Outpatient Prescription Drug Benefit Commercial Formulary

Transcription

1 Outpatient Prescription Drug Benefit Commercial Formulary Benefits Effective January 1, 2011 MedicareComplete retiree plans UnitedHealthcare Group Medicare Advantage (PPO)

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3 Please Read: This document contains information about the drugs covered under the outpatient prescription drug benefit. Note to Existing Members: The Formulary listing included within this document may have changed since last year. Please review this document to make sure that the Formulary still contains the drugs you take. For the most current Formulary information, please visit our website or give us a call. Our web address and phone numbers are listed on the back cover of this booklet. This Formulary was last updated July 2010.

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5 Table of Contents Your Outpatient Prescription Drug Benefit...1 Creditable Prescription Drug Coverage...1 What Do You Pay for Covered Drugs?...1 Does This Outpatient Prescription Drug Benefit Affect Coverage for the Drugs Covered Under Medicare Part A or Part B?...1 Definitions...1 What Drugs Are...3 What Is a Formulary?...3 Do You Find Out What Drugs Are on the Formulary?...3 What Are Drug Tiers?...3 Can the Formulary Change?...4 What if Your Drug Isn t on the Formulary?...4 Transition Policy...4 Drug Management Programs...5 Utilization Management...5 Drug Utilization Review...6 What Is an Exception?...6 Using Network Pharmacies To Get Your Prescription Drugs...7 Abbreviated Network Pharmacy Listing...7 What if a Pharmacy Is No Longer a Network Pharmacy?...8 Do You Fill a Prescription at a Network Pharmacy?...8 Our Plan s Network Mail Order Pharmacy Service...8 To Fill a Prescription Through Our Network Mail Order Pharmacy Service...9 Do You Submit a Paper Claim?...9 Does Your Prescription Drug Coverage Work if You Go to a Hospital?...10 Some Vaccines and Drugs May Be Administered in Your Doctor s Office...10 Outpatient Prescription Drug Appeals and Grievances...10 What Is an Appeal?...10 Expedited/72 Hour Appeal Procedures To Request an Expedited Appeal What Is a Grievance?...12 Grievance Procedures...12 Complaints Involving Quality of Care Issues...12 Medications Covered by Your Benefit...12 Formulary Exclusions and Limitations...13 To Use the Commercial Formulary Listing...15 The Commercial Formulary Index...16 Commercial Formulary...17 List of Drugs (alphabetical by Brand Name)...17 Index (alphabetical listing including both Drugs and Brand-Name Drugs)...32

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7 Your Outpatient Prescription Drug Benefit As a member of MedicareComplete retiree plan or UnitedHealthcare Group Medicare Advantage (PPO), also referred to as Plan, the Plan, your Plan, or our Plan, this outpatient prescription drug benefit is available to you. Please note that this outpatient prescription drug benefit is not a Medicare approved Part D drug plan. You may not be enrolled in the Plan and in a Medicare approved Part D drug plan at the same time. If you enroll in a Medicare approved Part D drug plan, you will be disenrolled from the Plan, and this outpatient prescription drug benefit will no longer be available to you either. Creditable Prescription Drug Coverage Each year (prior to November 15), your Plan Sponsor should provide a disclosure notice to you that indicates if your prescription drug coverage is creditable (meaning it expects to pay, on average, at least as much as Medicare s standard prescription drug coverage) and the options available to you. You must keep the disclosure notices that you get each year in your personal records to present to a Part D plan (if you later choose to enroll in one) to show that you have maintained creditable coverage. If you didn t get this disclosure notice, you may get a copy from your Plan Sponsor. What Do You Pay for Covered Drugs? The amount you pay for Covered Drugs (Cost Sharing) is listed in Chapter 3 of the Evidence of Coverage titled: Medical Benefits Chart (what is covered and what you pay). Does This Outpatient Prescription Drug Benefit Affect Coverage for the Drugs Covered Under Medicare Part A or Part B? We cover drugs that are covered under both Parts A and B of Medicare under the Plan, in addition to the Covered Drugs under this outpatient prescription drug benefit. The coverage you receive under this outpatient prescription drug benefit doesn t affect Medicare coverage for drugs that would normally be covered under Medicare Part A or Part B. Depending on where you may receive your drugs, for example in the doctor s office versus from a Network Pharmacy, there may be a difference in your Cost Sharing for those drugs. You may contact us about different costs associated with drugs available in different settings and situations. Definitions Appeal A special kind of complaint you make when you want a redetermination and a change to a decision (Coverage Determination) we have made to deny a request for prescription drugs or payment for prescription drugs you have already received. You may also make a complaint if you disagree with a decision to stop coverage for prescription drugs you are receiving. For example, you may ask for an Appeal if we don t pay for a drug you think you should be able to receive. The Outpatient Prescription Drug Appeals and Grievances section later in this booklet explains Appeals, including the process involved in making an Appeal. Brand Name Drug A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand Name Drugs have the same active ingredient formula as the version of the drug. ever, Drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the Brand Name Drug has expired. Coinsurance The percentage of the cost you pay for Covered Drugs. Coinsurance amounts are listed in the Evidence of Coverage. 1

