PartnershipAdvantage - Prescription Drug Benefit (Part D)
Medicare Part D Formulary
Click here to view the PartnershipAdvantage Formulary (Medicare Part D) - 2008.
A formulary is a list of all the drugs we cover. We have a formulary that lists all drugs that we cover. We 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 or through our network mail order pharmacy service and other coverage rules are followed. In certain situations, prescriptions filled at an out-of-network pharmacy may also be covered. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage.
The drugs on the formulary are selected by our Plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program.
Not all drugs are included on the formulary. In some cases, the law prohibits coverage of certain types of drugs. (See "Drug Exclusions," later in this section, for more information about the types of drugs that cannot be covered under a Medicare Prescription Drug Plan.) In other cases, we have decided not to include a particular drug.
You can find drugs within our formulary using either Medical condition/use or alphabetical listing.
- Medical condition/use. The drugs in this category are grouped into categories depending on medical conditions that they are used to treat. If you know what your drug is used for, look for the category name then look for the name of drug. Generic drugs and common brand name drugs are listed.
- Alphabetical listing. You can use the index to find your drug. Next to your selected drug will be a page number where you can find coverage information. Turn to the page number listed and find the name of your drug in the first column of the list.
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Changes to Medicare Part D formulary
We may add or remove drugs from the formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. If we remove drugs from the formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug, and you are taking the drug affected by the change, we will notify you of the change at least 60 days before the date that the change becomes effective. If we don't notify you of the change in advance, you will get a 60 day supply of the drug when you request a refill of the drug. However, if a drug is removed from our formulary because the drug has been recalled from the market, we will not give 60-days notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members about the change as soon as possible.
- January 2008 - Lipitor (Atorvastatin) deleted from formulary
- February 2008 - No formulary deletions.
SEROQUEL XR ( quetiapine sustained release) added 2/1/08
- March 2008 - No formulary deletions
- April 2008 - No formulary deletions
- May 2008 - Digitek (Brand digoxin) removed from formulary: Manufacturer Class I drug recall
- June 2008 - No formulary deletions
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Getting an exception to the formulary
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.
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Pharmacies
We have network pharmacies outside of the service area where you can get your drugs covered as a member of our plan. Please click here to view our Pharmacy/Provider Directories.
When you fill your prescriptions at our network pharmacies, the total cost of your Part D drugs (paid by PartnershipAdvantage) will be tracked. You will receive a statement by mail call the "Explanation of Benefits". It will list all Part D transactions from the previous month and display what you have spent if any and what your total drug costs are year to date.
PartnershipAdvantage contracts with
approximately 82 pharmacies in Solano, Napa, and Yolo Counties.
PartnershipAdvantage has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area.
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Out-of-network pharmacy coverage
Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. In this situation you may have to pay the full cost when you fill your prescription. Before you fill a prescription at an out-of-network pharmacy, please call Member Service to see if there is a network pharmacy available. For more information about what situations we will cover prescriptions that are filled at out-of-network pharmacy and how to file a claim, please refer to the Disclosure Form and Evidence of Coverage.
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Mail order services
You can use our Plan's network mail-order pharmacy service to fill prescriptions for what we call "mail order drugs" / "maintenance drugs". These are drugs that you take on a regular basis, for a chronic or long-term medical condition. Maintenance medications are those medicines that are taken regularly for medical conditions like high blood pressure, diabetes and high cholesterol. This does not include allergy medications such as antihistamines, antibiotics or medications for pain.
To set up mail order services call Walgreen's at 1-800-635-3070 or register through their web site at www.walgreensmail.com.
You are not required to use our mail order services to get an extended supply of maintenance medications. You can also obtain an extended supply through some retail network pharmacies.
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Medication therapy Management program and drug utilization management
We offer medication therapy management programs at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.
We offer the medication therapy management program(s) to members that meet specific criteria. We may contact members who qualify for these programs. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you do not need to pay anything extra to participate.
If you are selected to join a medication therapy management program we will send you information about the specific program, including information about how to get the program.
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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 pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of utilization management tools are prior authorizations, quantity limits, step therapy and generic substitution. You can find out if your drug is subject to any of these processes by looking in the formulary.
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Grievances and appeals
PartnershipAdvantage provides an appeals and grievance process for our members to ensure you get answers to any concerns or problems you may encounter
GRIEVANCES:
If you have concerns or problems with PartnershipAdvantage which are not about payment or drug coverage, you have the right to file a grievance. You may file a grievance by contacting the PartnershipAdvantage Member Services Department toll free at (866) 264-3626. We can be reached Monday through Friday, 8:00am to 8:00pm. You can also send a completed PartnershipAdvantage Appeal & Grievance Form, or write a letter, directly to:
PartnershipAdvantage
Grievance and Appeals Resolution Services
360 Campus Lane, Suite 100
Fairfield, CA 94534
You will receive a written letter telling you that PartnershipAdvantage received your grievance, the name and telephone number of the Resolution Specialist that is handling your grievance, and the estimated time for a written response. A written resolution letter will be mailed to you within 30 days of PartnershipAdvantage receiving your grievance.
