Part D prescription drug information

Providers are in the best position to identify and manage potential opioid overuse in the Medicare Part D population. New opioid policies from the Centers for Medicare & Medicaid Services (CMS) include:

• Improved safety alerts when opioid prescriptions are dispensed at the pharmacy
• Drug management programs for patients determined to be at-risk for misuse or abuse of opioids or other frequently abused drugs

People who are exempt from these interventions include those who are:

• Living in long-term care facilities
• Receiving hospice care
• Receiving palliative or end-of-life care
• Receiving treatment for active cancer-related pain 

These policies shouldn’t impact access to medication-assisted treatment (MAT), such as buprenorphine.

Part D plans are expected to implement safety alerts (pharmacy claim edits) for pharmacists to review at the time of dispensing the drug to prevent unsafe utilization. CMS encourages prescribers to resolve opioid safety edits expeditiously and avoid disruption of therapy by:

• Responding to pharmacy outreach in a timely manner 
• Giving the appropriate training to on-call prescribers when necessary 

Opioid safety alert #1

Seven-day supply limit for opioid naïve patients (“hard edit”)

Medicare Part D patients who have not filled an opioid prescription recently (such as within the past 60 days) will be limited to a supply of 7 days or less.

Limiting the amount dispensed with the first opioid prescription may reduce the risk of a future dependency or overuse of these drugs.

Important note: This alert should not impact patients who already take opioids.

Prescriber’s role

Patient may receive up to a 7-day supply or request a coverage determination for full days’ supply as written.

The physician or other prescriber has the right to request a coverage determination on patient’s behalf, including the right to request an expedited or standard coverage determination in advance of prescribing an opioid.

Prescriber only needs to attest to plan that the days’ supply is the intended and medically necessary amount.

Subsequent prescriptions written by prescribers are not subject to the 7-day supply limit, as the patient will no longer be considered opioid naïve.

Opioid safety alert #2

Opioid care coordination alert at 90 morphine milligram equivalent (MME)

This policy will affect Medicare patients when they present an opioid prescription at the pharmacy and their cumulative MME per day across all of their opioid prescription(s) reaches or exceeds 90 MME.

Some plans use this alert only when the patient uses multiple opioid prescribers and/or opioid dispensing pharmacies.

The prescriber will be contacted to resolve the alerts and to be informed of other opioid prescribers or increasing level (MME) of opioids.

Important note: This is not a prescribing limit. Decisions to taper or discontinue prescription opioids are individualized between the patient and prescriber.

Prescriber’s role

Regardless of whether individual prescription(s) are written below the threshold, the alert will be triggered by the fill of the prescription that reaches the cumulative threshold of 90 MME or greater.

The prescriber who writes the prescription will trigger the alert and will be contacted even if that prescription itself is below the 90 MME threshold.

Once a pharmacist consults with a prescriber on a patient’s prescription for a plan year, the prescriber will not be contacted on every opioid prescription written for the same patient after that unless the plan implements further restrictions.

On the patient’s behalf, the physician or other prescriber has the right to request a coverage determination for a drug(s), including the right to request an expedited or standard coverage determination in advance of prescribing an opioid.

Opioid safety alert #3

Concurrent opioid and benzodiazepine use or duplicative long-acting opioid therapy (“soft edits”)

The alerts will trigger when opioids and benzodiazepines are taken concurrently or if on multiple duplicate long-acting opioids.

Prescriber’s role

The pharmacist will conduct additional safety reviews to determine if the patient’s opioid use is safe and clinically appropriate. The prescriber may be contacted.

Medicare Part D plans may have a DMP that limits access to opioids and benzodiazepines for members considered by the plan to be at risk for prescription drug abuse.

The goal of a DMP is better care coordination for safer use. Coverage limitations under a DMP can include:

• Requiring the patient to get these drugs from a specified prescriber and/or pharmacy
• Implementing an individualized point-of-service (POS) edit that limits the amount of covered drugs  

The coverage limitation tools may be in place for 12 months and extend to another 12 months (total of 24 months).

