Members

Prescription Drug Information

Prescription Drug Information

Medicare Part D is the new Medicare prescription drug coverage. Everyone with Medicare is eligible for this coverage, regardless of income level and resources, pre-existing conditions, or current prescription expenses.

Prescription drugs can heal, cure, comfort, even prevent. Medicare Prescription Drug Coverage makes it easier to pay for the prescription drugs you need to stay healthy.

Medicare Prescription Drug Coverage can help you by covering both brand name and generic prescription drugs at participating pharmacies close to where you live. Qualified people with limited income and resources will have almost no drug expenses.

Medicare Prescription Drug Coverage can also help down the road. As we age and our medical conditions change, our need for prescription drugs may increase. And, Medicare, like most insurance, will cover a significant portion of prescription drug bills.

If you use few or no drugs now, you may wonder if it’s worth signing up. But what about the future? If you sign up now, Medicare coverage will help protect you against high drug costs if and when you need it. And, if you sign up with a Medicare Advantage Prescription Drug plan like Steward Health Choice Generations, you’ll have one plan providing both your medical and prescription drug benefits providing you better Coordination of Care.


How to use the Formulary

What is a formulary?

A formulary is a list of drugs that are covered by Steward Health Choice Generations HMO SNP. The formulary contains a wide range of drugs and includes both generics and brand name drugs. All the drugs on the formulary are approved by the Food and Drug Administration (FDA).

What if my medication is not on the Steward Health Choice Generations Formulary?

We want to make sure you have the medications you need. If a drug is not covered and you would like it to be covered, you can ask us to make an exception. If your doctor thinks it is important for you to be on a drug that is not on our formulary, you and your doctor can submit a formulary exception request. If we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor is required to explain the medical reasons why you need the medication. Also, some drugs have certain restrictions, such as a quantity limit or step therapy. If your doctor does not think your drug should have a restriction, you and your doctor can submit a formulary exception request.

Formulary (List of Covered Drugs)  
Formulario (Lista de medicamentos cubiertos)

2019 Utilization Management Criteria

Prior Authorization Grid
Step Therapy Criteria
Quantity Limit Criteria

Note:
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

For the most recent list of drugs or other questions, please contact Steward Health Choice Generations Member services at 1-844-457-8943, TTY 711, 8 a.m. – 8 p.m., 7 days a week.

Steward Health Choice Generations Mail-Order Program

Save time when ordering your prescriptions. Use Home Delivery from our Pharmacy. It’s a service available at no additional cost to you.

If you take prescription medications on a regular basis for allergies, high blood pressure, diabetes, arthritis or other ongoing conditions, consider Home Delivery.

As a value added service to our members, Steward Health Choice Generations offers members the option of ordering their prescriptions by mail.

When you order prescription drugs through our network mail order pharmacy service, you must order at least a 30-day supply, and no more than a 98-day supply of the drug.

Generally, it takes us 14 days to process your order and ship it to you. However, sometimes your mail order may be delayed. If for some reason your order cannot be delivered within 14 days, a pharmacy representative may contact you. For more information about mail order, call Steward Health Choice Generations Member Services.

If you should have any questions regarding the points above, please call Steward Health Choice Generations Member Services, 8 am – 8 pm, 7 days a week, at 1-844-457-8943. TTY users should call 711. Or, you may e-mail Member Services at Comments@steward.org.

Benefits of Home Delivery

  • You can skip the trip to a participating pharmacy – your prescriptions are delivered directly to your home.
  • You don’t have to pay for Home Delivery – standard shipping of your prescriptions is free.
  • You only need to order refills once every three months – you get up to a 90-day supply of your medication with each order.
  • You can speak to a pharmacist anytime, day or night – the Pharmacy never closes.
  • You can order refills from home – by phone, fax, mail or Internet.

For more information about getting your prescriptions delivered to your home from the Pharmacy, please call Steward Health Choice Generations Member Services at 1-844-457-8943. TTY users call 711, 8 am – 8 pm, 7 days a week.

Formulary Additions and Deletions

Formulary Adds and Deletions – Coming Soon
Formulary Adds and Deletions (Spanish) – Coming Soon

What if Steward Health Choice Generations Denies Coverage for a Prescription Drug?