8 Copayment The dollar amount you pay for Covered Drugs. Copayment amounts are listed in the Evidence of Coverage. Cost Sharing Cost Sharing refers to amounts that a member has to pay when drugs are received. It includes any combination of the following two types of payments: (1) any fixed Copayment amounts that you must pay when specific drugs are received; or (2) any Coinsurance amount that must be paid as a percentage of the total amount paid for a drug. Coverage Determination A decision from us about whether a drug prescribed for you is covered under the outpatient prescription drug benefit and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn t covered under the outpatient prescription drug benefit, that isn t a Coverage Determination. You need to call or write to us to ask for a formal decision about the coverage if you disagree. Covered Drugs The term we use to mean all of the outpatient prescription drugs covered under the outpatient prescription drug benefit. Covered Drugs are listed in our Formulary. Creditable Prescription Drug Coverage Coverage (for example, from an employer or union) that is at least as good as Medicare s Part D prescription drug coverage. Exception A type of Coverage Determination that, if approved, allows you to get a drug that is not on your Formulary (a Formulary exception), or get a non preferred drug at the preferred Cost Sharing level (a tiering exception). You may also request an Exception if we require you to try another drug before receiving the drug you are requesting, or we limit the quantity or dosage of the drug you are requesting (a Formulary exception). Formulary A list of Covered Drugs we provide. Your Formulary is the Commercial Formulary. Drug A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredients as the Brand Name Drug. Generally, Drugs cost less than Brand Name Drugs. Grievance A type of complaint you make about us or one of our Network Pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. See the Outpatient Prescription Drug Appeals and Grievances section later in this booklet for more information about Grievances. Network Pharmacy A pharmacy where members of our Plan can get their Covered Drugs. We call them Network Pharmacies because they contract with our Plan. In most cases, your prescriptions are covered only if they are filled at one of our Network Pharmacies. Non Formulary Drug Non preferred Drugs and Brand Name Drugs for 3 tier outpatient prescription drug benefit plans. (Please refer to your Evidence of Coverage to determine if your outpatient prescription drug benefit includes coverage for Non Formulary Drugs.) Some of these drugs may require Prior Authorization from us before they are covered. In many cases, the Formulary offers preferred and Brand-name therapeutic alternatives to these Non Formulary Drugs. Out of Network Pharmacy A pharmacy that does not have a contract with our Plan to coordinate or provide Covered Drugs to members of our Plan. As explained in this booklet, most drugs you get from Out of Network Pharmacies are not covered unless certain conditions apply. Prescription Unit The maximum amount (quantity) of prescription medication that may be dispensed per single Copayment or Coinsurance. For most oral medications, a Prescription Unit represents up to a 31 day supply of medication. The Prescription Unit for some medications may be set at a smaller quantity to promote appropriate medication use and patient safety. Quantity Limits are based on generally accepted pharmaceutical practices and the manufacturer s labeling. Prescriptions that are normally dispensed in pre packaged or commercially available units of 31 days or less will be considered a single Prescription Unit, including but not limited to, one inhaler, one 2