Process for coverage limitations

1. We identify potential at-risk members by opioid use that involves multiple doctors and pharmacies. 
2. We conduct case management and review with the prescriber.
3. We notify the member in writing to explain a possible coverage limitation. We make a reasonable effort to send the prescriber a copy of the letter. 
4. After our 30-day review, if we determine the member is at risk and implement a limitation, we’ll send the member a second written notice confirming the limitation and its duration.
5. If we limit coverage under a DMP, members and prescribers have the right to appeal our decision. You can read about Part D appeals later on this page. Or call us 1-800-624-3879 (TTY 711). Choose option 2. We’re here for you 8 a.m. to 8 p.m. 7 days a week.

Here are some transitions we allow for new and existing members as part of the TOC:

• New members get a one-time temporary fill if the drug they were taking before they joined our plan isn’t covered. 
• Existing members get a transition fill if a drug they’re currently taking isn’t going to be covered on the Mercy Care Advantage formulary in the new plan year.   

TOC communication

• Members who receive a transition fill for a drug receive a letter explaining the drug was filled under the transition-of-coverage process. 
• The prescribing provider will also receive notification. 
• The letter explains the action required for the member to receive plan approval for their existing drug or how to switch to another drug covered on the formulary. 

This one-time temporary fill gives the member an opportunity to work with their doctor to decide if they:

• Need to continue on their current drug to avoid disruption in treatment 
• Can get a prescription for another drug on the Mercy Care Advantage formulary

If members need to stay with their existing prescription, follow the instructions to submit a request to us for review. These instructions follow in the next topic: Coverage determination and exception requests.

We generally cover the drugs on our formulary if they’re medically necessary. You can ask for a Part D coverage determination on behalf of a member. 

When you ask for a formulary or utilization restriction exception, you’ll want to include a supporting statement to explain the medical reason.

Need to learn which drugs need prior authorization (PA) or have utilization restrictions? Review our online formulary. 

Ask for a coverage determination or make an exception request 

First, verify member eligibility before you provide services. You can check eligibility:

• Online: Log in to your Mercy Care web portal with your credentials.  
• By phone: Use our interactive voice recognition (IVR) system (PDF), available anytime. Or contact us for help.

Then, you can ask for a coverage determination or make an exception request:

• Online: Complete and submit the online coverage determination request form English | Spanish.
• By phone: Call 602-586-1730 or 1-877-436-5288 (TTY 711). We’re here for you 7 days a week, 8 a.m. to 8 p.m.
• By fax: Print and complete the coverage determination request form (PDF). Then, fax it with any supporting documentation to 1-855-230-5544.
• By mail: Print and complete the coverage determination request form (PDF). Then, mail it to:
  Mercy Care Advantage
  Part D Coverage Determination
  Pharmacy Department
  4750 S. 44th Place, Suite 150
  Phoenix, AZ 85040

What happens next

We’ll review the request and make a determination within the time frames Medicare requires. Then, we’ll let you and the member know the decision. 

Reminder: To cover a formulary exception, we need your statement that one of these situations apply:

• The member has tried at least two formulary alternatives in the same drug class and the alternatives didn’t work for them 
• The medical reason why the member can’t try at least two formulary alternatives in the same drug class

Request for redetermination of Medicare prescription drug denial 

If we denied a request for coverage of (or payment for) a prescription drug, members have the right to ask us for a redetermination (appeal) of our decision. 

Members (or their appointed representatives) can ask us for a redetermination (Level 1 appeal) within 65 calendar days from the date of our Notice of Denial of Medicare Prescription Drug Coverage. 

Providers can ask for redetermination (Level 1 appeal) on a member’s behalf. You can also ask for a fast (expedited) appeal if you believe the standard appeal time frame could seriously affect the member’s health. If we don’t agree, we’ll automatically move the redetermination to the standard appeal process. 

Providers and members can submit a redetermination request:

• Online: Complete our online coverage redetermination form English | Español. 

• By phone: Providers can call 602-586-1719 or 1-877-436-5288 (TTY 711). Members can call 1-877-436-5288 or 602-586-1730 (TTY 711).

• By fax: Print and complete the redetermination form (PDF). On the cover sheet, write: Attn: Part D Appeals-Pharmacy Department. Then, fax it to 1-855-230-5544.

• By mail: Print and complete the redetermination form (PDF). Then, mail it to:
  Mercy Care Advantage 
  Attn: Part D Appeals Pharmacy Department 
  4750 S. 44th Place, Suite 150 
  Phoenix, AZ 85040

Appeals after Level 1

You can still ask for an appeal on behalf of a member. To do so, the member must make you their representative by completing the appointment of representative form English (PDF) | Español (PDF). 