What to do if you have complaints

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage.

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Steward Health Choice Generations or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint.
Following is a brief explanation on grievances, coverage determinations, and appeals.

For detailed information about these processes and how to file a grievance, coverage determination and/or appeal please visit the Evidence of Coverage Chapter 9.

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Steward Health Choice Generations or one of our network pharmacies that does not relate to coverage for a prescription drug.

For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

What is a coverage determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug.

Coverage determinations include exceptions requests. You have the right to ask us for an exception if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

What is an appeal?

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

For a detailed explanation of Steward Health Choice Generations Complains and Grievances Procedure; how to request a Coverage Determination; and how to find out more information about Part D Appeals procedures and exception processes, please refer to your Steward Health Choice Generations Evidence of Coverage Chapter 9, or click on the links at the top of the page.

How do I request an exception to the Steward Health Choice Generations HMO Formulary?

You can ask Steward Health Choice Generations to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Steward Health Choice Generations limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our highest tier subject to the tiering exceptions process tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the lowest tier subject to the tiering exceptions process tier instead.

This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

If you are requesting an exception, you must provide a statement from your doctor. Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. Your doctor can mail or fax the statement to our plan. Or your doctor can tell us on the phone and then follow up by faxing or mailing the signed statement.

The statement can be faxed or mailed to:

Steward Health Choice Generations
Attn: Pharmacy Prior Authorizations
410 N 44th Street, Suite 943
Phoenix, AZ 85008
Fax: 1-877-424-5690

Coverage Determinations

If you would like Steward Health Choice Generations to make a decision on a Part D drug, such as a formulary exception, you and your doctor may complete a Coverage Determination Request Form. When Steward Health Choice Generations makes a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug. The decision by a pharmacist not to fill a prescription is not considered a denial by Steward Health Choice Generations.

Coverage determinations include:

  • Prior authorizations by Steward Health Choice Generations before a pharmacy may dispense certain drugs,
  • Limits set by Steward Health Choice Generations on the quantity (amount) of certain drugs that can be dispensed,
  • A decision to pay a claim for a drug you paid 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.

You, your authorized representative, or your prescribing physician may request a coverage determination. Decisions are made within 72 hours, unless your health is in jeopardy and a request is made for a fast-track decision. We verify the need for a fast-track decision and then make the coverage determination as quickly as possible – within 24 hours of the request.

Note:
You cannot request a Re-determination/Appeal if we have not issued a Coverage Determination.

If coverage is denied, you will be notified and receive a written explanation with a notice of appeal rights. If your request for a fast-track decision is denied and you disagree, you may file an expedited grievance. You are always notified of our decisions.

To request an expedited review, please call 1-844-457-8943. TTY/TTD users call 711.

You have the option of submitting your request in writing. You may mail or fax your written request for a coverage determination to:

Steward Health Choice Generations
Attn: Pharmacy Prior Authorizations
410 N 44th Street, Suite 943
Phoenix, AZ 85008
Fax: 1-877-424-5690

Coverage Re-determinations

If we deny part or all of the coverage determination and you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug, you may ask us to reconsider our decision. This is called an “appeal” or “request for re-determination”.

Note:
You cannot request a Re-determination/Appeal if we have not issued a Coverage Determination.

How you make your appeal depends on whether you are requesting reimbursement for a Part D drug you already received and paid for, OR authorization of a Part D benefit (that is, a Part D drug that you have not yet received).

If your appeal concerns a decision we made about authorizing a Part D benefit that you have not yet received, then you and/or your doctor will first need to decide whether you need a re-determination. The procedures for deciding on a standard or fast re-determination are the same as those described for a standard or fast coverage determination.

Please be assured, when we receive your request to reconsider the coverage determination, we give the request to healthcare professionals at our organization who were not involved in making the original coverage determination. This helps ensure that we give your request a fresh look.

How to Request a Re-determination

You must make your re-determination (appeal) request to Steward Health Choice Generations within 60 calendar days from the notice of the initial coverage determination. An expedited request may be made orally or in writing. A standard request may be made orally or in writing. You may choose to complete the re-determination form in the Form section on this page or you may submit your signed request in another format.

To request an expedited redetermination, please call 1-844-457-8943. TTY/TTD users call 711.

