Pending CMS Approval
PartnershipAdvantage (HMO SNP) - Formulary Information
Medicare Part D Formulary
Click here to view the PartnershipAdvantage Formulary (Medicare Part D) - 2012
Our formulary is set up in a grid. This grid should be read from left to right. Each line in the formulary shows you the name of the drug, what your copayment may be, and if we have any special rules to get these drugs. If a drug has a copayment of $3.30 or $6.50, that is a brand drug. If a drug name is in italics and only has a copayment of $0, that is a generic drug:
Premiums, co-pays, co-insurance and deductibles may vary based on the level of Extra Help that beneficiaries may receive. Please contact the Plan for details. Please contact the Plan for details.
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. Quantity limitations and restrictions may apply.
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.
Return to Menu
Utilization Management Tools
Click here to see our Prior Authorization Criteria 2012
Click here to see our Step Therapy Criteria 2012
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.
In general, our rules encourage you get a drug that works for your medical condition and is safe. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan's rules are designed to encourage you and your doctor to use that lower-cost option. We also need to comply with Medicare's rules and regulations for drug coverage and cost sharing.
Using generic drugs whenever you can
A "generic" drug works the same as a brand-name drug, but usually costs less. When a generic version of a brand-name drug is available, our network pharmacies must provide you the generic version. However, if your doctor has told us the medical reason that the generic drug will not work for you, then we will cover the brand-name drug. (Your share of the cost may be greater for the brand-name drug than for the generic drug.)
Getting plan approval in advance
For certain drugs, you or your doctor need to get approval from the plan before we will agree to cover the drug for you. This is called "prior authorization." Sometimes plan approval is required so we can be sure that your drug is covered by Medicare rules. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.
Trying a different drug first
This requirement encourages you to try safer or more effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "Step Therapy."
Quantity limits
For certain drugs, we limit the amount of the drug that you can have. For example, the plan might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
Return to Menu
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.
Return to Menu
Coverage determinations
We will make timely decisions when you ask us 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 you 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.
To request a coverage determination by phone, call 1-866-264-3626 from 8am to 8pm, 7 days a week. TTY users should call 1-800-735-2929 or call 711.
To fax a coverage determination, send your request to 707-863-4415.
To mail your coverage determination request, send your request to: Partnership HealthPlan of California, Attn: Pharmacy Department, 360 Campus Lane, Suite 100, Fairfield, CA 94534.
Members and Providers may make coverage determinations using the following form:
Model Coverage Determination Request Form
Return to Menu
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.
Return to Menu
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).
Return to Menu
Our Transition Policy
New members in our Plan may be taking drugs that aren't on 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 a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Chapter 9, Section 6.2 under "What is an exception?" 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 authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different 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 must be at least 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 OR provide you with the opportunity to request a formulary exception in advance for the following year.
When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover up to a 90-day supply (unless the prescription is written for fewer days). After we cover the temporary supply (up to 90 days), 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 the prescription is 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. If the resident has been enrolled in our Plan for more than 90 days and 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 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. See Chapter 5 for information about non-Part D drugs.
To ask for a temporary supply, call Member Services (see "Contacting PartnershipAdvantage (HMO SNP) for our number).
During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. For more information, check your Evidence of Coverage (EOC) or call our Member Services Department.
Return to Menu
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):
$0.00 for Generic Drug
$3.30 for Brand Drugs
If you are over 100% of the Federal Poverty Level (FPL):
$0.00 for Generic Drug
$6.50 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.
"Some members qualify for $0 co-payments all year, if they are in a Skilled Nursing Facility (SNF). If you feel you qualify for a lower cost-sharing amount for generic or brand drugs, you may submit evidence of your Medi-Cal or SNF status by contacting our Member Services Department. For more information, click on the link below."
http://www.cms.hhs.gov/PrescriptionDrugCovContra/17_Best_Available_Evidence_Policy.asp
To find out more about the Low Income Subsidy, and to see if you qualify, contact the Social Security Administration at the number provided below. The Social Security Administration is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens who are 65 or older; or who have a disability; or end stage renal disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare and pay the Part B premium. Social Security handles the enrollment process for Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office.
Social Security Administration
CALL 1-800-772-1213
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.
You can use our automated telephone services to get recorded information and conduct some business 24 hours a day.
TTY 1-800-325-0778
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.
WEBSITE http://www.ssa.gov
Return to Menu
|