Also known as “Extra Help,” the LIS program helps cover the cost of prescription drugs for people with low incomes who are eligible for the Medicare Part D program. 

Mercy Care Advantage plan members typically qualify for Extra Help and receive a copy of the LIS Rider that explains their Part D prescription drug cost-sharing responsibilities. 

Here are the 2026 cost-sharing amounts for members who qualify:

• Mercy Care Advantage monthly plan premium: $0
• Mercy Care Advantage yearly deductible: $0
• Copayment amount for generic/preferred multisource drugs: no more than: $0 / $1.60 / $5.10 (each prescription)
• Copayment amount for all other drugs: no more than: $0 / $4.90 / $12.65 (each prescription)

The $0 cost share (copayment) applies to members who:

• Live in a long-term care facility
• Have reached the catastrophic coverage stage of Part D prescription benefit coverage in the current calendar year

Medication Therapy Management (MTM) Program

MedWatchers will perform all elements required for Medication Therapy Management per CMS required standards for Medicare Part D to include all of the following:

• Qualify members for MTM services based on plan’s custom qualification criteria. Eligible Medicare Part D patients are targeted for qualification based on their prescription claims history. The qualification will be completed per annual CMS MTM Program Submission. At-risk beneficiaries (ARBs) under a Drug Management Program (DMP) will need to be provided to MedWatchers monthly to allow for incorporation into standard MTM Services
• Mail welcome letters and conduct initial telephonic outreach within 60 days of qualification to introduce our collaborative MTM services.
• Complete targeted medication reviews (TMRs), at least quarterly, with provider-facing interventions via fax throughout the calendar year.
• Engage members to complete their annual comprehensive medication review (CMR) via multiple methods to include telephonic, SMS, and telehealth and via various touchpoints including LTC/SNF and providers/caregivers/other authorized individuals for cognitively impaired members. Includes caller authentication technology solutions and finding alternative phone numbers.
• Conduct the CMR, where a pharmacist or pharmacy intern will:

1. Review the member’s entire medication list, including prescription medications, over-the counter medications, herbal therapies, and dietary supplements.
2. Deliver member-specific interventions with the goals to ensure optimal therapeutic outcomes, reduce the risks for medication-related adverse effects, improve member adherence, provide opportunity for potential cost savings.
3. Provide provider communications via electronically fax/direct secure messaging or phone of actionable recommendations for resolving any medication related problems, concerns, or closure of gap measures
4. Document all elements of the program within MedWatchers’ proprietary MTM platform, Care Management Application (CMAPP).

• Mail a complete personal medication list (PML), a To-Do-List, and any other approved member educational documents to each member that completes a CMR within seven (7) calendar days, to allow time for redelivery of any returned, undelivered mail.
• Provide a toll-free number for members to call inbound during standard business hours with a voicemail system for calls outside of normal business hours.
• Deliver on a weekly basis, a list of member contact information, specifically for incorrect/disconnected phone numbers and members who express an indication to not to be contacted again (DNC).
• Establish the ability to accept warm transfers of eligible MTM members to a pharmacist to complete MTM services directly from customer service, care management, or other health plan programs.
• Provide all data elements required for end of year reporting specific to the services outlined herein in order for CVS to complete the required annual CMS MTM reporting as outlined in Section III, Medication Therapy Management Programs of the Medicare Part D Reporting Requirements.
• Support all CMS Data Validation audit needs related to the services provided by MedWatchers. The client manager and an IT representative will be available to provide assistance and support during the data validation audit itself and throughout the entire process.

We are committed to ensuring you have the best information and the latest technology and tools. So we’ve partnered with CoverMyMeds® and SureScripts to provide a new way to request a pharmacy PA through the ePA. You can look forward to:

• Saving time: Less paperwork, fewer phone calls and faxes for PA requests 
• Quicker determinations: Reduced average wait times with resolution often in minutes
• A secure process with HIPAA compliance

Easy start with no cost for ePA

• Getting started is easy and costs nothing. Choose how you’d like to enroll:
• Visit the CoverMyMeds website or call 1-866-452-5017
• Visit the SureScripts website or call 1-866-797-3239

ePA details you may need

• BIN: 610591
• Group: RX8803
• PCN: MEDDADV