Part D: Prescription Drug Benefits

Formulary and Utilization Criteria

Formulary (List of Covered Drugs)

2021 Formulary Updated 10/2021

2022 Formulary Updated 10/2021

or

Search our online 2021 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:

2021 Prior Authorization Criteria Updated 10/2021
2022 Prior Authorization Criteria
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.

2021 Step Therapy Criteria No changes made since 10/2020
2022 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.  For complete information about the coverage determination process or appeal process, view the Coverage Determination menu below or refer to the Evidence of Coverage on this page.

Opioid Requirements and Drug Management Program

Safe Use of Opioid Pain Medication – Information for Medicare Part D Patients

Prescription opioid pain medications—like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine—can help treat pain after surgery or after an injury, but they carry serious risks, like addiction, overdose, and death. These risks increase with the higher the dose you take, or the longer you use these pain medications, even if you take them as prescribed. Your risks also increase if you take certain other medications, like benzodiazepines (commonly used for anxiety and sleep), or get opioids from many doctors and pharmacies.

Medicare is dedicated to helping you use prescription opioid pain medications more safely, and introduced new policies for opioid prescriptions in the Medicare Part D prescription drug program beginning in January 2019.

Safety reviews when opioid prescriptions are filled at the pharmacy

Your Medicare drug plan and pharmacist will do safety reviews of your opioid pain medications when you fill a prescription. These reviews are especially important if you have more than one doctor who prescribes these drugs. In some cases, the Medicare drug plan or pharmacist may need to first talk to your doctor.

Your drug plan or pharmacist may do a safety review for:

• Potentially unsafe opioid amounts.
• If you take opioids with benzodiazepines like Xanax®, Valium®, and Klonopin®.
• New opioid use—you may be limited to a 7-day supply or less. This does not apply to you if you already take opioids.

If your pharmacy can’t fill your prescription as written, including the full amount on the prescription, the pharmacist will give you a notice explaining how you or your doctor can contact the plan to ask for a coverage decision. If your health requires it, you can ask the plan for a fast coverage decision. You may also ask your plan for an exception to its rules before you go to the pharmacy, so you’ll know if your plan will cover the medication.

Drug Management Programs (DMPs)

Starting January 1, 2019, some Medicare drug plans (Part D) will have a DMP. If you get opioids from multiple doctors or pharmacies, your plan may talk with your doctors to make sure you need these medications and that you’re using them safely.

If your Medicare drug plan decides your use of prescription opioids and benzodiazepines isn’t safe, the plan may limit your coverage of these drugs. For example, under its DMP your plan may require you to get these medications only from certain doctors or pharmacies to better coordinate your health care.

Before your Medicare drug plan places you in its DMP, it will notify you by letter. You’ll be able to tell the plan which doctors or pharmacies you prefer to use to get your prescription opioids and benzodiazepines. After you’ve had the opportunity to respond, if your plan decides to limit your coverage for these medications, it will send you another letter confirming its decision. You and your doctor can appeal if you disagree with your plan’s decision or think the plan made a mistake. The second letter will tell you how to contact your plan to make an appeal.

Note: The safety reviews and DMPs should not apply to you if you have cancer, get hospice, palliative, or end-of-life care, or if you live in a long-term care facility.

Talk with your doctor

Talk with your doctor about all your pain treatment options including whether taking an opioid medication is right for you. There might be other medications you can take or other things you can do to help manage your pain with less risk. What works best can be different for each patient. Treatment decisions to start, stop or reduce prescription opioids are individualized and should be made by you and your doctor. For more information on safe and effective pain management, visit CDC.gov/drugoverdose/patients.

Additional Resources

Contact your Medicare drug plan for additional information. You can find contact information in your member materials or on your membership card.

