A Healthy CollaborationSM

Frequently Asked Questions for Members

1. What if my drug is not on the formulary?

If your prescription is not listed on our formulary, you should first contact Member Services to be sure it is not covered. If Member Services confirms that we do not cover your drug, you have three options:

  • Community CCRxSM can help you find another drug to treat your medical condition that is part of our formulary.

  • You can ask us to make an exception and cover your drug.

  • You can pay out of pocket for the drug and request that the plan reimburse you.

2. How can I request an exception to Community CCRx's formulary?

You can ask us to make an exception to our coverage rules. Access our process and form for filing an exception.

3. Are there any restrictions on my coverage?

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

Prior Authorization: Community CCRx requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from before you fill your prescriptions. If you don’t get approval, may not cover the drug.

Quantity Limits: For certain drugs, Community CCRx limits the amount of the drug that will cover. For example, Community CCRx provides 30 tablets per prescription for simvastatin per 30-days. This may be in addition to a standard one month or three month supply.

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

You can find out if your drug has any additional requirements or limits by searching the formulary.

4. What are my rights and protection under Community CCRx?

Because you have Medicare, you have certain rights to help protect you. This section will enable you to access explanations of your Medicare rights and protections as a member of Community CCRx. We will tell you what you can do if you think you are being treated unfairly or your rights are not being respected. Learn more about your rights and protection under Community CCRx.

5. Does Community CCRx have materials that are in Spanish?

Yes, Community CCRx has Spanish materials available, such as the 2009 Summary of Benefits. You can request that Spanish materials be mailed to you by calling 1-866-566-8741 (TTY for the hearing impaired: 1-866-684-5351) 8 a.m to 8 p.m., everyday. A Community CCRx representative will be happy to help you.

S5803_09P0008_v1 (04/2009) Last Updated: 04/01/2022

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