MedStar Family Choice
District of Columbia- Healthy Families
Frequently Asked Questions about Pharmacy
What is a Formulary?
A formulary is a list of medicines. The MFC Formulary is the list of medicines that are routinely available for members of MFC. We say these medicines are “formulary” or “on the formulary.” Other medicines not on the list are called “non-formulary.” You can find a copy of the MFC Formulary listing on this website. Your practitioner should be familiar with the medicines that are on the formulary. If you are prescribed a medicine by mistake that is not on the formulary, we will sometimes ask the prescriber to change the prescription to a formulary medication. If you need a medicine that is not listed on the formulary, there is a process for your practitioner to make a special request for it. The special process is called a ‘Medical Exception’ request. It is used to when you need a non-formulary medicine or other special request. If you are told by a pharmacist that MFC will not allow your prescription to fill, you should contact your practitioner or MFC and start the “Medical Exception” process.
How do I get help with a pharmacy problem?
You can call us from 8:00 AM to 5:30 PM, Monday through Friday at 1-888-404-3549. If you need a medicine in an emergency when we are closed, please have the PHARMACIST call 1-855-210-6203 to get instructions on how to reach the person on call.
What drugs need our approval?
A list of all the drugs that need our approval is in the front section of our ‘Formulary’ in the section called ‘Prior Authorization.’ Non-formulary medicines will need approval, too. Your doctor will need to submit information to us to get the approval.
What does it mean if a medicine is on Step Therapy?
It means that MFC expects you to have tried one medication (or more) before you can fill the medicine on the step therapy. For example, Crestor® is on step therapy. It is a brand name medicine used to treat high cholesterol. There are several other generic medicines on the formulary for treating high cholesterol that MFC would expect you to try before moving up to Crestor®. If you are having a problem filling a medication on step therapy you should call you practitioner or MFC for assistance.
What does it mean when a medicine is an “over-the-counter” medicine?
An over-the-counter medicine is a medicine that you can usually buy at a drug store without a prescription. Examples of over-the-counter medicines are aspirin, medicines for coughs and colds, ointments for rashes, and many others.
Are over-the-counter medicines covered?
Yes, there are a lot of these medicines on the formulary. There is a list of them in the front section of the “Formulary” document in the section called “Over-the–Counter (OTC) Drug Coverage”. You will need a prescription from your practitioner to use your MFC card to pay for over-the-counter medicines. Your practitioner can write, call or fax the prescription to the pharmacy. There can be refills if your practitioner includes that with the prescription. Plan B emergency contraception for women and condoms do not need a prescription. Ask the pharmacist for help with which kinds are covered.
What happens if I get a prescription for a medicine that is not listed in the Formulary?
If you need a medicine that is not listed, your doctor will need to send information to us by telephone (202-243-5400 or 855-210-6203) or by fax (202-243-5405) to request a “Medical Exception.”
What happens if I get a prescription for a medicine that is not covered?
If a medicine is in the ‘not covered” group, MFC will not pay for it. There are very few medicines that are not covered. An example of a medicine that is not covered is diet pills. If a medicine is not covered, you will have to pay for it.
Are there limits to prescriptions?
Most medicines are limited to a one month supply. Refills can be written for twelve months. Some medicines have quantity limits. This means that only a limited number of pills or tablets are allowed for a period of time. MFC sets the limits based on recommendations for safety from the Food and Drug Administration.
What if you need two prescriptions for the same medicine at the same time, for example, one for home and one for school?
You can obtain two prescriptions, but it is a special request. You should contact your doctor. Your doctor’s office needs to call us and we will approve the second medicine.
What if I am planning to go out of town for a long period of time?
You can have medicine for when you travel, but it is a special request. You doctor’s office needs to call us. MFC has a policy that says you may only get one extra month’s supply for travel.
What if my medicine is lost or stolen?
If it is lost or stolen, you will need a new prescription. Your doctor’s office needs to call us and we will replace the medicine. If the medicine is a pain medicine (narcotic), we may ask to see a police report.
Will the pharmacist give me a generic medication?
Yes, a pharmacist is required to give you a generic version of the medication if one is available. Generic medications contain the same active ingredient at the same dosage strength as a brand medicine. They are the same as the brand medication. The MFC pharmacy network will only dispense generic medications with an “A” rating by the Food and Drug Administration. An “A” rating means that the generic drug has been tested and is equal in strength and safety to the brand medication.
How can I get a brand name medicine?
For MFC to approve a brand name medicine when a generic version is available, the doctor needs to send information about why you cannot take the generic medicine.
Can a therapeutic substitution be made by the pharmacist or by MFC?
A therapeutic substitution is when a similar medicine is given to you by the pharmacy. Pharmacists in the District of Columbia are not allowed to perform a therapeutic substitution.
What should I do if I paid for a medicine myself but I think it should have been paid for with my MFC card?
Sometimes, but not always, you can get your money back from MFC. You can call us from 8:00 AM to 5:30 PM, Monday through Friday at 1-888-404-3549. We will review the situation and give you advice on what you need to do.