Part D Prescription Drug Program
We know that getting the medications you need is very important, having the right guidance and information can help you and your healthcare provider make the right decisions. Our Part D Prescription Drug Program is designed to provide you with the prescription drug and pharmacy information that other members have found helpful as they plan for years of healthy living.
As a member of the CPHL family, we want to make your healthcare experience as easy as possible. We are available to help if you should have any questions or feedback on ways to enhance your membership. Please call or send us any comments you may have, so that we can continue to make CPHL the best program available.
Important Message About What You Pay for Vaccine - Our plan covers most Part D vaccines at no cost to you, even if you haven't paid your deductible. Call Member Services for more information.
Important Message About What You Pay for Insulin - You won't pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it's on, even if you haven't paid your deductible.
You Can Ask for an Exception
You and your provider 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 provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule.
For example, you can ask the plan to cover a drug even though it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.
If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will tell you about any change in the coverage for your drug for next year. You can ask for an exception before next year and we will give you an answer within 72 hours after we receive your request (or your prescriber’s supporting statement). If we approve your request, we will authorize the coverage before the change takes effect.
If you and your provider want to ask for an exception, Chapter 10, Section 6.4 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.
Quality Assurance & Utilization Management Policies & Procedures
Programs to Help Members Use Drugs Safely
We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.
We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:
- Possible medication errors.
- Drugs that may not be necessary because you are taking another drug to treat the same medical condition.
- Drugs that may not be safe or appropriate because of your age or gender.
- Certain combinations of drugs that could harm you if taken at the same time.
- Prescriptions written for drugs that have ingredients you are allergic to.
- Possible errors in the amount (dosage) of a drug you are taking.
If we see a possible problem in your use of medications, we will work with your doctor to correct the problem.
IMPORTANT UPDATES TO 2023 FORMULARY
DSNP/ISNP/MAP PAWEB (Prior Authorization Requirements)- Last updated 08/23
DSNP/ISNP/MAP STEPWEB (Step Therapy Requirements)- Last updated 08/23
DSNP/ISNP/MAP Future Formulary - Last updated 09/2023