Part D: Prescription Drug Benefits

Formulary

As a Mercy Care Advantage plan member, your plan includes coverage for Part D prescription drugs. Mercy Care Advantage has a formulary also called a list of drugs. Mercy Care Advantage consulted with team of health care providers to develop the formulary. It includes prescription therapies believed to be a necessary part of a quality treatment program. Some covered drugs may have restrictions or limitations. Mercy Care Advantage generally covers the drugs listed in our formulary as follows:

the drug is medically necessary,
the prescription is filled at a Mercy Care Advantage network pharmacy,
other plan rules are followed

The formulary is subject to change during the year. You have two ways to view the Mercy Care Advantage formulary online:

Download the Formulary (List of Covered Drugs)

2018 Formulary 10-1-2018

Search our online 2018 Formulary

Are there any restrictions on my drug coverage? Yes, some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

2018 Prior Authorization Criteria 10-1-2018: Mercy Care Advantage requires you (or your physician) to get prior authorization for some drugs. This means that you need to get approval from Mercy Care Advantage before you fill your prescriptions. If you don’t, Mercy Care Advantage may not cover the drug.

2018 Step Therapy Criteria: Sometimes Mercy Care Advantage needs you first to try certain drugs to treat your medical condition before it covers another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Mercy Care Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work, you can ask Mercy Care Advantage to cover Drug B.

As a Medicare beneficiary, you have rights under your Part D prescription drug benefits. The information in the menu options below will explain the Part D prescription drug benefits available to you and your rights as a Mercy Care Advantage plan member. You, your authorized representative or your doctor has the right to request a coverage determination or exception for a drug that you feel should be covered for you or to request we pay for a prescription drug you already bought. Below is a copy of the form that can be used to request a coverage determination. For complete information about the coverage determination process or appeal process, select from the menu options below or refer to your 2018 Evidence of Coverage.

Coverage Determination Form: Submit online form

Coverage Determination Form: Download and print form

Low-Income Subsidy (LIS) Information

The Low-Income Subsidy (LIS) Program, also called “Extra Help” helps cover the cost of prescription drugs for people with low incomes who are eligible for the Medicare Part D program. If you are enrolled in Mercy Care Advantage you were sent a copy of the Low Income Subsidy Rider that explains your Part D prescription drug cost sharing responsibilities.

2018 Low Income Subsidy (LIS) Rider – Benefit increase (English | Espanol)

2018 Low Income Subsidy (LIS) Rider – Benefit decrease (English | Espanol)

Do I qualify for extra help?

People with limited income and resources may qualify for extra help in one of two ways: automatically or by submitting an application. The amount of extra help you get depends on your income and resources. If you automatically qualify, you do not need to apply. Medicare will send you a letter. You automatically qualify for extra help if one of the following is true:

You have full coverage from a state Medicaid Program like AHCCCS
You get help from Medicaid paying your Medicare Part B premiums
You get Supplemental Security Income (SSI) benefits

Apply

If you do not automatically qualify, but have limited income and resources, you may file an application with the Social Security Administration at 1-800-772-1213 or visit www.socialsecurity.gov. You also may apply at your State Medical Assistance (Medicaid) office at 602-417-4000 or 1-800-654-8713 or visit www.healthearizona.org/. They will determine if you meet the eligibility criteria.

How much do you pay for drugs covered by this plan?

If you qualify for extra help with your drug costs, the cost for your drugs would normally depend on certain factors. These factors include your income and coverage levels, the type of drug and whether you are filling your prescription at an in-network or out-of-network pharmacy.

Low Income Subsidy Eligibility and Benefits Information:

Your monthly plan premium is: $0

Your yearly deductible is: $0

Your cost sharing amount for generic/preferred multi-source drugs is no more than:

$0 / $1.25 / $3.35 (each prescription)

Your cost sharing amount for all other drugs is no more than:

$0 / $3.70 / $8.35 (each prescription)

* There is $0 cost share required for members in a long-term care facility or who have reached the catastrophic coverage stage of your Part D prescription benefit coverage in the current calendar year.

Please note: Mercy Care Advantage does not have a monthly plan premium. You must continue to pay your Medicare Part B premium. If you are a full-dual eligible your monthly Part B premium is paid by the State.

