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Prescription Drug Benefits

Part D Prescription Drug Coverage

All SummaCare Medicare Advantage Prescription Drug plans include Medicare Part D prescription drug coverage for no additional monthly plan premium.

Personal Prescription Coverage Information

Log in to review your prescription copay information, mail service details and your prescription history.

Prescription Drug Formulary Information 

What is the SummaCare Medicare Formulary?

The SummaCare Medicare Formulary is a list of covered drugs under each SummaCare Medicare Advantage plan. SummaCare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed.

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

How Does SummaCare Organize Covered Drugs?

SummaCare organizes our covered drugs into six tiers:

  • Tier 1 Preferred Generic
  • Tier 2 Generic
  • Tier 3 Preferred Brand Name
  • Tier 4 Non-Preferred
  • Tier 5 Specialty
  • Tier 6 Select Care Drugs (includes Vaccines)

In addition, SummaCare covers some common non-prescription over-the-counter (OTC) generic drugs at a $0 copay if prescribed by a doctor.

What Drugs Are Covered?

2023 Comprehensive Formulary (Complete list of covered drugs) - Updated March 1, 2023

Drug List Changes Posted January 2022
Drug List Changes Posted May 2022
Drug List Changes Posted May 2022
Drug List Changes Posted June 2022
Drug List Changes Posted July 2022
Drug List Changes Posted August 2022

Can the Formulary Change?

Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

Formulary Information

2023 Prior Authorization Requirements - Updated March 1, 2023

2023 Step Therapy Requirements - Updated March 1, 2023

2023 Transition Process - Updated October 1, 2022 - Effective January 1, 2023

Appeals and Grievances Information

Appeals and Grievances Information

Medicare Part D Prescription Drug Exceptions Process

If your drug is not included in the SummaCare Medicare Part D formulary (list of covered drugs), you can ask SummaCare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

Medication Therapy Management Program

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management program, or MTM.

View 2022 MTM program information.
View the 2023 MTM program information.

Find Your Pharmacy

Learn what pharmacies are in our network and search for pharmacies by using our Find Your Pharmacy tool.

MedImpact: Prescription Drug Mail Service

As a valued SummaCare member, we are happy to offer you a program for getting your routine prescription drugs delivered to your home through Birdi. The Birdi program is designed to reduce costs, ensure satisfaction and improve the convenience of home delivery while helping to manage the costs of your prescription drugs. Learn more about the Birdi program or download and print the Birdi Order Form.

Vaccine Coverage

Most preventive vaccines are covered under Medicare Part D Prescription Drug Coverage while a few are covered under the Part B Medical Coverage. It’s important to know what vaccines are covered, your potential out-of-pocket costs and where to get your vaccine.

Learn more about vaccine coverage.

Questions?  We are here to help.

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