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  Prescription Drug Information

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All our plans include Part D prescription drug coverage. This means you don't have to purchase a separate Part D drug plan! You'll have access to thousands of retail and specialty pharmacies nationwide, as well as our mail order pharmacy for easy access to your prescriptions. To see if your drug is covered, simply click on our Formulary (drug list) below. If you have any questions, we’re here to help.

Please contact one of our friendly representatives at:
  • Toll-Free: 1-855-858-7526
  • TTY/TDD users should call 711
  • Monday through Sunday 8 a.m. to 8 p.m.

The PDF documents can be downloaded and then viewed with Adobe Reader.

 
 
The Drug List Can Change During the Year

Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the Drug List. For example, the plan might:

  • Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.
  • Move a drug to a higher or lower cost-sharing tier.
  • Add or remove a restriction on coverage for a drug.
  • Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug List. If we make any such change to our Formulary during the year, and you are taking the drug affected by the change, we will notify you of the change at least 60 days in advance. However, if a drug is recalled from the market, we will remove the drug from our Formulary immediately and notify you about the change as soon as possible.

Changes to our Formulary (both additions and deletions) are also listed on this website in the following document.


 

Medicare’s Extra Help Program

Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. If you qualify, you get help paying for Ultimate Health Plans’ monthly premium (because our premium includes coverage for both medical services AND prescription drugs). If you get Extra Help, your Ultimate Health Plans premium will be less than if you didn’t get Extra Help. Extra Help also helps pay your yearly deductible and prescription copayments. If you don’t already get Extra Help, you should see if you qualify. Call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
  • The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
  • Your State Medicaid Office. (See Section 6 of Chapter 2 of the EOC for contact information.)

Medicare uses data from states and Social Security to determine the level of Extra Help (also called the low-income subsidy) for which a person may qualify. If Medicare doesn’t have the right information, its systems may show incorrect copayment levels, or they may not show that an eligible person qualifies for Extra Help. This discrepancy may happen when the state hasn’t successfully reported a person’s Medicaid or institutionalized status. Ultimate Health Plans must use "Best Available Evidence" (BAE) to correct information about a person’s level of Extra Help. Once we get BAE documentation, we can’t charge a person more than the maximum cost sharing for that person’s level of Extra Help. If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us. For more information on our process, please refer to the EOC, Chapter 2, Section 7, Information about programs to help people pay for their prescription drugs.

The PDF documents can be downloaded and then viewed with Adobe Reader.

 

You can also download the document below for detailed information on how to use Best Available Evidence to correct your LIS status.

To view and download materials related to the CMS Best Available Evidence (BAE) policy, please click on the following link: CMS Website BAE Page for Policy and Guidance


Monthly Plan Premium for People who get Extra Help from Medicare

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
This table shows you what your monthly plan premium will be if you get extra help.

Your level of extra help Monthly Premium for Ultimate Premier (HMO)* Monthly Premium for Ultimate Premier Plus (HMO)* Monthly Premium for Ultimate Elite (HMO)* Monthly Premium for Ultimate Elite Plus (HMO)*
100% $0 $0 $0 $0
75% $0 $0 $0 $0
50% $0 $0 $0 $0
25% $0 $0 $0 $0

*This does not include any Medicare Part B premium you may have to pay.

To download the Ultimate Health Plans’ LIS Premium Summary Sheet, including information on how to find out if you qualify, please click on the following link.

Ultimate Health Plans’ Pharmacy Benefits Manager is Magellan Rx Management

You will see Magellan’s name and logo on many of the forms we use to communicate about your prescription drug benefits. Magellan Rx Management processes and pays prescription drug claims on behalf of Ultimate Health Plans. They also develop and maintain our drug list, contract with pharmacies, and negotiate discounts and rebates with drug manufacturers on our behalf.

Magellan Rx Management Logo

Special Rules Apply to Some Prescriptions Drugs

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work medically just as well as a higher cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

Prior Authorization

For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. If your drug requires prior authorization, please download the form below and ask for your provider’s help to complete it.

The PDF documents can be downloaded and then viewed with Adobe Reader.

 

Asking Us for An Exception to Plan Rules About the Drugs You Take

We hope that your drug coverage will work well for you, but it’s possible that you might have a problem. If your drug is not on the Drug List or is restricted, here are things you can do (please see the EOC, Chapter 5: Using the plan’s coverage for your Part D prescription drugs, for more detailed information):

  • You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
  • You can change to another drug.
  • You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

If you and your provider want to ask for an exception, Chapter 9, Section 6.4 of the EOC tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. You will also need to fill out one of the forms below, depending on the type of exception you are requesting.

The PDF documents can be downloaded and then viewed with Adobe Reader.

 

Other Important Information About Your Prescription Drugs

  • Ultimate Health Plans Prescription Drug Transition Policy: Ultimate Health Plans will cover a Transition Supply for enrollees who have a level of care change which is defined as when enrollees:
    • Enter a Long-Term-Care (LTC) facility from a hospital or other setting.
    • Leave a Long-Term-Care (LTC) facility and return to the community.
    • Are discharged from a hospital to a home.
    • End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Part D plan Formulary.
    • Revert from hospice status to standard Medicare Part A and Part B benefits; and
    • Are discharged from a psychiatric hospital with a medication regimen that is highly individualized.

    Ultimate Health Plans will provide the member with a written notice after Ultimate Health Plans covers the Transition Supply. This notice will explain the steps they can take to request an exception and how to work with their doctor to decide if they should switch to an appropriate drug that Ultimate Health Plans covers.

  • Medication Therapy Management Program (MTMP): Ultimate Health Plans provides a Medication Therapy Management Program (MTMP) to help members improve the way they use their medicines so that they get the most benefit out of their medicines and reduce the risk for harmful drug events and interactions. This program is not a benefit but part of the pharmacy medication management program. This program is managed and conducted by licensed pharmacists and certified pharmacy technicians. MTMP Services including Comprehensive Medication Reviews provide members (or designees) with medication reviews and care plans along with member and provider education on specific drug therapy topics. This service is available to Ultimate Health Plans members who meet the MTMP eligibility criteria. For complete information on the Medication Therapy Management Program, please click on the link below.
  • Quality Assurance, Member Safety and Utilization Management: Our goal is to ensure that our members receive safe, high-quality, cost-effective medication therapy. To achieve this goal, we use a Pharmacy and Therapeutics committee, whose goal is to improve the quality of care for Ultimate Health Plans members. To find out more about how Ultimate Health Plans ensures that your drugs are appropriate, medically necessary, and not likely to result in adverse medical effects, please click on the following link:

 

This page was last modified: 6/14/2017 11:45:52 AM
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Ultimate Health Plans is an HMO plan with a Medicare contract. Enrollment in Ultimate Health Plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Medicare beneficiaries may also enroll in Ultimate Health Plans through the CMS Medicare Online Enrollment Center located at www.medicare.gov. Ultimate Health Plans does not collect any member information through this website.

 

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