APPEALS:
As a member, you can file an appeal if PartnershipAdvantage makes a decision to not pay for, not approve, or stop a service you think should be covered or provided to you. This could include denials for drugs or involving payment for services (including co-payments and billing issues or reimbursement) you received or believe you should receive under the PartnershipAdvantage pharmacy program. You or your appointed representative must file the appeal within sixty (60) calendar days from the date of the notice of the coverage determination (i.e., the date printed or written on the notice). To appeal a decision, please contact PartnershipAdvantage Member Services Department by calling toll free (866) 264-3626. We can be reached Monday through Friday, 8:00am to 8:00pm. You can also send your appeal in writing to:
PartnershipAdvantage
360 Campus Lane, Suite 100
Fairfield, CA 94534
We will review your appeal and send you a letter telling you our decision within seven (7) days of receiving your appeal request. If you think your health could be seriously harmed by waiting for a decision about the drug, you can request a faster decision which is issued within 24 hours of receiving your appeal. In both cases, you will receive a written notice of the outcome of your appeal, including any additional appeal rights which include an independent review entity; hearings before an Administrative Law Judge, review by the Medicare Appeals Council, and judicial review.
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Coverage determinations
We will make timely decisions when you ask use to cover a Medicare Part D prescription drug.
A decision about whether we will cover a Part D prescription drug can be:
- a “standard decision” that is made with the standard time frame ( typically within 72 hours), or
- it can be a “fast decision” that is made more quickly ( typically within 24 hours).
A fast decision is called an “expedited coverage determination.” You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could harm your health or your ability to regain maximum function. Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you have already received.
If we do not grant your or your physician’s request for a “fast” review, we will make our decision within the “standard” 72 hours time frame discussed above. If we tell you about our decision not to provide a “fast” review by phone, you can request an expedited grievance at that time if you disagree. Otherwise, we will send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a “grievance” if you disagree with our decision to deny you request for a “fast” review, and will explain that we will automatically give you a fast decision if you get a doctor’s explanation.
Members may make coverage determinations using the following form:
http://cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/ModelCoverageDeterminationRequestForm.pdf
Providers may make coverage determinations for their patients using the following form:
http://www.cms.hhs.gov/MLNProducts/Downloads/Form_Exceptions_final.pdf
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Quality assurance (medication errors, adverse drug interactions and medication use)
PartnershipAdvantage has established quality assurance measures and systems to reduce medication errors, adverse drug interaction and improve medication use.
We have policies and procedures that define standards for pharmacy practice. They include the following:
- drug utilization reviews each time you fill a prescription for all of our members to make sure that they are getting safe and appropriate care. During these reviews, we look for medication problems such as duplicate drugs that are unnecessary, drugs that are inappropriate because of your age or gender, possible harmful interactions between drugs you are taking, drug allergies and drug dosage errors.
- reporting of our quality assurance practices to Centers for Medicare and Medicaid Services (CMS)
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Transition
New members in our Plan may be taking drugs that aren’t in our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to an appropriate drug that we cover or request a formulary exception (which is a type of coverage in order to get coverage for the drug. See Section 10 (under “What is an exception”) in the Evidence of Coverage (EOC) to learn more about how to request an exception.
Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior or step therapy or will no longer be on our formulary next year, and you need help switching to an appropriate drug that we cover or requesting a formulary exception.
During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year. This will provide you with the opportunity to work with your physician to switch to an appropriate drug that we cover or request a formulary exception.
For each of the drugs that isn’t on our formulary or that has coverage restrictions or limits, we will cover a temporary 30 day supply (unless the prescription is written for fewer days) when a new member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). After we cover the temporary 30 day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31 day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan, when that member is a resident of a long-term-care facility. If a new member, who is a resident of a long-term-care facility and has been enrolled in our Plan for more than 90 days, needs a drug that isn’t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31 day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.
Please note that our transition policy applies only to those drugs that are “Part D drugs” and that are bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access.
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Low Income Subsidy
Members who qualify for PartnershipAdvantage have Medicare and Full-Scope Medi-Cal. By qualifying for Medi-Cal, you also qualify for "Extra Help" with you Prescription Drug Coverage through Medicare Part D.
This "Extra Help" is also called the Low Income Subsidy. Qualifying for this subsidy means you have no Part D premium under PartnershipAdvantage, and you have the following co-pays for drugs in the coverage gap:
If you are at, or below 100% of the Federal Poverty Level (FPL):
$1.05 for Generic Drug
$3.10 for Brand Drugs
If you are over 100% of the Federal Poverty Level (FPL):
$2.25 for Generic Drug
$5.60 for Brand Drugs
Members of PartnershipAdvantage receive this information in an attachment to their Evidence of Coverage, called the Low Income Subsidy Rider upon enrollment and each following year.
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