Other resources include:

• “Your Guide to Medicare Prescription Drug Coverage” at: www.Medicare.gov/publications
• “How Medicare Drug Plans use Pharmacies, Formularies, & Common Coverage Rules” at: https://www.medicare.gov/Pubs/pdf/11136-Pharmacies-Formularies-Coverage-Rules.pdf
• Call the State Health Insurance Assistance Program (SHIP). Visit www.shiptacenter.org or call 1-800-MEDICARE for the phone number of your SHIP.
• For resources and information about the National Opioid Crisis go to: www.hhs.gov/opioids or the Center for Disease Control (CDC) at: https://www.cdc.gov/drugoverdose/epidemic/index.html
• For more information on what Medicare covers and drug coverage rules, visit Medicare.gov. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
  
  

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.

2021 Low Income Subsidy (LIS) Rider – Benefit increase (English | Espanol)

2021 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:

1. You have full coverage from a state Medicaid Program like AHCCCS
2. You get help from Medicaid paying your Medicare Part B premiums
3. 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 the Social Security website. You also may apply at your State Medical Assistance (Medicaid) office at 602-417-4000 or 1-800-654-8713. 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.

2021 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 / $1.30 / $3.70 (each prescription)

Your cost sharing amount for all other drugs is no more than:
$0 / $4.00 / $9.20 (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 (MTM) program

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 program?
We will automatically enroll you in the Mercy Care Advantage MTM Program at no cost to you if all three conditions apply: 

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

• Asthma
• Chronic obstructive pulmonary disease (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 $4,376 in yearly prescription drug costs paid by you and the plan. 

Your participation is voluntary, and does not affect your coverage.  The program is no cost to you and is open only to those who are invited to participate.  The program is not a benefit for all plan members. 

What services are included in the program?
The program provides you with a: 

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

Comprehensive Medication Review (CMR)
The review 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 medications you take. If more information is needed, the pharmacist may contact your prescribing doctor. The review takes about 30 minutes and is usually offered once each year—if you qualify. At the end of your discussion, the pharmacist will provide you a Personal Medication List with the medications you discussed during your review. 

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 for tracking your prescriptions. 

Targeted Medication Review (TMR)
With this review, we mail, fax or call your doctor with suggestions 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 program?
If you qualify, we will mail you a letter. Also, you may receive a call inviting you to participate in this one-on-one medication review.

Who will contact me about the review?
You may receive a call from a pharmacy where you recently filled one or more of your prescriptions.  You will be given the option to choose an in-person review or a phone review.

You may be contacted by a call center pharmacist to provide your review, and ensure that you have access to the service if you want to participate.  These 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 program?
Please contact us if you would like additional information about our program, or if you do not want to participate after being enrolled in the program.  Our Member Services numbers are 602-586-1730 or 1-877-436-5288, 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 Member Services. 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 (TTY 711) 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 member's Medicare Part D benefit:

• Call Mercy Care Advantage at 1-877-436-5288, 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 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 31-day supply of that prescription drug (or less, as prescribed, up to a 31-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 31-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 31-day supply, you can get it refilled until you reach the 31-day supply.

If you are an existing member and are taking a Part D drug that is not on the  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), you are entitled to receive a 31-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 31-day supply, you can get it refilled until you reach the 31-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 31-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 31-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 31-day supply (unless the prescription is written for less) during your transition period.  If your prescription is written for less than a 31-day supply, we will allow multiple fills to provide up to a maximum of 31-days of medication.

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

Coverage Determination/Exception form download

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. 

Appointment of Representative (AOR) and AOR form

If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” This may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, or other person to be your representative you must provide a completed Appointment of Representative (AOR) form. A copy of the AOR form is available below for download and printing or you can contact Member Services and ask for the Appointment of Representative form to be mailed to you. You can reach Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week.

The form must be completed and signed by you and by the person who you would like to act on your behalf. The completed and signed form is valid for one year.  You are not required to use the AOR, you can also provide a written notice that contains the information below:

1. Enrollee’s name, address, and telephone number;
2. Enrollee’s Medicare Identifier Number
3. The name, address, and telephone number of the individual being appointed;
4. A statement that authorizes the representative to act on your behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to your representative;
5. Must be signed and dated by the enrollee making the appointment; and
6. Must be signed and dated by the individual being appointed as your representative, and is accompanied by a statement that the individual accepts the appointment.

