Pharmacy Frequently Asked Questions

MedStar Family Choice District of Columbia (MFC-DC)
DC Healthy Families
Frequently Asked Questions about Pharmacy

What is a Formulary?  

A formulary is a list of medicines. The MFC-DC Formulary is the list of medicines that are routinely available for enrollees of MFC-DC. 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-DC 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. If you are told by a pharmacist that MFC-DC will not allow your prescription to fill, you should contact your practitioner or MFC-DC and ask to start the process of a “Non-Formulary Medication Request.

How do I get help with a pharmacy problem?

You can call us from 8:00 a.m. to 5:30 p.m., Monday through Friday at 888-404-3549. If you need a medicine in an emergency when we are closed, please have the pharmacist call 855-210-6203 to get instructions on how to reach the pharmacy nurse on call.

What drugs need our approval?

A list of all the drugs that need our approval before they will fill at the pharmacy is in the front section of our ‘Formulary’ in the section called ‘Prior Authorization.’ Non-formulary medicines will need approval, too. Your practitioner 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-DC expects you to have tried one medication (or more) before you can fill the medicine on the step therapy. For example, Sklice® is on step therapy. It is a brand name medicine used to treat head lice. There are other generic medicines on the formulary for treating head lice that MFC-DC would expect you to try before moving up to Sklice®. If you are having a problem filling a medication on step therapy you should call you practitioner or MFC-DC 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-DC 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.

Which medicines are covered to treat HIV/AIDS?

Medications for the treatment of HIV and AIDS are supplied through the AIDS Drug Assistance Program (ADAP). All enrollees must apply to the ADAP program and renew every 6 months. Prescriptions for HIV and AIDS medications must be filled at ADAP-participating pharmacies. Click here for a list of medicines available at ADAP Pharmacies.

What pharmacy can I use to get my HIV/AIDS medicines?

Click here for a list of participating ADAP (AIDS Drug Assistance Program) Pharmacies.

Does MedStar-DC cover HIV PrEP (HIV Pre-Exposure Prophylaxis)?

Prescriptions for PreP (HIV pre-exposure prophylaxis) may be filled at any in-network pharmacy. Please ask your practitioner to write on the prescription that the medicine is for PrEP as this will help the medicine process at the pharmacy more quickly.

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 practitioner will need to provide information to us by telephone (855-798-4244) or by fax (202-362-1393) about why you need a non-formulary medicine instead of a medicine on the formulary.

What happens if I get a prescription for a medicine that is not covered?

If a medicine is in the ‘not covered” group, MFC-DC will not pay for it. There are very few medicines that are not covered. Examples of medicines that are not covered are diet pills and medications for erectile dysfunction. If a medicine is not covered, you will have to pay for it.

Are there limits to prescriptions?

In general, medication can be filled for a one-month supply when filled at a retail pharmacy chain. However, enrollees can fill a 90-day supply of most chronic medications at a retail pharmacy or they may use the Mail Order service through CVS to obtain a 90-day supply. A list of medications available in 90-day supplies (either by retail or through Mail Order) is available on the MFC-DC website.

Refills can be written for a maximum of twelve months. Some medications have quantity limits. This means that only a limited number of pills or tablets are allowed for a period of time. MFC-DC sets the limits based on the 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 practitioner. Your practitioner’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 practitioner’s office needs to call us. MFC-DC does not fill extra medicine for travel if the medicine is “controlled” [e.g. pain medicine/opioids, benzodiazepines (like Ativan or Valium), ADHD medicine, and many others]. There are exceptions if you have cancer, sickle cell, or are at the end of your life.

What if my medicine is lost or stolen?

If it is lost or stolen, you will need a new prescription. Your practitioner’s office needs to call us and we will replace the medicine. MFC-DC does not replace lost or stolen medicine if the medicine is “controlled” [e.g. pain medicine/opioids, benzodiazepines (like Ativan or Valium), ADHD medicine, and many others]. There are exceptions if you have cancer, sickle cell, or are at the end of your life.

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-DC 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-DC to approve a brand name medicine when a generic version is available, your practitioner needs to send information about why you cannot take the generic medicine.

Can a therapeutic substitution be made by the pharmacist or by MFC-DC?

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-DC card?

Sometimes, but not always, you can get your money back from MFC-DC. You can call us from 8:00 AM to 5:30 PM, Monday through Friday at 888-404-3549. We will review the situation and give you advice on what you need to do.

 

This program is funded in part by the Government of the District of Columbia Department of Health Care Finance.
Information current as of: 09/25/20