9 vial of ophthalmic medication, one tube of topical ointment or cream. Prior Authorization Approval in advance to get certain drugs that may or may not be on our Formulary. Some drugs are covered only if your provider gets Prior Authorization from us. Covered Drugs that need Prior Authorization are marked in the Formulary. Quantity Limits A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time. Step Therapy A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed. What Drugs Are What Is a Formulary? A Formulary is a list of the Covered Drugs that we provide. We will generally cover the drugs listed on our Formulary as long as the drug is medically necessary, the prescription is filled at a Network Pharmacy and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits are described later in this booklet under Utilization Management. Your Formulary is the Commercial Formulary. We select the drugs on the Formulary with the help of a team of health care providers. Both Brand Name Drugs and Drugs are included on the Formulary. A Drug is a prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the Brand Name Drug. Generally, Drugs cost less than Brand Name Drugs. Not all drugs are covered under the outpatient prescription drug benefit. In some cases, the law prohibits coverage of certain types of drugs. In other cases, we have decided not to include a particular drug on our Formulary. See the Formulary Exclusions and Limitations section later in this booklet for more information about the types of drugs that are limited or not covered under the outpatient prescription drug benefit. In certain situations, prescriptions filled at an Out of Network Pharmacy may also be covered. See information later in this section about filling a prescription at an Out of Network Pharmacy. Please note: Some of our outpatient prescription drug benefits do include coverage for Non Formulary Drugs. Please refer to the much you pay for outpatient prescription drugs section in Chapter 3 Medical Benefits Chart (what is covered and what you pay) of your Evidence of Coverage to determine if Non Formulary Drugs are covered under your outpatient prescription drug benefit. If your outpatient prescription drug benefit includes coverage for Non Formulary Drugs, the copayment or coinsurance amount you will pay for Non Formulary Drugs is also listed here. Do You Find Out What Drugs Are on the Formulary? Each year, we send you an updated Formulary so you can find out what drugs are on our Formulary. You can get updated information about the drugs covered under the outpatient prescription drug benefit by visiting our website. You may also call us to find out if your drug is on the Formulary or to request an updated copy of our Formulary. Our web address and phone numbers are listed on the back cover of this booklet. What Are Drug Tiers? Drugs on our Formulary are organized into different drug tiers, or groups of different drug types. Your Coinsurance or Copayment depends on which drug tier your drug is in. Please refer to the much you pay for outpatient prescription drugs section in Chapter 3 Medical Benefits Chart (what is covered and what you pay) of your Evidence of Coverage for specific Copayment or Coinsurance amounts. You may ask us to make an Exception (which is a type of Coverage Determination) to your drug s tier placement. See the What Is an Exception? section 3

10 later in this booklet to learn more about how to request an Exception. Can the Formulary Change? We may make certain changes to our Formulary during the year. Changes in the Formulary may affect which drugs are covered and how much you will pay when filling your prescription. The kinds of Formulary changes we may make include: Adding or removing drugs from the Formulary Adding Prior Authorizations, Quantity Limits, and/ or Step Therapy Restrictions on a drug Moving a drug to a higher or lower Cost Sharing tier If we remove drugs from the Formulary, or add Prior Authorizations, Quantity Limits and/or Step Therapy Restrictions on a drug or move a drug to a higher Cost Sharing tier and you are taking the drug affected by the change, you will be permitted to continue taking that drug at the same level of Cost Sharing for the remainder of your Plan Sponsor s plan year. ever, if a Brand Name Drug is replaced with a new Drug, or our Formulary is changed as a result of new information on a drug s safety or effectiveness, you may be affected by this change. We will notify you of the change at least 60 days before the date that the change becomes effective or provide you with a 60-day supply at the pharmacy. This will give you an opportunity to work with your physician to switch to a different drug that we cover or request an Exception. (If a drug is removed from our Formulary because the drug has been recalled from the pharmacies, we will not give 60 days notice before removing the drug from the Formulary. Instead, we will remove the drug immediately and notify members taking the drug about the change as soon as possible.) What if Your Drug Isn t on the Formulary? If your prescription isn t listed on your copy of our Formulary, you should first check the Formulary on our website which we update at least monthly (if there is a change). In addition, you may contact us to be sure it isn t covered. (Our web address and phone numbers are listed on the back cover of this booklet.) If we confirm that we don t cover your drug, you have two options: 1. You may ask your doctor if you can switch to another drug that is covered by us. If you would like to give your doctor a list of Covered Drugs that are used to treat similar medical conditions, please contact us or go to our Formulary on our website. 2. You or your doctor may ask us to make an Exception (a type of Coverage Determination) to cover your drug. See the section titled What Is an Exception? later in this booklet to learn more about how to request an Exception. If you pay out of pocket for the drug and request an Exception that we approve, we will reimburse you. If the Exception isn t approved, you may Appeal our denial. See the section titled Outpatient Prescription Drug Appeals and Grievances in this booklet for more information on how to request an Appeal. In some cases, we will contact you if you are taking a drug that isn t on our Formulary. We can give you the names of Covered Drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment. If you recently joined the Plan, you may be able to get a temporary supply of a drug you were taking when you joined our Plan if it isn t on our Formulary. 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 the section titled What Is an Exception? later in this booklet to learn more about how to request an Exception. Please contact us 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 4

