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.
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 8, 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.
Medication Therapy Management
If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program. MTM is a service offered by Centers Plan for Healthy Living at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS). This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.
To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, you will be invited to participate in the program and we will send you information about the program, including how to access the program. Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.
To qualify for Centers Plan for Healthy Living’s MTM program, you must meet ALL of the following criteria:
- Have at least 2 of the following conditions or diseases: Chronic Heart Failure (CHF), Diabetes, Dyslipidemia, Hypertension, Asthma, Chronic Obstructive Pulmonary Disease (COPD), AND
- Take at least 7 covered Part D medications, AND
- Be likely to have medication costs of covered Part D medications equal to or greater than $1,094 per quarter ($4,376 per year).
The MTM program includes a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This review, or CMR, is provided via telephone by The University of Arizona, Medication Management Center, which provides this service on behalf of Centers Plan for Healthy Living. You will get a written summary of this call to help you get the most from your medications. You can take this summary with you when you talk with your doctors. Additional services are offered to both you and your doctors, which are aimed to improve your health.
If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please contact member service 7 days a week 8am-8pm at 1-877-940-9330 (toll free) TTY users call 711.
Please note this Medication Therapy Management (MTM) Program is not considered a benefit.
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.
Prescription Drug Transition Policy – Last updated 09/14/2020
IMPORTANT UPDATES TO 2021 FORMULARY
MAPD PAWEB (Prior Authorization Requirements) - Last updated 03/01/21
MAPD STEPWEB (Step Therapy Requirements) - Last updated 03/01/21
DSNP/ISNP/MAP PAWEB (Prior Authorization Requirements) - Last updated 03/01/21
DSNP/ISNP/MAP STEPWEB (Step Therapy Requirements) - Last updated 03/01/21