Q&A: Pharmacy benefit guideline

What is a formulary?

Prevea360 Medicare Advantage plans use a list of covered drugs (Formulary or “Drug List”). The drug list tells which Part D prescription drugs are covered by Prevea360 Medicare Advantage plans. The drugs on this list are selected by Prevea360 Medicare Advantage with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. See the Comprehensive Formulary.

Can the formulary change?

Yes, we may make certain changes to the Formulary during the year. Most changes in the formulary happen at the beginning of each year (Jan. 1). However, during the year there may also be changes. For example, we might:

• Add or remove drugs from the drug list. New drugs, including new generic drugs may become available or there is a new use for an existing drug. We may remove a drug because it has been found to be ineffective or there may be a drug recall.
• Move a drug to a higher or lower cost-sharing tier.
• Add or remove restrictions on coverage for a drug, such as quantity limits or needed prior authorization. (For more information about restrictions on drug coverage, see your Evidence of Coverage.)
• Replace a brand-name drug with a generic drug.
• Members will receive 60-day notice for any changes that would negatively affect them, such as a cost increase.

In most cases Prevea360 Medicare Advantage must get approval from Medicare for changes to the drug list. To get updated information about the drugs covered by Prevea360 Medicare Advantage plans, call Member Services at 1-877-232-7566, TTY: 711.

How do I find an in-network pharmacy in my area?

Advantage plans have approximately 60,000 participating pharmacies available for your use nationwide.

You may look in your pharmacy directory or call Member Services, whichever is easiest for you. You may also contact Member Services to request a revised list of in-network pharmacies by dialing 1-877-232-7566, TTY: 711.

Note: Prevea360 Medicare Advantage has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid Services (CMS) requirements for pharmacy access in your area.

Filling prescriptions outside of the network

Generally, we only cover drugs filled at an out-of-network pharmacy when a network pharmacy is not available. Before you fill your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• Coverage for out-of-network access of emergency drugs and some routine drugs will be provided when you cannot access a network pharmacy and one of the following conditions exists: You are traveling outside the service area and run out or become ill and need a covered drug.
• You are unable to obtain a covered drug in a timely manner at a network pharmacy in your service area (e.g. no access to a 24 hour/7 days a week network pharmacy).
• You are unable to obtain a particular drug as it is not regularly stocked at an accessible network pharmacy or mail order pharmacy (e.g. orphan or specialty drug with limited distribution).
• The network mail-order pharmacy is unable to get the covered drug to you in a timely manner and you run out of your drug.
• Drug is dispensed to you by an out-of-network institution based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery or other outpatient settings.

If you do go to an out-of-network pharmacy for the reasons listed above, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost. Send us your request for payment along with your documentation of any payment you have made. You may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay, consistent with the circumstances listed above, will count toward any required deductibles.

How will I find out if my drug coverage has been changed?

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we will send you a notice. Normally, we will let you know at least 60 days in advance for any negative changes. If a drug is suddenly recalled because it has been found to be unsafe we will remove the drug from the drug list immediately. We will notify members taking the drug about the change as soon as possible.

What do I do if I think I am entitled to a cost-sharing subsidy?

Under Medicare Part D, certain Part D members are entitled to a cost-sharing subsidy, which is extra financial assistance for Part D members who have limited income and resources. CMS determines which individuals qualify for the cost-sharing subsidy. In making this determination, CMS currently relies on files from the states and Social Security Administration. The eligibility status of the member is then updated in the CMS system and provided to Part D plan sponsors. Review the information at the link below to review the policy and how to submit documents supporting your eligibility for a cost-sharing subsidy.
Best Available Evidence

Is there a mail order option for prescriptions? 

Yes, we use Costco for our mail order program. Find out more.