11 drug that we cover or requesting a Formulary Exception. Our phone numbers are listed on the back cover of this booklet. 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 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, we will cover a 31 day supply (unless the prescription is written for fewer days). After we cover the temporary 31 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 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. Members who are discharged from an inpatient hospital or who are admitted to or discharged from a long term care facility and who are prescribed a Non Formulary Drug must use the Exceptions process to continue coverage of the Non Formulary Drug. If a new member or current member is stabilized on a medication that belongs to one of the special classes listed below, we will not require the member to transition to a Formulary alternative. Cancer chemotherapy medications Anti depressants Anti psychotics Anti seizure medications Immunosuppressants HIV/AIDS medications A new member or current member, who is stabilized on a Non Formulary medication that does not belong to one of the drug classes listed above, will be referred to his/her physician to discuss alternative drug therapy. As necessary, a one time supply of medication of up to 31 days will be provided to allow the member time to discuss alternative drug therapy with his/ her physician and/or to complete the Non Formulary Exceptions process. The member or member s physician may initiate an Exceptions request for coverage of the Non Formulary drug. Please note that our transition policy applies only to those drugs that are bought at a Network Pharmacy. The transition policy can t be used to buy a drug out of network, unless you qualify for out of network access. Drug Management Programs 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/or pharmacists developed these requirements and limits for us to help us provide quality coverage to our members. Please consult the Formulary listing later in this booklet or 5

12 the Formulary on our website for more information about these requirements and limits. The requirements for coverage or limits on certain drugs are listed as follows: Prior Authorization: We require you to get Prior Authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don t get the necessary information to satisfy the Prior Authorization, we may not cover the drug. Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 18 tablets every 31 days for a Formulary drug. Step Therapy Requirements: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. Substitution: When there is a version of a Brand Name Drug available, our Network Pharmacies may recommend and/or provide you the version, unless your doctor has told us that you must take the Brand Name Drug and we have approved this request. You can find out if the drug you take is subject to these additional requirements or limits by looking in the Formulary or on our website, or by calling us at one of the phone numbers listed on the back cover. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren t able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an Exception (which is a type of Coverage Determination). See the section titled What Is an Exception? later in this booklet to learn more about how to request an Exception. Drug Utilization Review We conduct drug utilization reviews for all of our members to provide information to help providers make decisions regarding safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as: possible medication errors; duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition; drugs that are inappropriate because of your age or gender; possible harmful interactions between drugs you are taking; drug allergies; drug dosage errors. If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem. What Is an Exception? An Exception is a type of initial determination (also called a Coverage Determination ) involving a drug. You or your doctor may ask us to make an Exception to our coverage rules in a number of situations. You may ask us to cover your drug even if it is not on our Formulary. You may 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 may ask us to waive the limit and cover more. See the section titled Utilization Management earlier in this booklet to learn more about our additional coverage restrictions or limits on certain drugs. You may ask us to provide a higher level of coverage for your drug. For instance, if your 6

13 outpatient prescription drug benefit includes coverage for Non Formulary Drugs and your drug is contained in our Non Formulary Drug tier, you may ask us to cover it at the Cost Sharing amount that applies to drugs in the Brand Name Drug tier instead. This would lower the copayment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our Formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, we will only approve your request for an Exception if the alternative drugs included on the Formulary or the drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your doctor must submit a statement supporting your Exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the Exception request. If we approve your Exception request, our approval is valid for the remainder of your Plan Sponsor s plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe for treating your condition. If we deny your Exception request, you may Appeal our decision. Note: If we approve your Exception request for a Non Formulary Drug, you cannot request an Exception to the Copayment or Coinsurance amount we require you to pay for the drug. You may call us at the phone number found in the section titled Outpatient Prescription Drug Appeals and Grievances later in this booklet to ask for any of these requests. Using Network Pharmacies To Get Your Prescription Drugs We contract with many of the largest retail pharmacy chains as well as many local independent pharmacies. You may have your prescriptions filled at any of our Network Pharmacies nationwide. Below is an abbreviated list of our Network Pharmacies. This is not a complete list, and this list of Network Pharmacies is subject to change. If you do not see your pharmacy listed, please call us or visit our website. Our phone numbers and web address are listed on the back cover of this booklet. Abbreviated Network Pharmacy Listing Giant Food Stores Giant Pharmacy Martins Pharmacy Stop & Shop Pharmacy Super G Pharmacy Tops Pharmacy Ukrop s Pharmacy Costco CVS Longs Kmart Pharmacies Baker s Pharmacy City Market Dillon Pharmacies Fred Meyer Fry s Pharmacy Gerbes King Soopers Kroger Pay Less Pharmacy QFC Pharmacy Ralphs Grocery Company Smith s Food & Drug Medicap Pharmacy Medicine Shoppe Pharmacy Rite Aid Carrs Dominick s 7

