive a welcome letter in the mail giving them the opportunity to call and schedule a comprehensive medication review (CMR), or to contact Member Services for any additional questions about the program.

Eligible members may also be contacted by Community y Más’s contracted MTM pharmacists to schedule a CMR.

Purpose and Benefits of the MTM Program

The goal of the program is to help you:

• Get the most from your medications 

• Lower your risk for harmful drug reactions

• Find lower-cost alternatives to your medications

Get answers to your questions about prescriptions and over-the-counter (OTC) medications

Services offered with the MTM Program:

• Comprehensive Medication Review (CMR). This service is provided annually.

• Targeted Medication Review (TMR). This service is provided quarterly.

What is a Comprehensive Medication Review (CMR)?

A CMR is an interactive, person-to-person consultation with a pharmacist to review prescription and OTC medications. The review takes about 30 minutes to complete. After the CMR, the pharmacist will provide a written summary of the discussion which includes a personalized medication action plan and a personal medication list.

A blank copy of the Personal Medication List can be requested by calling Member Services. You can also download a blank copy by clicking on the following link: Personal Medication List

What is a Targeted Medication Review (TMR)?

A TMR is performed quarterly by pharmacists to assess medication use, to monitor whether any unresolved issues need attention, and to determine if new drug therapy problems have come up. The findings from these quarterly reviews can help determine if a follow-up intervention is necessary for the member and/or their prescriber.

Both CMRs and TMRs can be done in person or over the phone.

If you have any questions about our MTM program, please contact Member Services at 1-800-232-3133, TTY/TDD: 1-855-266-4584, 24 hours a day, 7 days a week, for additional information.

Drug Transition Policy

As a new member to Community y Más you may be taking drugs that are not covered by our plan or may have certain restrictions. These may require prior authorization or step therapy. Existing members may be impacted by changes in our formulary from one year to the next. Please review Community y Más Drug Transition Policy, by clicking on the following link:

• Drug Transition Policy

Formulary Changes

Community y Más may make changes to our formulary during the year. Some of the changes may affect covered drugs and how much you will pay when filling your prescription. These changes include:

• Removing or adding drugs from the formulary

• Requiring prior authorizations, changes to quantity limits, and/or step-therapy restrictions on a specific drug

• Moving a drug to a higher or lower cost-sharing tier    

Formulary Changes 02/01/2024       

Formulary Changes 04/01/2024

Formulary Changes 05/01/2024 

Formulary Changes 06/01/2024

What if your drug isn't on the formulary?

If you cannot locate your prescription in Community y Más formulary, please call Member Services to be sure it isn't covered. Once Member Services has confirmed that your drug is not covered, you have the following options:

• You can request your doctor to change you to another drug that is covered in our formulary.

• You can request Community y Más to make an exception to cover your drug.

• You may choose to pay out-of-pocket for the drug and request that Community y Más reimburse you by requesting an exception. Please note that this doesn’t mean that Community y Más will reimburse you if the exception request isn't approved. You may appeal the Plan’s denial, if the exception isn't granted.

Drug Coverage Determination

You, your representative acting on your behalf, your prescribing physician, or other prescriber can request a standard or fast organization/coverage determination. A written request may be made by printing one of the forms below:

• CMS Part D Coverage Determination Request Form

• MedImpact Part D Coverage Determination Form

The completed form should be faxed, mailed, or delivered in person to:

Community y Más
Attention: Pharmacy & Formulary
2420 Fenton Street, Suite 100
Chula Vista, CA 91914

For a fast decision call our Member Services Department at 1-800-232-3133 (TTY 1-855-266-4584). Community y Más representatives are available 24 hours a day, 7 days a week, including holidays.

Community y Más will make timely decisions when you ask us to cover a Medicare Part D prescription drug. A decision about whether Community y Más will cover a Part D prescription drug can be:

• A "standard decision" that is made with the standard time frame (typically within 72 hours)

• A "fast decision" that is made more quickly (typically within 24 hours)

You can ask for a fast decision only if you, your doctor, or other prescriber believe that waiting for a standard decision could harm your health or your ability to function.

Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you have already received.

If we tell you about Community y Más decision not to provide a "fast" review by phone, you can request an expedited grievance at that time if you disagree.

Community y Más will send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a "grievance" if you disagree with Community y Más decision to deny your request for a "fast" review, and will explain that Community y Más will automatically give you a fast decision if you get a doctor's, or other prescriber's explanation.

Please refer to the Member Handbook for more details about this process.

