4-tier QHP full formulary (2022)

4-tier QHP full formulary (2021)
4-tier QHP full formulary (2020)
4-tier QHP full formulary (2019)

Employer- Group: Large employers (>50 employees)

Complete formularies:
4-tier full formulary
3-tier full formulary
2-tier full formulary

Quick reference guide:
4-tier quick reference
3-tier quick reference
2-tier quick reference

Employer- Group: Small employers: (<50 employees) Qualified Health Plans (QHP’s)

4-tier QHP full formulary

The website formulary files are updated on a continuous basis.  Please check back regularly to ensure you are aware of any changes to the formulary.

Please contact MercyCare’s customer service department at (800) 895-2421 if you wish to receive a printed copy of any formulary.

Prescription Benefit Portal

MercyCare members can log onto this secured site to access a host of medication related topics, including:

Search network pharmacies
Pharmacy claim information
Drug information
Drug pricing
Medical condition information
Copay information
Explanation of benefits for prescription drug benefits
Drug spend amount for prescription drug benefits

Forms/ Information

Prior authorization forms To submit form and start the prior authorization process click  
Explanation of drug plans
Prescription drug policies and coverage criteria
Mail order program
Specialty pharmacy
Preferred medication list for provider administered medications
IL uniform prior authorization form for prescription drug benefits

Med Sync Program

Medication Synchronization is offered at both Riverside and Mall Pharmacies – allowing patients fewer trips to the pharmacy as most of their medications are due on the same monthly / quarterly cycle. Med Sync can be compared to an automatic refill program. Mercy pharmacists work with each patient to align their medication to a 30 or 90 day refill cycle. Patients are then contacted before their refills are due to make sure there have not been any changes to their therapy. Mercy pharmacy then gets the prescriptions ready for delivery to the patient in their preferred method – either pick up at the pharmacy or mailed to their home. This leads to better adherence rates, and it is convenient for patients as they make less trips to the pharmacy. Med Sync also eliminates the need to call the pharmacy to order your refills. There is no additional cost to Med Sync – if shortened fills are needed to align the medications, MercyCare also prorates the copay for those fills.

Prescription Drug Claim Forms

Foreign claim – direct member reimbursement
Compound claim
Direct member reimbursement
OTC-COVID 19 at home test claim – direct member reimbursement

Explanation of drug plans

Two-tiered drug plan

This drug plan has an extensive list of covered prescription medications divided into two tiers. Tier-1 is the lowest co-pay level and includes preferred generics and over-the-counter medications. Tier-2 is the higher co-pay level and includes preferred brands.  All medications listed in the formulary have been reviewed for safety and effectiveness and are chosen by a committee of physicians and pharmacists.

Three-tiered drug plan

The list of medications has been divided into three tiers. Tier-1 is the lowest copay level and includes preferred generics and over-the-counter medications.  Tier-2 is the higher copay level and is composed of preferred brands. Tier-3 is the highest co-pay level and includes non-preferred brands and generics. All medications listed in the formulary are reviewed for safety and effectiveness and chosen by a committee of physicians and pharmacists. Other changes may occur to this formulary as determined by MercyCare Health Plans.

Four-tiered drug plan

This four-tiered drug plan incorporates four levels of benefits. Tier 1 is for preferred generic drugs, preferred tier 1 brand name drugs, and covered over-the-counter (OTC) drugs, and has the lowest co-payment. Tier 2 covers selected generic drugs and our preferred tier 2 brand name drugs, and has the second lowest co-payment. Tier 3 represents all non-preferred drugs, except specialty drugs, and has the third lowest co-payment. Tier 4 covers only selected generic drugs, selected brand name drugs, specialty drugs, and clinically-appropriate non-covered drugs by approval, and has the highest co-payment. This drug plan is a closed formulary, which means that only those drugs listed in the formulary are available to our members. All medications listed in the formulary are reviewed for safety and effectiveness and chosen by a committee of physicians and pharmacists. Other changes may occur to this formulary as determined by MercyCare.

Prescription drug benefits are not available for the following:

  • Replacement of any lost, stolen or destroyed medications
  • Fertility drugs
  • Therapeutic devices or appliances including hypodermic needles or syringes (except for diabetic supplies)
  • Any drug or medicine administered or delivered to you by the prescriber
  • Any drug or medicine taken by or administered to you while a patient in a licensed hospital, rest home or sanitarium, extended care facility, convalescent hospital, skilled nursing facility or similar institution
  • Any drug labeled “Caution: limited by Federal Law to investigational use” or wording having similar intent; or experimental drugs, even though a charge is made to you, except that coverage shall be provided for any prescription drug which meets the following criteria:
    1. Is prescribed for the treatment of HIV infection or illness or medical condition arising from or related to HIV infection; AND
    2. Is approved by the Federal Food and Drug Administration (FDA), including phase-3 investigational drugs; AND
    3. If the drug is an investigational new drug, is prescribed and administered in accordance with the treatment protocol approved by the FDA for the investigational new drugs.
  • Anabolic steroids
  • Anti-obesity and anorexients
  • Growth hormones
  • Any prescription drug for a non-covered procedure
  • Any prescription drug for a sickness or bodily injury not covered by your plan
  • Medication other than prescription drugs with or without a prescription order
  • Prescription drugs, which the eligible person is entitled to receive without charge from any worker’s compensation laws or any municipal state or federal program
  • Nutritional supplements
  • Any prescription drugs dispensed to prior to the effective date of coverage under the plan or after the termination date
  • Any drug used for cosmetic treatment of the aging process
  • Any drug used for treatment of hair loss
  • Any medication or device used to obtain, treat or enhance sexual performance and/or function, including dysfunction caused by organic diseases
  • Any prescription drugs administered by injection, except for insulin injections and injections approved by the plan’s pharmacy and therapeutics committee and covered under the pharmacy benefit
  • Homeopathic medications
  • Special formulations of covered drugs such as sustained release intended primarily for convenience
  • Special packaging of covered drugs intended primarily for convenience
  • Tretinoin topical (e.g., Retin A), for members over the age of 40