14 Genuardi s Pavilions Randalls Pharmacies Safeway Tom Thumb Vons Bigg s Pharmacy Cub Pharmacy Farm Fresh Pharmacy Sav-on Drugs/Osco Pharmacy Shop N Save Pharmacy Shoppers Pharmacy SuperValu Target Walgreens Sam s Club Wal-Mart With few exceptions, which are noted later in this booklet, you must use Network Pharmacies to get your prescription drugs covered. A Network Pharmacy is a pharmacy that has a contract with us to provide your covered prescription drugs. The term Covered Drugs means all of the outpatient prescription drugs that are covered under the outpatient prescription drug benefit. Covered Drugs are listed in our Formulary. In most cases, your prescriptions are covered only if they are filled at one of our Network Pharmacies. You aren t required to always go to the same pharmacy to fill your prescription; you may go to any of our Network Pharmacies. ever, if you switch to a different Network Pharmacy than the one you have previously used, you must either have a new prescription written by a doctor or have the previous pharmacy transfer the existing prescription to the new pharmacy if any refills remain. To find a Network Pharmacy in your area, please review the Abbreviated Network Pharmacy Listing above. You can also visit our website or give us a call. Our web address and phone numbers are listed on the back cover of this booklet. What if a Pharmacy Is No Longer a Network Pharmacy? Sometimes a pharmacy might leave the Plan s network. If this happens, you will have to get your prescriptions filled at another Plan Network Pharmacy. Please review the Abbreviated Network Pharmacy Listing above to find another Network Pharmacy in your area. You can also call us or visit our website. Our phone numbers and web address are listed on the back cover of this booklet. Do You Fill a Prescription at a Network Pharmacy? To fill your prescription, you must show your member ID card at one of our Network Pharmacies. If you don t have your member ID card with you when you fill your prescription, you may have the pharmacy call Prescription Solutions Help Desk to obtain the necessary information. If the pharmacy is unable to obtain the necessary information, you may have to pay the full cost of the prescription. If you pay the full cost of the prescription (rather than paying just your Coinsurance or Copayment) you may ask us to reimburse you for our share of the cost by submitting a claim to us. To learn how to submit a paper claim, please refer to the paper claims process described in the section titled Do You Submit a Paper Claim? later in this booklet. Our Plan s Network Mail Order Pharmacy Service When you order prescription drugs through our network mail order pharmacy service, you may order up to a 90-day supply of the drug. Generally, it takes the mail order pharmacy 7 days to process your order and ship it to you. ever, sometimes your mail order may be delayed. If you do run out of your prescription drug, you should ask your doctor for a new prescription for a one month supply. Have this prescription filled at any Network Pharmacy and have the pharmacy call Prescription Solutions Help Desk for an override. 8

15 To get order forms and information about filling your prescriptions by mail, using our network mail order pharmacy service, follow the instructions below. To Fill a Prescription Through Our Network Mail Order Pharmacy Service You may fill a prescription through our network mail order pharmacy service by mailing in a mail service pharmacy order form with your new prescription(s) or by calling Prescription Solutions at the number below to request a new prescription from your doctor. Additionally, your doctor may telephone prescriptions directly to a Prescription Solutions pharmacist. By telephone 1. Call Prescription Solutions to speak to one of our Prescription Solutions representatives at (TTY ), 24 hours a day, 7 days a week. When you speak to the Prescription Solutions representative, please have the name and telephone number of your doctor available, along with your specific drug information, such as the name(s) and strength(s) of the prescription drug(s) you are taking. 2. The Prescription Solutions representative will ask for your preferred method of payment by check, money order or credit card. 3. Prescription Solutions will then call your doctor and request your prescription. 4. Processing time for these requests depends on the response time from your doctor. You can check on the status of the order by calling Prescription Solutions at the number listed above. Using the mail service pharmacy order form 1. Contact your doctor s office to request a 90-day prescription for each drug you need. Have your doctor write a prescription for a 90-day supply, including three additional 90-day refills. If you are trying a new drug for the first time, you may want to ask your doctor for two prescriptions; one that can be filled for a 31-day supply at a retail Network Pharmacy and one for a 90-day supply, which can be forwarded to Prescription Solutions. By trying a smaller quantity of the drug before receiving a 90-day supply, you and your doctor can determine if the new prescription is right for you. Note: A new written prescription is required to have your prescriptions filled using the mail service pharmacy order form. You may obtain a mail service pharmacy order form by calling Prescription Solutions at (TTY ), 24 hours a day, 7 days a week or by visiting our website at 2. On the website you will need to enter some basic information, such as member status, state of residence, plan type, etc. Select the Pharmacy tab, then click on Mail Service Order Form and print the form. 3. Enclose your written prescriptions (with your date of birth written on each prescription), payment information (check, money order or credit card) and order form. Make the check or money order payable to Prescription Solutions. Standard delivery is no charge to U.S. territories, and if you prefer rush delivery, medications can be shipped overnight for an additional charge. 4. If you need assistance completing the form or determining your Copayment or Coinsurance amounts, call Prescription Solutions at (TTY ), 24 hours a day, 7 days a week. Do You Submit a Paper Claim? You may submit a paper claim for reimbursement of your drug expenses in the situations described below: Drugs purchased out of network. When you go to a Network Pharmacy and use your member ID card, your claim is automatically submitted to us by the pharmacy. ever, if you go to an Out of Network Pharmacy and attempt to use your member ID card for one of the reasons listed, the pharmacy may not be able to submit the claim 9

