Drug Formulary

  A formulary is a list of drugs selected by Leon Cares in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Leon Cares will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Leon Cares network pharmacy, and other plan rules are followed.

Drug Utilization Management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Please consult your copy of our formulary or the formulary on this website for more information about these requirements and limits. The requirements for coverage or limits on certain drugs are listed as follows:

Prior Authorization
  Prior Authorization - Leon Cares requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Leon Cares before you fill your prescriptions. If you don’t get approval, Leon Medical Centers Health Plans may not cover the drug.

Quantity Limits
  Quantity Limits - For certain drugs, Leon Cares limits the amount of the drug that Leon Cares will cover. For example, Leon Cares provides 30 per prescription for VYTORIN. This may be in addition to a standard one month or three month supply.

Step Therapy
  Step Therapy - In some cases, Leon Cares 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 A and Drug B both treat your medical condition, Leon Cares may not cover drug B unless you try Drug A first. If Drug A does not work for you, Leon Cares will then cover Drug B.

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. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 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 60-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. To get updated information about the drugs covered by Leon Medical Centers Health Plans - Leon Cares, please call Member Services at 1-866-393-5366, TTY 711, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays.  

Formulary Change Notification Effective January 1, 2019