You have the option of submitting your request in writing. You may mail or fax your written request for a coverage redetermination to:

Steward Health Choice Generations
Attn: Pharmacy Prior Authorizations
410 N 44th Street, Suite 943
Phoenix, AZ 85008
Fax: 1-877-424-5690

Medicare Prescription Drug Coverage and Your Rights

You have the right to get a written explanation from Steward Health Choice Generations if:

  • Your doctor or pharmacist tells you that Steward Health Choice Generations will not cover a prescription drug in the amount or form prescribed by your doctor.
  • You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.
    Steward Health Choice Generations written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan’s decision.

You also have the right to ask Steward Health Choice Generations for an exception if:

  • You believe you need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;” or
    You believe you should get a drug you need at a lower cost-sharing amount.

What you need to do:

  • Contact Steward Health Choice Generations to ask for a written explanation about why a prescription is not covered, or to ask for an exception if you believe you need a drug that is not on your drug plan’s formulary, or believe you should get a drug you need at a lower cost-sharing amount.
  • Refer to the Summary of Benefits you received from Steward Health Choice Generations or call Member Services at 1-844-457-8943
  • When you contact Steward Health Choice Generations, be ready to tell them:
    • The name of the prescription drug(s) that you believe you need.
    • The name of the pharmacy or physician who told you that the prescription drug(s) is not covered.

The date you were told that the prescription drug(s) is not covered.

You can find detailed information regarding the Grievance and Appeals processes in your Evidence of Coverage booklet.

You may also call Member Services at 1-844-457-8943, 8 a.m. – 8 p.m., 7 days a week for assistance with problem solving related to your Part D benefits or for questions about processes or appeal status (TTY users call 711).

Coverage Determination Request Form – Coming Soon
Coverage Determination Request Form (PDF) – Coming Soon

An enrollee, or the appointed representative, or the prescribing physician may use this model form to request a coverage determination from the plan.

Redetermination Request Form – Coming Soon
Redetermination Request Form (PDF) – Coming Soon

Prior Authorization

For certain drugs, you or your doctor need to get prior approval from Steward Health Choice Generations before we will agree to cover the drug for you. This is called prior authorization. Sometimes plan approval is required so we can be sure that your drug is covered by Medicare. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If prior approval is not obtained, your drug might not be covered. The drugs that require prior approval can be identified in your Steward Health Choice Generations Formulary. Those are the drugs with the PAR symbol in the Restrictions column.

A prior authorization form is attached for your doctor to obtain Prior Authorization.

Pharmacy Medication Prior Authorization Form – Coming Soon
Pharmacy Medication Prior Authorization Form (PDF) – Coming Soon

Medical Services Prior Authorization Form – Coming Soon

2019 Transition Policy

Transition Policy and Procedure – Coming Soon

When you join Steward Health Choice Generations you may learn that we do not cover a prescription drug you were taking before you joined our Plan. You may be able to get a temporary supply of the drug that would give you and your doctor time to change to another drug. This is called a transition fill.

If you receive a temporary fill for a drug, we will send you a letter explaining that the drug was filled under the Transition process. The letter will explain the action you can take to get approval for the drug or how to switch to another drug on the plan formulary.

If you are a new member and are taking a Part D drug that is not on the formulary, or the drug is subject to a utilization management requirement (such as step therapy, prior authorization, or a quantity limit), we will cover a temporary supply during the first 90 days of your membership in Steward Health Choice Generations. This temporary supply will be for a maximum of 31 days (30 days retail and 31 days LTC) and must be filled at a network pharmacy.

If you live in a Long Term Care facility, we will cover a temporary supply during the first 90 days of your membership in the plan. We will allow you to refill your prescription until we have provided you with up to a 98-day supply (unless the prescription is written for less) during your transition period.

If you are existing member, who was on the plan last year are taking a Part D drug that was removed from the formulary, or the drug now has a new utilization requirement or limitation at the beginning of the new year, we will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of 31 days (30 days retail and 31 days LTC), unless the prescription is written for fewer days. The prescription must be filled at a network pharmacy.