Appeals and Grievances

Community y Más provides an appeals and grievance process for our members to ensure you get answers to any concerns or problems you may encounter. You may also reference the "Complaints and Appeals" Section of the Member Handbook for additional detail regarding Grievances and Appeals.

Appeals

As a member, you can file an appeal if Community y Más made a decision to not pay for, not approve, or stop a service you think should be covered or provided to you. This could include denials for drugs or involve payment for services (billing issues or reimbursement) you received or believe you should receive under the Community y Más pharmacy program. You, your prescribing physician or other prescriber acting on your behalf and upon providing notice to you, or your appointed representative must file a written request for appeal within sixty (60) calendar days from the date of the notice of the coverage determination (i.e., the date printed or written on the notice).

You must send your appeal in writing to:

Community y Más
Attention: Appeals Supervisor
2420 Fenton Street, Suite 100 
Chula Vista, CA 91914 

Or fax to (619) 476-3834 

Community y Más Plan will review your appeal and respond to you in writing advising you of our decision within 30 days of receiving your appeal request. If you think your health could be seriously harmed by waiting for a decision about a service, your prescribing physician or other prescriber can request a faster decision which is issued within 72 hours of receiving your appeal.

In both cases, you will receive a written notice of the outcome of your appeal.

Grievances

A grievance is a type of complaint you make if you are dissatisfied with Community y Más or our contracted providers for reasons other than a coverage decision. Grievances do not involve problems related to approving or paying for Part D drugs. You or your appointed representative may file a grievance about a Part D drug within 60 days of the event or incident. You may file a grievance by contacting the Community y Más Member Services Department toll free at 1-800-232-3133 (TTY 1-855-266-4584). Community y Más representatives are available 24 hours a day, 7 days a week, including holidays. You may opt to submit your Grievance in a letter and send it directly to Community y Más at the following address:

Community y Más
Attention: Grievance and Appeals Supervisor
2420 Fenton Street, Suite 100 
Chula Vista, CA 91914

Or fax to (619) 476-3834

You will receive a written letter telling you that Community y Más received your grievance, and the estimated time for a written response. A written resolution letter will be mailed to you within thirty (30) days of Community y Más receiving your grievance.

For questions about the status of your grievance, call Member Services Department at 1-800-232-3133 (TTY 1-855-266-4584). Community y Más representatives are available 24 hours a day, 7 days a week, including holidays.

For additional information regarding Community y Más grievance process, please see the Member Handbook.

There are two kinds of grievances that you can request:

Expedited (Fast) Grievance (24 hour): You, any doctor, or your appointed representative can ask for a fast grievance if you disagree with Community y Más Cal Plan decision not to give you a fast decision on a medical care issue, or if you disagree with our decision to take a time extension on an initial decision or appeal. Community y Más Plan will respond to this type of grievance by telephone, within 24 hours from the time that we received your complaint and within three calendar days, you will receive a written letter.

Standard Grievance (30 days) is any other type of complaint. Community y Más Plan must respond to you promptly as your medical condition requires, but no later than 30 calendar days after receiving your complaint.

If you are concerned about the quality of care you received, you can also send your complaint to Community y Más Plan, the Quality Improvement Organization (QIO), an independent review organization, or both. The QIO is called Livanta. Complaints to Livanta must be in writing to the following address:

Livanta

BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 207011 

1-877-588-1123 

TTY: 1-855-887-6668 

Livanta California Medicare Beneficiary Complaints Helpline: 1-877-588-1123, or TTY 1-855-887-6668. 

Appointment of Representative

You have the option to appoint a representative to act on your behalf and request a coverage determination, formulary exception, grievance and/or an appeal.

You can name a relative, friend, advocate, doctor, or someone else to act for you. You have the option to appoint a representative to act on your behalf and request a coverage determination, formulary exception, grievance and or an appeal. When completed, this form allows this person legal permission to act as your authorized representative. Please click on the following link to access CMS' Appointment of Representative Form (Form CMS -1696):

• Appointment of Representative Form (English)

• Appointment of Representative Form (Spanish)

The completed form should be faxed, mailed, or delivered in person to:

Community y Más
Attention: Pharmacy & Formulary
2420 Fenton Street, Suite 100 
Chula Vista, CA 91914

Or fax to (619) 476-3834

Electronic Complaint Form

To download a blank copy of the Electronic Complaint Form, click https://www.medicare.gov/MedicareComplaintForm/home.aspx

You may also access additional information on Medicare’s website at https://www.medicare.gov/

Last Website Update 05/01/2024
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