Medication Therapy Management Program (MTMP)

The Mercy Care Advantage (HMO SNP) Medication Therapy Management (MTM) program helps you get the greatest health benefit from your medications by:

Preventing or reducing drug-related risks
Increasing your awareness
Supporting good habits

Who qualifies for the MTM program?

We will automatically enroll you in the Mercy Care Advantage Medication Therapy Management Program at no cost to you if all three (3) conditions apply:

You take eight or more Medicare Part D covered maintenance drugs, and
You have three or more of these long term health conditions:

Asthma
COPD
Diabetes
Depression
Osteoporosis
Chronic Heart Failure
HIV
Cardiovascular Disorders such as High Blood Pressure, High Cholesterol, or Coronary Artery Disease

and

3. You reach $3,967 in yearly prescription drug costs paid by you and the plan.

Your participation is voluntary, and does not affect your coverage. This program is free of charge and is open only to those who are invited to participate. The MTM program is not considered a benefit for all members.

What services are included in the MTM program?

The MTM Program provides you with a:

Comprehensive Medication Review (CMR), and a
Targeted Medication Review (TMR)

Comprehensive Medication Review (CMR)

A CMR is a one-on-one discussion with a pharmacist, to answer questions and address concerns you have about the medications you take, including:

Prescription drugs
Over-the-counter (OTC) medicines
Herbal therapies
Dietary supplements and vitamins

The pharmacist will offer ways to manage your conditions with the drugs you take. If more information is needed, the pharmacist may contact your prescribing doctor. A CMR review takes about 30 minutes and usually offered once each year—if you qualify. At the end of your discussion, the pharmacist will give you a Personal Medication List of the medications you discussed during your CMR.

You will also receive a Medication Action Plan. Your plan may include suggestions from the pharmacist for you and your doctor to discuss during your next doctor visit.

Here is a blank copy of the Personal Medication List PDF Opens In New Window for tracking your prescriptions.

Targeted Medication Review (TMR)

A TMR is where we call, mail or fax suggestions to your doctor every three months about prescription drugs that may be safer, or work better than your current drugs. As always, your prescribing doctor will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your doctor decide to change them. We may also contact you by mail or phone, with suggestions about your medications.

How will I know if I qualify for the MTM program?

If you qualify, we will mail you a letter letting you know that you qualify for the MTM program. Afterward, you may receive a call from a partner pharmacy, inviting you to schedule a one-on-one medication review at a convenient time.

Will the MTM program pharmacist be calling from my regular pharmacy?

Yes, the MTM program pharmacist may be calling from your regular pharmacy if your regular pharmacy chooses to participate in the MTM Program as a service provider. You will be given the option to choose an in-person review or a phone review.

If your regular pharmacy does not participate in the program, you may be contacted by a Call Center pharmacist to provide your MTM review, and ensure that you have access to the service if you want to participate. Call center reviews are conducted by phone.

Why is a review with a pharmacist important?

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:
Discuss how your prescription drugs and OTC medications may affect each other.
Identify any prescription drugs and OTC medications that may cause side effects, and offer suggestions to help.
Help you get the most benefit from all of your prescription drugs and OTC medications.
Review opportunities to help you reduce your prescription drug costs.

How do I benefit from talking with a pharmacist?

Discussing your medications can result in real peace of mind knowing that you are taking your prescription drugs and OTC medications safely.
The pharmacy can look for ways to help you save money on your out-of-pocket prescription drug costs.
You benefit by having a Personal Medication List and a Medication Action Plan to keep and share with your doctors and health care providers.

How can I get more information about the MTM program?

To find out more about MTM, call Mercy Care Advantage Member Services at 602-263-3000 (Phoenix Metro Area) or 1-800-624-3879, 8:00 a.m. - 8:00 p.m., 7 days a week. TTY users should call 711.

Prescription Drug Mail Order

For certain kinds of drugs, you can use the plan’s network mail-order services to get prescriptions drugs shipped to your home. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs that are not available through the plan’s mail-order service are marked as “non-maintenance” drugs in our Drug List.

When you order prescription drugs through the network mail-order pharmacy service, you must order at least a 75-day supply, and no more than a 90-day supply of the drug. Take the mail order drug form to your doctor and ask your doctor to write a new prescription(s) for up to the maximum mail order day supply. Fill out the order form completely, including your member ID#, your doctor's name, and any allergies, illnesses or medical conditions you may have.

