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MetroPlus Medicare Prescription Drug Coverage 2012
Formulary
Pharmacy Network
Drug Utilization Management Information
Exceptions and Appeals Resources
Coverage Determination
Exceptions
Appeals
Grievances
How to obtain grievances, appeals and exceptions information
Transition Process
Medication Therapy Management Program (MTMP)
Potential for contract termination
Rights and Responsibilities upon Disenrollment
Best Available Evidence
Prior Authorization
Quantity Limits
Step Therapy
Best Available Evidence Policy
What is the MetroPlus Medicare Advantage Plan Formulary?
A formulary is a list of covered drugs selected by MetroPlus in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. MetroPlus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a MetroPlus network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
2012 MetroPlus Abridged Formulary (coming soon)
2012 MetroPlus Comprehensive Formulary
Formulary Look-Up
Can the Formulary change?
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or improve the safety of your drugs.
MetroPlus will provide at least 60 days notice prior to making changes to the formulary except in cases of safety where we have been notified of a possible safety issue by the FDA or the drug manufacturer has removed the drug.
Pharmacy Network - MetroPlus Health Plan has over 2100 network pharmacies in our service area.
• Description of Out of Network Coverage
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Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. There may be restrictions for prescriptions filled at out-of-network pharmacies, such as a limit on the amount of the drug you can receive.
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If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs. Note: We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for medical emergency.
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You need prescriptions related to care for a medical emergency or urgent care.
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If you are unable to obtain a covered drug in a timely manner within our service area, because there is no network pharmacy within reasonable driving distance that provides 24-hour service.
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If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail order pharmacy (including high cost and unique drugs).
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Drug Utilization Management Information
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Prior Authorization: We require you to get prior authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don't get the necessary information to satisfy the prior authorization, we may not cover the drug.
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Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to a 30-day supply per 30-day period for a formulary drug.
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Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
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• How to obtain grievances, appeals and exceptions information
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Please contact Customer Services for information on the number of grievances, appeals and exceptions.
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• Transition Process
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MetroPlus has a process in place which allows new members to receive a temporary supply of a drug in the following circumstances - if your drug is not covered on our formulary or is covered on our formulary but we have placed a prior authorization, quantity limit or other limit on it.
During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered.
Please read on for details on which temporary supply policy meets your situation.
Members who are new to the plan and are not in a long-term care facility: MetroPlus will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days.
New members who are residents in a long-term care facility: MetroPlus will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31 days or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
Members of the plan for more than 90 days who are residents of a long-term care facility and need a supply right away: MetroPlus will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
To ask for a temporary supply, please call MetroPlus Customer Services at 866-986-0356 or TTY 800-881-2812, Monday through Saturday from 8 am to 8 pm.
Here are your options after you have used up your temporary supply:
You can change to another drug - In some cases, there is a different drug covered by the plan that might work just as well for you. Please talk to your doctor about this. You can call Customer Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor to find a covered drug that might work for you.
You can file an exception - You and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule.
If you have any questions about this Transition (Temporary) Supply Policy, please call MetroPlus Customer Services at 866-986-0356 or TTY 800-881-2812, Monday through Saturday from 8 am to 8 pm.
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• Medication Therapy Management Program (MTMP)
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At MetroPlus, we are committed to ensure that you receive the best possible care and service. We have programs to improve the way our members use prescription drugs. One of these programs is the Medication Therapy Management Program which is for members who have multiple medical conditions, are taking many prescription drugs and have high drug costs. We will contact you by mail if you are eligible to participate in the program.
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• Potential for contract termination
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MetroPlus may not be available for the following contract year because by law, MetroPlus can choose to not renew our contract with CMS or reduce our service area. CMS may also refuse to renew the contract, thus, resulting in a termination or non-renewal.
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• Rights and Responsibilities upon Disenrollment
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You have the opportunity to make one change to your health coverage during the Medicare Advantage Annual Disenrollment Period from January 1 to February 14. During this time, you can cancel your Medicare Advantage enrollment and switch to Original Medicare. If you choose to switch to Original Medicare, you may also choose a separate Medicare prescription drug plan at the same time. In certain situations, you may be eligible to end your membership at other times of the year. Please contact Customer Services for additional information.
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• Best Available Evidence
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If you believe that you qualify for extra help and you may be paying the wrong copayment amount for prescription drugs, please contact MetroPlus Customer Services. We will work with you to update your LIS status based on the best available evidence. For example, you might provide us with evidence of Medicaid status, which may show that you qualify you for Extra Help. Once you provide us with acceptable evidence, we will update our system and notify CMS. When you go to the pharmacy, the copayment you pay will be based on the latest information we receive. For more information on acceptable forms of evidence, contact Customer Services.
Best Available Evidence Policy
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H0423_MKT1093 CMS APPROVED 1222011
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