For medical care, your doctor can request a coverage decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it will automatically be forwarded to Level 2.  To request any appeal after Level 2, your doctor must be appointed as your representative.

For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or Level 1 or Level 2 appeal on your behalf. To request an appeal after Level 2, your doctor or other prescriber must be appointed as your representative.

Appointment of Representative Form (English | Español)

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:

• Submit form online
• Download printable form

To submit a redetermination request call 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week.

Mail your redetermination request to:
Mercy Care Advantage
Attn: Part D Appeals
Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

You can also fax your redetermination request to: 1-855-230-5544

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.

Description

1. Redetermination by Mercy Care Advantage

2. Reconsideration by Independent Review Entity (IRE)

3. Hearing with Administrative Law Judge (ALJ)

4. Review by Medicare Appeals Council (MAC)

5. Federal District Judge

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.

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.

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.

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.

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

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.

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.

Same as standard appeal.

Same as standard appeal.

Same as standard appeal.

More information on appeals

The prescription drug coverage expedited appeals (redetermination) process 
You may file a request for an expedited appeal for drug coverage if you believe that applying the standard appeals process could jeopardize your health. If Mercy Care Advantage decides that the timeframe for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.

1. You, your appointed representative or your doctor or other prescriber can request an expedited appeal. An expedited request can be submitted orally or in writing to Mercy Care Advantage and your doctor or other prescriber may provide oral or written support for your request for an expedited appeal.
2. Mercy Care Advantage must provide an expedited appeal if it determines that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.
3. A request made or supported by your doctor or other prescriber will be expedited if he/she tells us that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

Appointment of representative 
If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” Please go to the Appointment of Representative menu on this page to learn more and get a copy of the form.

Coverage Determination Form:

• Submit form online  
• Download printable form

Please see Chapter 9, Section 7 of the Evidence of Coverage on this page for more information about Part D prescription drug coverage determinations and appeals.

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week.

Part D - Coverage Determinations

As a member of Mercy Care Advantage, 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 included on the Mercy Care Advantage formulary, and some drugs covered under our formulary may require prior authorization, step therapy or have quantity limits that apply. You can view the formulary, prior authorization criteria and step therapy criteria in the Formulary menu on this page.

A coverage determination is any determination (e.g. an approval or denial) made by Mercy Care Advantage for the following reasons:

1. A decision about whether to provide or pay for a Part D drug (including a decision not to pay) because:

• the drug is not on the plan’s formulary
• the drug is determined not to be medically necessary
• the drug is furnished by an out-of-network pharmacy
• Mercy Care Advantage determines that the drug is otherwise excluded under section 1862(a) of the Act (if applied to Medicare Part D) that the enrollee believes may be covered by the plan

2. Failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the enrollee;

3. A decision concerning a tiering exceptions request;

4. A decision concerning a formulary exceptions request;

5. A decision on the amount of cost sharing for a drug; or

6. A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement.

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.

In order for us to cover a formulary exception, your doctor must provide a statement that says you have tried formulary alternatives in the same drug class and they didn’t work for you, or a medical reason why you can’t try the formulary alternatives in the same drug class.

If we approve the request, you will be notified and the drug or payment will be provided.

If we deny the request, 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, excluded from Part D coverage, 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).

Coverage determination 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
Coverage 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: 
602-586-1730 or 1-877-436-5288 TTY: 711  
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

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week.

 