Download the Prescription Drug Mail-order Form (English | Español) here.

To get an order form mailed to you or for more information about filling your prescriptions by mail call Mercy Care Advantage Member Services at 602-263-3000 (Phoenix Metro Area) or 1-800-624-3879, 8:00 a.m. - 8:00 p.m., 7 days a week (TTY: 711). You can also register online with CVS Caremark at http://www.caremark.com. Once registered, you will be able to order refills, renew your prescriptions and check the status of your order.

Mail the order form and the prescription(s) to:

CVS Caremark
PO Box 94467
Palatine, IL 60094-4467

Generally, it takes CVS Caremark 7-10 days to process your order and ship it to you. However, please allow 14 days for the initial mail order fill. Usually a mail-order pharmacy order will get to you in no more than 10 calendar days. If a mail order is delayed by the mail order pharmacy 10 calendar days or more, you will be contacted and told about the delay. If you have not received an order within 10 calendar days of when you sent the order, call CVS Caremark Customer Care at 1-800-552-8159 (hearing impaired only, TTY 1-800-231-4403) and they will begin processing a replacement order. The order will be quickly sent to you. Calls to this number are free.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Limitations, copayments, and restrictions may apply. This information is not a complete description of benefits. Contact the plan for more information.

Specialty Drugs

How to order specialty drugs for Mercy Care Advantage members

For authorization to administer a specialty drug covered under the members Medicare Part D benefit:

Call Mercy Care Advantage at 1-800-624-3879, select option #2 for providers, then select option 1 to initiate a coverage determination for the requested specialty medication.

Or

Complete the Coverage Determination Request Form and fax to the Mercy Care Advantage Pharmacy Department at 1-855-230-5544.

For authorization to administer a specialty drug covered under a members Medicare Part B benefit:

You can fax your authorization request to 1-800-217-9345.
Or call Mercy Care Advantage Member Services at 602-263-3000 (Phoenix Metro Area) or 1-800-624-3879, 8:00 a.m. - 8:00 p.m., 7 days a week, (TTY: 711) to initiate an organization determination (prior authorization) for the requested specialty medication.
For additional information about Medicare Part B verses D coverage rules, please see Appendix C of Chapter 6 of the Medicare Prescription Drug Manual.

Part D Transition of Coverage Policy

When you join Mercy Care Advantage (HMO SNP) and you learn that we do not cover a prescription drug you were taking before you joined our Plan, you may be able to get a one-time temporary fill of a 30-day supply of that prescription drug (or less, as prescribed, up to a 30-day supply) at a retail pharmacy. This gives you the opportunity to work with your doctor to complete a successful transition to your new coverage year and avoid disruption in your treatment. This is called the Transition of Coverage (TOC) process. If you receive a transition fill for a drug, we will send you a letter explaining that the drug was filled under the Transition of Coverage process. The letter will explain the action you can take to get approval for the drug or how to switch to another drug on the plan formulary.

Right to Transition Fill

If you are a new member and are taking a Part D drug that is not on the Mercy Care Advantage formulary, or is subject to a utilization management requirement or limitation (such as step therapy, prior authorization, or a quantity limit), you are entitled to receive a 30-day supply of the drug within the first 90-days of your enrollment. This period of time is called your “transition period”. If your prescription is written for less than a 30-day supply, you can get it refilled until you reach the 30-day supply.

If you are an existing member and are taking a Part D drug that is not on the 2018 Mercy Care Advantage formulary, or is subject to a new utilization management requirement or limitation (such as step therapy, prior authorization, or a quantity limit) in 2018, you are entitled to receive a 30-day supply of the drug within the first 90-days of the new plan year. This period of time is called your “transition period”. If your prescription is written for less than a 30-day supply, you can get it refilled until you reach the 30-day supply.

Existing members, who are taking a Part D drug that was removed from the formulary, or the drug now has a new utilization requirement or limitation at the beginning of the new plan year, may ask Mercy Care Advantage to make a Coverage Determination and Exception Request for your drug.

In general, we will determine your right to a 30-day fill at the pharmacy when you go to fill your prescription. In some situations, we will need to get additional information from your doctor before we can determine if you are entitled to a transition 30-day fill.