You may also be eligible to receive a transition supply if you experience a level of care change. This is a change from one treatment setting to another. Examples of a level of care change include:

  • A discharge from a hospital to you home
  • Anyone that has ended their skilled nursing stay
  • Anyone that has ended a stay in a long term care facility and returns to the community
  • A discharge from a psychiatric hospital

It is important that you understand that the transition fill is a temporary supply of this drug. Before this supply ends, you should speak to our Plan and/or your physician regarding whether you should change the drug(s) you are currently taking, or request an exception from our Plan to continue coverage of the drug. You, your authorized representative or your provider can ask for an exception request.

To access additional information on the coverage determination and exception process, click here.

If you have any questions regarding the transition process or your temporary supply you may call us at 1-844-457-8943 (TTY: 711) 7 days a week, 8:00 a.m. to 8:00 p.m.

Steward Health Choice Generations Medication Therapy Management Program

What is the Medication Therapy Management (MTM) program?

The MTM program is designed to improve the way Steward Health Choice Generations members take their medication. The plan works with doctors and pharmacists to make sure members get the most medically appropriate, safe and cost-effective medications.

This process has two goals:

  • To get you the prescriptions you need, even if they are not on the list of drugs the plan covers.
  • To protect you from drug interactions that might harm you.

MTM programs can help identify potential errors and gaps in your medical care; help reduce the risk of medication errors; provide current information on medical practices to help you and your doctor decide the best treatment; and help you understand your condition and medications so you can take an active role in managing your healthcare.

Generally, people who are enrolled in an MTM program take multiple medications; have chronic illnesses or diseases; or have high drug costs.

The voluntary program is free to all Steward Health Choice Generations members who meet eligibility requirements. It is not a benefit of Steward Health Choice Generations plan.

This is a sample of the Personal Medication List that is part of the MTM program. If you would like a blank copy or have questions, please call our Member Services department at 1-844-457-8943, 8:00 a.m. to 8:00 p.m.

Sample Personal Medication List – Coming Soon

How do I enroll and what happens in the MTM program?

Steward Health Choice Generations members will be sent a questionnaire to fill out and return or they can call Member Services to ask about the program or enroll. Members could also receive a call from a Steward Health Choice Generations Case Management nurse. If a member is contacted, we hope you will join the MTM program.

The information will be sent to the Steward Health Choice Generations Medical Management department who will review the medical information and medications take by the member for interactions, appropriateness and compliance. This review could take some time so please do not be alarmed if you do not hear from a Steward Health Choice Generations representative right away. The Medical Management team will then contact the member and enroll them into the MTM program.

If Steward Health Choice Generations identities any emergent or urgent issues they will be discussed with the member and/or the member’s physician for immediate action. Follow-up calls will be scheduled as needed with a call at least every 6 months.

You will be enrolled through the calendar year and can be involved every year that you meet the eligibility requirements.

Long term care (LTC) members who meet eligibility will be sent a letter without a questionnaire and auto-enrolled into the MTM program. The LTC members will be sent information in the mail along with an 800 number to call if they have any questions about their medications or the information that was sent to them.

How would a member disenroll?

  • A member or a member’s caregiver or physician may disenroll from the MTM program at anytime. Please give our Member Services department a call at 1-844-457-8943 (TTY 711), 7 days a week from 8 am to 8pm to get information on how to do this.

Low -Income Subsidy Category Deductible Copayment Up To Out-of-Pocket Threshold* Copayment Above Out-of-Pocket Threshold*

Institutionalized Full Benefit Dual Eligible; or

Beneficiaries Receiving Home and Community-Based Services

$0 $0 $0

Full Benefit Dual Eligible ≤ 100% FPL

 

$0 $1.25 generic,
$3.70 brand
$0

Full Benefit Dual Eligible > 100% FPL; or

Medicare Saving Program Participant (QMB-only, SLMB-only, or QI); or

Supplemental Security Income (but not Medicaid) Recipient; or

Applicant < 135% FPL with resources ≤$9,060 ($14,340 if married) **

$0 $3.35 generic
$8.35 brand
$0
Applicant < 150% FPL with resources between $9,60- $14,100 ($14,340 – $28,150 if married)** $83 15% $3.35 generic,
$8.35 brand

*Out-of-Pocket Threshold is $5,000 for 2018.
** Resource limits displayed include $1,500 per person for burial expenses.


 


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