16 directly to us. When that happens, you will have to pay the full cost of your prescription and submit a paper claim to us. Drugs paid for in full when you don t have your member ID card. If you pay the full cost of the prescription (rather than paying just your Coinsurance or Copayment) because you don t have your member ID card with you when you fill your prescription, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us. Drugs paid for in full in other situations. If you pay the full cost of the prescription (rather than paying just your Coinsurance or Copayment) because it is not covered for some reason (for example, the drug is not on the Formulary or is subject to coverage requirements or limits) and you need the prescription immediately, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us. You may ask us to reimburse you for our share of the cost of the prescription by sending a written request to us. Although not required, you may use our reimbursement claim form to submit your written request. You can get a copy of our reimbursement claim form on our website or you can give us a call. Our web address and phone numbers are listed on the back cover of this booklet. Please include your receipt(s) with your written request. Please send your written reimbursement request to the address listed in the section titled Outpatient Prescription Drug Appeals and Grievances later in this booklet. Does Your Prescription Drug Coverage Work if You Go to a Hospital? If you are admitted to a hospital for a Medicare covered stay, your medical (Part C) benefit should generally cover the cost of your prescription drugs while you are in the hospital. Once you are released from the hospital, your prescription drugs will be covered under the outpatient prescription drug benefit, as long as the drugs meet all of our coverage requirements (such as drugs are on our Formulary, filled at a Network Pharmacy and aren t covered by our medical benefit (Part C)). We will also cover your outpatient prescription drugs if they are approved under the Exceptions or Appeals process. Some Vaccines and Drugs May Be Administered in Your Doctor s Office We may cover vaccines that are preventive in nature and aren t already covered by our Plan s medical benefit (Part C). This coverage includes the cost of vaccine administration. Please refer to the section titled much you pay for outpatient prescription drugs section in Chapter 3 Medical Benefits Chart (what is covered and what you pay) of your Evidence of Coverage for more information about your Cost Sharing for covered vaccines. Outpatient Prescription Drug Appeals and Grievances What Is an Appeal? An Appeal is a special kind of complaint you make when you want a redetermination and a change to a decision (Coverage Determination) we have made to deny a request for prescription drugs or payment for prescription drugs you have already received. You may also make a complaint if you disagree with a decision to stop coverage for prescription drugs you are receiving. For example, you may ask for an Appeal if we don t pay for a drug you think you should be able to receive. You also have a right to ask us for a copy of information regarding your Appeal. You must submit your request for a standard redetermination in writing at the address listed below. You, or your appointed representative, may request a redetermination (Appeal) of an unfavorable Coverage Determination related to a prescription drug. Someone else may file the Appeal for you on your behalf. It can be someone already legally appointed as your representative, such as a Durable Power 10

17 of Attorney, Health Care Proxy, Legal Guardian, or according to the applicable state laws. You may appoint an individual to act as your representative to file the Appeal for you by following the steps below: 1. Fill out the Form CMS You may print a copy from the Internet by visiting this site: 2. cms1696.pdf You must sign and date the Form Your representative must also sign and date this form. 4. You must include this signed form with your Appeal. In the event of your death, the executor of your estate is your legal representative. An Appeal is considered a redetermination by the Centers for Medicare & Medicaid Services (CMS). The redetermination process is required to be completed within 30 calendar days of our receipt of the request for a pre service Appeal or 60 days for a post service (claims) Appeal. You must submit a written request for a redetermination to: Appeals & Grievance Department P.O. Box 6106 MS: CA Cypress, CA or you may fax your written request to You must submit your written request within 60 calendar days of the date of the notice of the initial Coverage Determination. You are not required to submit additional information to support your request for redetermination (Appeal). We are responsible for gathering all necessary medical information. ever, it may be helpful to include additional information to clarify or support your request. For example, you may want to include information in your Appeal request, such as medical records or doctor opinions in support of your request. Note: The 60-calendar day limit may be extended for good cause. Include in your written request the reason you could not file within the 60-calendar day timeframe. We will conduct a redetermination and notify you in writing of the decision within 30 calendar days for a pre service and 60 calendar days for a post service from the receipt of your request. Our reconsideration decision will be made by a person or persons not involved in the initial decision. If we reverse the original adverse decision, we must authorize or provide coverage no later than 30 calendar days from the date your request for an Appeal was received; or pay your claim within 30 calendar days from the date your request for an Appeal was received. Expedited/72-Hour Appeal Procedures You have the right to request and receive an expedited 72-hour redetermination (Appeal) in situations in which waiting for a redetermination (Appeal) decision to be made within the standard timeframe could seriously jeopardize your life, health, or your ability to regain maximum function. If we decide, based on medical criteria, that your situation is medically necessary we will issue a decision as expeditiously as possible, but no later than 72 hours after receiving the request. To Request an Expedited Appeal To request an expedited Appeal review, you or your authorized representative may call, write or fax UnitedHealthcare. Be sure to ask for an expedited 72 hour review when you make your request. Call: TTY: a.m. to 8 p.m. local time, Monday through Friday Write: UnitedHealthcare Appeals & Grievance Department P.O. Box 6106 MS: CA Cypress, CA