If you live in a Long Term Care facility, and are entitled to a transition supply, we will allow you to refill your prescription until we have provided you with up to a 98-day supply (unless the prescription is written for less) during your transition period. If your prescription is written for less than a 98-day supply, we will allow for a total of up to a 98-day supply.

You may also be eligible to receive a transition fill outside of your 90-day transition period. For example, you may be eligible to receive a temporary supply of a drug if you experience a change in your “level of care” (i.e., if you have returned home from a stay in the hospital with a prescription for a drug that isn’t on the formulary). There are other situations where you may be entitled to receive a temporary supply of a prescription drug.

It is important that you understand that the transition fill is a temporary supply of this drug. Before this supply ends, you should speak to our Plan and/or your physician regarding whether you should change the drug(s) you are currently taking, or request an exception from our Plan to continue coverage of the drug. You, your authorized representative or your provider can ask for an exception request.

Mercy Care Advantage Coverage Determination and Exception request forms available below.

Coverage Determination/Exception form online

Fill out the Coverage Determination Form online.

You can also fill out this form in Spanish.

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

Coverage Determination/Exception form download

This form may be sent to us by mail or fax:

Mail:
Mercy Care Advantage
Part D Coverage Determination
Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

Fax: 1-855-230-5544

You may also ask us for a coverage determination by phone at 602-263-3000 or 1-800-624-3879 or through our website. We are available 8:00 a.m. - 8:00 p.m., 7 days a week. TTY/TDD users should call 711.

If you have questions about whether you are entitled to a temporary supply of a drug in a particular situation or you want to request for Mercy Care Advantage to make a Coverage Determination and Exception for your drug, please call Mercy Care Advantage Member Services at 602-263-3000 or toll-free at 1-800-624-3879, (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week.

Part D - Appeals

Appeals
If you are notified of a coverage determination denial by Mercy Care Advantage, you or your appointed representative may submit a redetermination request (1st level of appeal) within 60 calendar days from the date of the written notice. You may submit an appeal after this timeframe if you have good cause.

You may submit a redetermination request by calling Mercy Care Advantage or sending a request in writing. You or your physician may request a fast (expedited) appeal if it is believed that applying the standard timeframe could seriously affect your health. If Mercy Care Advantage does not agree, you will be notified and your redetermination will be automatically moved to the standard process.

Redetermination Request Form:

To submit a redetermination request call 602-453-6098 or 1-800-624-3879. TTY/TDD users should call 711.

Mail your redetermination request to:
Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040

You can also fax your redetermination request to: 602-351-2300

When you or your representative requests a redetermination, a special team will review your request, collect evidence and findings that the denial was based on and any additional evidence from you or your doctors. The case will then be reviewed by a different physician than the one who made the original determination. Mercy Care Advantage will notify you and your doctor of the redetermination decision, following the timeframes below.

If Mercy Care Advantage fails to make a redetermination decision and notify you within the timeframe, Mercy Care Advantage must submit your redetermination case file to IRE for review. Mercy Care Advantage will notify you if this action should occur. You have the right to a timely redetermination (see table below) and may file an expedited grievance if we do not notify you of our decision within this timeframe (see Grievances).

If Mercy Care Advantage notifies you of an unfavorable decision, and you disagree, you may submit a reconsideration request (second-level appeal) to the Independent Review Entity. Additional instructions will be included in the written notice.

1. Redetermination by Mercy Care Advantage

Standard appeal

Upon receipt of your appeal (redetermination), the Appeals Unit Coordinator will gather evidence on the basis of the denial of the Part D prescription drug, and additional evidence from you or your representative and prescribing doctor.

Your appeal will be evaluated by a clinical expert.

Mercy Care Advantage will notify you by telephone as fast as your health condition requires but not later than 7 calendar days from the receipt of the appeal.

Expedited appeal

You or your doctor may request Mercy Care Advantage to expedite your appeal if it believes that waiting for the standard timeframe will cause you serious harm.

Mercy Care Advantage will notify you of the decision by telephone as fast as your health condition requires but not later than 72 hours after receipt of your appeal.

If Mercy Care Advantage does not agree that your appeal requires a fast review, you will be notified that the standard timeframe will be applied.

