PART D COVERAGE

Medicare Part D Coverage Details, Formulary, Drug Pricing

Formulary

Care Improvement Plus enrollees have special rights and protections with regard to their prescription drug benefits. These protections include procedures and timelines for making "coverage determinations," about what drugs are covered or paid for under their health plan. Care Improvement Plus uses a formulary developed and maintained in partnership with a pharmacy benefit management company, Medco. Coverage determinations are made based on our formulary. In addition to formulary status, we consider the medical necessity, safety, appropriateness, and whether the drug prescribed is for indications as approved by the FDA.

For new members or members transitioning from a hospital or LTC facility, if their medication is not on the formulary they are guaranteed a transition supply until their doctor can determine if there are formulary alternatives that they can utilize or request an exception from the health plan. Our policy is described in more detail here.

To view a comprehensive listing of our plans' covered drugs, click here. (Revised 7/2010)

Drug Pricing Tool

Each Care Improvement Plus Plan has a drug pricing tool that was specifically designed to show beneficiaries how much their prescriptions will cost during all coverage stages (initial coverage, coverage gap – doughnut hole, and catastrophic coverage).

• Click on a link.
• Select the beneficiary's state from the dropdown list and click Continue.
• Enter drug name and click Search, or use the alphabet list of commonly prescribed medications to find a drug that begins with that letter.
• Select the drug's strength..
• The prices that display reflect the cost of the entered drug in all coverage stages.

• Regional PPO
• PPO

Upcoming Changes to Care Improvement Plus' Formulary

Care Improvement Plus may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, add quantity limits and/or step therapy restrictions on a drug, and/or move a drug at a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, in which case we will immediately remove the drug from our formulary.

Click here to view Upcoming Changes to Care Improvement Plus' Formulary. (Revised 8/2010)

2010 Prior Authorization Criteria

Our formulary includes an extensive array of drugs, dosage amounts and forms of administration, member cost-sharing "tiers," and, for certain drugs, pre-authorization requirements and quantity limits.

Your patient will need to get prior authorization for certain drugs on our formulary. Drugs will need a prior authorization (PA) if they have a B/D and/or a PA next to them on the formulary. You or your patient can call 1-800-753-2851 to request a prior authorization. For more information regarding the criteria for medications that have prior authorization, please click here.

Part D Vaccines

If you have purchased and/or administered a Part D vaccine in your office, please submit the completed HCFA 1500 claim form to:

Medco Health Solutions, Inc.
PO BOX 14718
Lexington, KY 40512

Upon receipt of the HCFA 1500 from the physician including the charge for the vaccine, NDC number of the vaccine and administration charge, Medco will process the paper claim and return reimbursement to the physician's office with an explanation of payment including the beneficiary's cost share, if any, for collection.

Medication Therapy Management Program

People with very complicated medication therapy will benefit from the Care Improvement Plus Medication Therapy Management Program. This program is available at no additional cost to you. If you take five (5) or more prescription medications every day and have two (2) or more long-term health conditions and might spend more than $3,000 a year on medications, you will be automatically enrolled in this program.

Below is a list of health conditions that may make you eligible for the Medication Therapy Management Program. You need to have two or more of these conditions to qualify for this program.

• Asthma
• Depression
• COPD
• Diabetes
• Hypertension
• Heart Failure
• Osteoporosis
• High Cholesterol
• End Stage Kidney disease requiring dialysis

Contact Member Services at: 1-800-204-1002 (TTY users, please call: 1-800-713-1603) to get more information regarding the Medication Therapy Management Program.

• prior authorizations by Medco before a pharmacy may dispense certain drugs,
• limits set by Medco on the quantity or amount that can be dispensed of certain drugs,
• a decision to pay a claim for a drug the enrollee pays for,
• a decision whether a prescribed drug is medically necessary, appropriate, or used for an FDA-approved indication, and
• a request for an exception to the formulary as discussed below

Requesting a coverage determination is easy. Most of the time, these decisions are made when the prescription is presented at the pharmacy, and a pharmacist may call you to discuss or modify a prescription.

You, as the prescribing physician, may request an exception to the formulary, a quantity limit, or other coverage determination on behalf of a Medicare enrollee. You do not have to have legal authorization from the enrollee to request a drug coverage determination. Exceptions are further discussed below.

To help the process work, you may use the Provider Medicare Part D Exception Request or contact us using the information provided below.

Timelines for Prior authorization coverage determinations are very prompt. Decisions are made within 72 hours, unless an expedited decision is needed. In expedited cases, the decision will be made as quickly as possible but no later than 24 hours from time of request. The expedited track is used when the longer (72 hour) period could jeopardize the life, health or ability of the enrollee to regain maximum function. We will automatically grant your request. Sometimes, an enrollee may ask you to support an expedited decision, and your support will be considered a validation of the urgency.

Exceptions are requests for a non-formulary drug, a lower copayment tier, or to remove the formulary's pre-authorization requirements or quantity limits. In some cases, it may be medically necessary and appropriate for the Care Improvement Plus enrollee to have an "exception" to the formulary. You or the enrollee may request the exception by phone, fax, or mail using the contact information below. You may use the form Provider Medicare Part D Exception Request suggested above. (Enrollees have another form that they may print and use.) Exception requests are made directly to Care Improvement Plus, where pharmacy and medical clinicians will make a determination. Decisions for standard exception requests are made no later than 72 hours of receiving complete supporting information from the physician. Determinations for expedited requests are made no later than 24 hours of receipt of complete supporting information from the physician.

For prescription drug coverage determinations (such as prior authorizations), inquiries, or a status update on a coverage request but not exception requests, contact Medco

By phone: 1-800-753-2851 (TTY: 1-800-713-1603)
By fax: 1-888-235-8551
By mail:
Medco Health Solutions, Inc.
Attn: Medicare Reviews
P.O. Box 63067
Irving, TX 75063-0118

For formulary exceptions requests, contact Care Improvement Plus

By phone: 1-800-204-1002 (TTY: 1-800-713-1603)

By fax: 1-866-683-3272