18 Fax: Expedited Redeterminations: Attention: Appeals & Grievance Department If your request does not meet the definition of medically necessary, it will be handled within the standard review process of 30 calendar days. You will be informed by telephone that your request for the expedited 72-hour review has been denied and that the request will be processed within the standard review timeframe. What Is a Grievance? A Grievance is a type of complaint that you make about us or one of our Network Pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. Grievance Procedures If you have a Grievance, we encourage you to first call Customer Service. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this our Formal Grievance process. This process is required to be complete within 30 calendar days of our receipt of request. You may submit a written request for a Grievance to: Appeals & Grievance Department P.O. Box 6106 MS: CA Cypress, CA You may fax your written request to You must submit your written request within 60 calendar days of the date of the incident. Note: The 60-day limit may be extended for good cause. Include in your written request the reason why you could not file within the 60-day timeframe. We must notify you of our decision about your Grievance no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. Complaints Involving Quality of Care Issues All complaints that involve quality of care issues are referred to UnitedHealthcare s Health Services department for review. We will investigate the complaint with the involved Network Pharmacy and appropriate departments. You may need to sign an authorization to release your medical records. We will confirm receipt of your complaint within 30 calendar days of receiving your complaint. The results of the quality management review are confidential. Medications Covered by Your Benefit When prescribed by your provider as medically necessary and filled at a Network Pharmacy, subject to all the other terms and conditions of this outpatient prescription drug benefit, the following medications are covered: Federal Legend Drugs: Any medicinal substance which bears the legend: Caution: Federal law prohibits dispensing without a prescription. Drugs: Comparable Drugs may be substituted for Brand Name Drugs. For Brand Name Drugs that have FDA approved equivalents, a prescription may be filled with a Drug unless a specific Brand Name Drug is Medically Necessary and Prior Authorized by UnitedHealthcare. Please note: For 2-tier outpatient prescription drug benefit plans: Prior Authorization is necessary even if your provider writes Dispense as Written or Do Not Substitute on your prescription. If you choose to use a medication not included on the Formulary and not Prior Authorized by UnitedHealthcare, you will be responsible for the full retail price of the medication. ever, you have the option of selecting a Non Formulary Brand-Name Drug that has a Drug equivalent on the 12

19 Formulary at a cost that is generally lower than retail. The cost is the Drug Copayment or Coinsurance plus the difference between UnitedHealthcare s contracted rate for the Drug and Brand Name Drugs. You will not pay a rate higher than UnitedHealthcare s contracted rate for the Brand Name Drug. If the Brand Name Drug with the Drug equivalent is Medically Necessary, it may be Prior Authorized by UnitedHealthcare. If it is approved, you will only pay your Brand Name Drug Copayment or Coinsurance. Miscellaneous Prescription Drug Coverage: For the purposes of determining coverage, the following items are considered outpatient prescription drug benefits and are covered when medically necessary: glucagons, insulin, insulin syringes, blood glucose test strips, lancets, inhaler extender devices, urine test strips and anaphylaxis prevention kits (including, but not limited to, EpiPen, Ana Kits, and Ana Guard ). See the Evidence of Coverage for coverage of other injectable medication and equipment. Oral Contraceptives: Federal Legend oral contraceptives, prescription diaphragms and oral medications for emergency contraception. Sexual Dysfunction Medication: Prescription medications for the treatment of sexual dysfunction are Non Formulary Drugs and require Prior Authorization by UnitedHealthcare. Medically necessary prescription medications prescribed by a provider for the treatment of sexual dysfunction are limited to 12 tablets every 31 days. State Restricted Drugs: Any medicinal substance that may be dispensed by prescription only according to State law. Formulary Exclusions and Limitations While the outpatient prescription drug benefit covers most medications, there are some that are not covered or limited. These drugs are listed below. Some of the following excluded drugs may be covered under your medical benefit. Please refer to your Evidence of Coverage for more information about medications covered by your medical benefit. Administered Drugs: Drugs, medicines and some vaccines delivered or administered to the member by the prescriber or the prescriber s staff are not covered. Injectable drugs are covered under your medical benefit when administered during a physician s office visit or self administered pursuant to training by an appropriate health care professional. Compounded Medication: Any medicinal substance that has at least one ingredient that is Federal Legend or State Restricted in a therapeutic amount; compounded medications are not covered unless Prior Authorized by UnitedHealthcare. Diagnostic Drugs: Drugs used for diagnostic purposes are not covered. Dietary or nutritional products, food supplements and medical foods, whether prescription or non prescription, including vitamins (except prenatal), minerals, health or beauty aids, herbal supplements and/or alternative medicine are not covered. Phenylketonuria (PKU) testing and treatment is covered under your medical benefit including those formulas and special food products that are a part of a diet prescribed by a provider provided that the diet is medically necessary. Drugs prescribed by a dentist or drugs when prescribed for dental treatment are not covered. Enhancement medications when prescribed for the following non medical conditions are not covered: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti aging for cosmetic purposes, and mental performance. Examples of drugs that are excluded when prescribed for such conditions include, but are not limited to, Penlac, Retin A, Renova, Vaniqa, Propecia, Lustra, Xenical, or Meridia. This exclusion does not exclude coverage for drugs when Prior Authorized as medically necessary to treat morbid obesity or diagnosed medical conditions affecting memory, including, but not limited to, Alzheimer s dementia, or medically necessary medications directly related to non covered services when complications 13