2. Reconsideration by Independent Review Entity (IRE)

Standard appeal

If Mercy Care Advantage upholds the original denial for your prescription drug, you may send your appeal to the CMS-contracted IRE within 60 calendar days of the Mercy Care Advantage notice. The IRE will review your appeal and make a decision within 7 calendar days.

Expedited appeal

You may file a fast appeal with the IRE if you or your doctor believes that waiting for the standard timeframe will cause you serious harm. The IRE will review your appeal and notify you if they do not agree that your appeal requires a fast review, and will apply the standard timeframe. If the IRE agrees, they will notify you of their decision within 72 hours from the time your appeal was received.

3. Hearing with Administrative Law Judge (ALJ)

Standard appeal

If the IRE decision is unfavorable and the amount in dispute meets the requirements, you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE.

Expedited appeal

Same as standard appeal.

4. Review by Medicare Appeals Council (MAC)

Standard appeal

If the ALJ decision is unfavorable, you may appeal to the MAC, which is within the Department of Health and Human Services. The MAC oversees the ALJ decisions.

Expedited appeal

Same as standard appeal.

5. Federal District Judge

Standard appeal

If you do not want to accept the decision, you might be able to continue to the next level of the review process. It depends on your situation. Whenever the reviewer says no to your appeal, the notice you get will tell you whether the rules allow you to go on to another level of appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.

Expedited appeal

Same as standard appeal.

Part D - Coverage determinations (exceptions)

As a member of the Mercy Care Advantage health plan, you, your authorized representative or your doctor have the right to request a coverage determination or exception for a drug that you feel should be covered for you or to pay for a prescription drug you already bought. If your pharmacist tells you that your prescription drug claim was rejected, you will be given a written notice that explains how you can request a coverage determination or exception. This information is also explained in chapter 9 of the Evidence of Coverage.

Mercy Care Advantage has a list of covered Part D prescription drugs called a “formulary.” Your network doctor will refer to the formulary and typically prescribe a drug from the formulary that will meet your medical needs. Not all prescription drugs are listed on the Mercy Care Advantage formulary, and some formulary prescription drugs may require prior authorization, step therapy or have quantity limits that apply. Click to view the Mercy Care Advantage Formulary 10-1-2018.

A coverage determination is a decision (approval or denial) made by Mercy Care Advantage regarding whether to provide or pay for a Medicare Part D prescription drug. There may be times that you, your authorized representative or your doctor will want to ask for a coverage determination or exception. Mercy Care Advantage must review and process the request within the expedited (24 hours) or standard (72 hours) timeframes required by Medicare.

If the decision is yes to cover part or all of what was requested, you will be notified and the drug or payment will be provided.

If the decision is no, you will be notified and receive a written notice explaining why it was denied and how you can appeal this decision. An unfavorable decision could be because the drug is not on the formulary, determined not to be medically necessary, or you have not tried a similar drug listed on the formulary. It could also be based on whether or not you have satisfied the prior authorization requirement. In most situations, this process cannot be applied to any medications excluded from Part D under federal law (e.g. over-the-counter medications).

Requests can be made in writing, by phone or by fax. Members can call Mercy Care Advantage Member Services at the numbers provided below to request a coverage determination or exception. You may also use the Request for Coverage Determination Form to submit your request.

Coverage Determination Form:

Coverage Determination Form: Submit online
Opens In New WindowCoverage Determination Form: Download and print

Providers can call or fax a coverage determination or exception request to Mercy Care Advantage at the numbers below. A request for an exception needs to include a supporting statement from your doctor to provide the medical reasons for the drug requested.

Coverage Decisions for Part D Prescription Drugs

Mercy Care Advantage Members:
602-263-3000 in the Phoenix Metro Area
1-800-624-3879 (calls to this number are free)
TTY: 711
Hours of Operation: 8:00 a.m. - 8:00 p.m., 7 days a week

Fax Number:
Mercy Care Advantage
Part D Coverage Determination
Fax: 1-855-230-5544

Write:
Mercy Care Advantage
Part D Coverage Determination Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

Request to Satisfy a Prior Authorization (PA) or other utilization management (UM) requirement

Standard coverage determination timeframe

MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision as fast as your health condition requires but not later than 72 hours from the receipt of the request.