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.

Opioid safety alert #4

Optional safety alert at 200 MME or more (“hard edit”)

Some plans may implement a hard safety alert when a patient’s cumulative opioid daily dosage reaches 200 MME or more.

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

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

This alert stops the pharmacy from processing the prescription until an override is entered or authorized by the plan.

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.

In the absence of other approved utilization management requirements, once the prescriber(s) attests that the identified cumulative MME level is the intended and medically necessary amount, the medication will be dispensed to the patient.

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 and prior authorization criteria (PDF). 

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
  4500 E. Cotton Center Blvd.
  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 60 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 
  4500 E. Cotton Center Blvd. 
  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 2024 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 / $1.55 / $4.50 (each prescription)
• Copayment amount for all other drugs: no more than: $0 / $4.60 / $11.20 (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

The MTM program helps members get the most from their medications by:

• Preventing or reducing drug-related risks
• Supporting good lifestyle habits
• Providing options for safe medication disposal

Who qualifies for the MTM program? 
We’ll enroll members if they have coverage limitations in place for medications with a high risk for dependence and/or abuse.

We’ll also enroll members who meet all these criteria:

• Have three of more of these conditions:
  
  
  • Asthma
  • Chronic heart failure (CHF)
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Chronic alcohol and drug dependence
  • HIV/AIDS

• Take eight or more covered maintenance medications  
• Are likely to spend more than $4,696 in prescription drug costs in 2022

This no-cost program is voluntary and doesn’t affect the member's coverage. It’s not a plan benefit and is open only to those who qualify. 

How will a member know if they qualify? 
We’ll mail the member a letter. They may also receive a call to set up a one-on-one medication review.

What services are included? 
Members receive these services from a health care provider:

• Comprehensive medication review
• Targeted medication review

What is a comprehensive medication review? 
This review is a discussion that includes all the member’s medications:

• Prescriptions
• Over-the-counter (OTC)
• Herbal therapies
• Dietary supplements

A health care provider reviews the medications with members in person or over the phone. This review usually takes less than 20 minutes to complete. 

During the review, the member may ask any questions about medications or health conditions. The health care provider may offer ways to help them manage their health and get the most from their medications. If the health care provider needs more information, they may contact the prescriber.

At the end of the review, the health care provider gives a summary of the discussion. The summary includes:

• The medication action plan may include suggestions for the member and the prescriber to discuss during the member’s next visit.
• The personal medication list includes all the medications discussed during the review. Members can keep this list and share it with prescribers and/or caregivers.

Members can print and complete the personal medication list (PDF) (English and Español in one) to track their medications. 

Who will contact the member about completing the review? 
Members may receive a call from the pharmacy where they recently filled one or more of their prescriptions. They can choose to complete the review in person or over the phone. 
 
A health care provider may also call members to complete the review over the phone. When they call, members can schedule the review at a time that works best for them.  

Why is this review important? 
Different prescribers may write prescriptions for members without knowing all the medications they take. For that reason, the MTM program health care provider will:

• Review all the member’s medications
• Discuss how the medications may affect each other
• Identify any side effects from the medications
• Help reduce prescription drug costs

How do members benefit from talking with a health care provider? 
These medication reviews can help members:

• Understand how to safely take medications
• Get answers to any questions about medications or health conditions
• Review ways to help save money on drug costs

Track medications with a personal medication list (PDF) (English and Español in one) and medication action plan to keep and share with prescribers and/or caregivers

What is a targeted medication review? 
With a targeted medication review, a health care provider reviews the member’s medications at least once every three months. With this review, we mail, fax or call the prescriber with suggestions about prescription drugs that may be safer or work better for the member. 

As always, the prescriber can decide whether to consider our suggestions. The member’s prescription drugs won’t change unless the member and the prescriber decide to change them. We may also contact the member by mail or phone with suggestions about medications.

How can members learn more about the MTM program? 
They can contact us to learn more or tell us if they don’t want to take part at 602-586-1730 or 1-877-436-5288 (TTY 711). We’re here for them 8 a.m. to 8 p.m., 7 days a week. 

How do members safely dispose of medications they don’t need? 
Members should dispose of unneeded medications as soon as possible. They can do so through a local safe disposal program or for some medications, at home. Here are some options:

Local drug take-back sites: People can enter their ZIP code or city to find a local drop-off site. This is the best way to safely dispose of medications.

Authorized drug disposal sites: People can mail their medications to authorized sites using approved packages. 

Safe at-home medication disposal: People can safely dispose of many medications through the trash or by flushing them down the toilet. For safe disposal in the trash:

• Remove medication labels to protect personal information
• Mix medications with undesirable substances, such as dirt or used coffee grounds
• Place mixture in a sealed container, such as an empty margarine tub

Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs and other ways for safe disposal. Pharmacies and local police departments (non-emergency number) can give people other options.

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