20 exceed routine follow up care such as life threatening complication of cosmetic surgery. Immunizations: Some immunizations are not covered under the outpatient prescription drug benefit, but rather they are covered under the core medical benefit. Infertility: All forms of prescription medication when prescribed for the treatment of infertility are not covered under the outpatient prescription drug benefit. If your Plan Sponsor has purchased coverage for infertility treatment, prescription medications for the treatment of infertility may be covered under the medical benefit. Injectable Medications: Except as described in Chapter 3 Medical Benefits Chart (what is covered and what you pay) of the Evidence of Coverage, injectable medications including, but not limited to, self injectables, infusion therapy, allergy serum, immunization agents and blood products are not covered as an outpatient prescription drug benefit. ever, these medications are covered under your medical benefit as described in and according to the terms and conditions of your Evidence of Coverage. Outpatient injectable medications administered in the Physician s office (except insulin) are covered as a medical benefit when part of a medical office visit. Injectable medications may be subject to UnitedHealthcare s Prior Authorization requirements. For additional information, refer to your medical Evidence of Coverage. Inpatient Medications: Medications administered to a member while an inpatient in a hospital or while receiving skilled nursing care as an inpatient in a skilled nursing facility are not covered under this outpatient prescription drug benefit. Please refer to your Evidence of Coverage for information on coverage of prescription medications while hospitalized or in a skilled nursing facility. Outpatient prescription drugs are covered for members receiving custodial care in a rest home, nursing home, sanitarium, or similar facility if they are obtained from a Network Pharmacy in accordance with all the terms and conditions of coverage set forth in this Pharmacy Program Booklet. When a member is receiving Custodial Care in any facility, relatives, friends or caregivers may purchase the medication prescribed by a provider at a Network Pharmacy, and pay the applicable Copayment or Coinsurance on behalf of the member. Investigational or Experimental Drugs: Medication prescribed for experimental or investigational therapies are not covered. For non Food and Drug Administration approved indications, see Off Label Drug exclusion. Medications dispensed by an Out of Network Pharmacy are not covered except for prescriptions required as a result of an emergency or urgently needed service. For Plans that do not have coverage for out of network services, medications prescribed by out of network providers or out of network facilities are not covered, except for prescriptions required as a result of an emergency or urgently needed services. Refer to Chapter 3 Medical Benefits Chart (what is covered and what you pay) of your Evidence of Coverage to determine if your Plan covers out of network services. New procedures, services, supplies and medications are not covered until they are reviewed and approved by UnitedHealthcare for safety, efficacy and cost effectiveness or unless they are Prior Authorized by UnitedHealthcare as medically necessary. Non Covered Medical Condition: Outpatient prescription medications for the treatment of a non covered medical condition are not covered. This exclusion does not apply to medically necessary medications directly related to non covered services when complications exceed follow up care, such as life threatening complications of cosmetic surgery. Non Formulary Drugs: Drugs determined by UnitedHealthcare s Pharmacy and Therapeutics Committee to be ineffective, duplicative or have preferred therapeutic alternatives available may require Prior Authorization. Off Label Drug Use: Off Label Drug Use means that the Provider has prescribed 14