Description	Standard coverage determination timeframe	Expedited coverage determination timeframe
Request to Satisfy a Prior Authorization (PA) or other utilization management (UM) requirement	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.	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 no later than 24 hours after receiving the request.
Request to Waive a Prior Authorization (PA) or other utilization management (UM) requirement – Formulary Exception Request	If an enrollee or an enrollee's prescribing physician or other prescriber is asking MCA to waive a PA or other UM requirement because the physician or other prescriber feel that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support this type of request. 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 no later than 72 hours after receiving the physician's or other prescriber's supporting statement for standard cases.	If an enrollee or an enrollee's prescribing physician or other prescriber is asking MCA to waive a PA or other UM requirement because the physician or other prescriber feel that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support this type of request. 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 no later than 24 hours after receiving the physician's or other prescriber's supporting statement for standard cases.
Request for Reimbursement for drug already received that involves waiving a Prior Authorization (PA) or other utilization management (UM) requirement – Exception Request	If an enrollee is asking to be reimbursed for a drug purchased that requires MCA to waive a PA or other UM requirement because the physician or other prescriber feel that the enrollee would suffer adverse effects if he or she were required to satisfy the PA requirement, this is considered an exception request. The prescribing physician or other prescriber must submit a statement to support the request. MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision (and make payment when appropriate) no later than 14 calendar days after receiving the request.	Reimbursement requests do not qualify for expedited processing.
Request for Tiering Exception - drug not yet received	If an enrollee wishes to obtain a tiering exception for a drug not yet received, his or her prescribing physician or other prescriber must provide the plan sponsor with a statement to support the request.   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 no later than 72 hours after receiving the physician’s or other prescriber's supporting statement.	If an enrollee wishes to obtain a tiering exception for a drug not yet received, his or her prescribing physician or other prescriber must provide the plan sponsor with a statement to support the request.   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 no later than 24 hours after receiving the physician’s or other prescriber's supporting statement.
Request for Tiering Exception Reimbursement	If an enrollee is asking for a reimbursement related to a tiering exception. The prescribing physician or other prescriber must submit a statement to support the request.   MCA must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision (and make payment when appropriate) no later than 14 calendar days after receiving the request.	Reimbursement requests do not qualify for expedited processing.

Appointment of representative
If you need help with a coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.” Please go to the Appointment of Representative menu on this page to learn more and get a copy of the form.

 

Part D - Grievances

How to file a grievance
You have the right to file a complaint (also called a “grievance”) if you have a problem or concern. A grievance is any complaint or dispute, other than one that involves a coverage determination or an LIS (Low-Income Subsidy) or LEP (Late Enrollment Penalty) determination, expressing dissatisfaction with any aspect of the operations, activities or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times and the customer service you receive.

You may file a grievance if you have a problem with Mercy Care Advantage or one of our network providers or pharmacies. Some examples of why you might file a complaint/grievance include:

You believe your plan's customer service hours of operation should be different. You have to wait too long for your prescription. The plan is sending you materials that you didn’t ask to get and aren’t related to the drug plan. The plan didn’t make a timely decision about a coverage determination in level 1 and didn’t send your case to the IRE. You disagree with the plan’s decision not to grant your request for an expedited (fast) coverage determination or first-level appeal (called a “redetermination”). The plan didn't provide the required notices. The plan's notices don't follow Medicare rules.

We may use your complaint type to track trends and identify service issues. Please see Chapter 9 of the Evidence of Coverage on this page for detailed information and timelines for filing a grievance.

If you want to file a grievance, contact us promptly – either by phone or in writing. Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can reach Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works:

If you ask for a written response, file a written grievance or your complaint is related to quality of care, we will respond to you in writing. If we cannot resolve your complaint over the phone, we will respond to your complaint within 30 calendar days.

Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 days after you had the problem you want to complain about. If you need an interpreter, one can be provided at no cost to you. Please submit written complaints to the address below, or by faxing them to 602-351-2300.

Mercy Care Advantage
Attn: Grievance Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

You may file a request for a "fast complaint" (expedited grievance) if you disagree with our decision not to process your request for a "fast response" to a coverage decision or appeal. If you request a fast complaint, we must give you an answer within 24 hours.

If you have a complaint about your quality of care, you may file a grievance with the plan by calling Member Services and filing the complaint over the phone. The plan Quality Team will research the complaint and send a response to you. You may also file a grievance with Arizona's Quality Improvement Organization, Livanta at 1-877-588-1123.

Livanta LLC
BFCC-QIO
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701-1105
1-877-588-1123  TTY: 1-855-887-6668

Fax:
1-833-868-4063

If you would like to learn how many appeals, grievances and exceptions Mercy Care Advantage has processed, please contact our representatives at 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week.