Transition Process
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than must be at least 90 days.
If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
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Exceptions and Coverage Determination
Coverage Determination
When Express Scripts receives a request for payment or to provide a Part D drug to a member, it must decide or determine whether or not requested prescription drug is necessary and appropriate and what your share of the cost is for the drug. These actions by Express Scripts are known as “coverage determinations”. Coverage determinations include exception 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 doctor must provide a statement to support your request. Before you ask for a coverage determination, please call Express Scripts at 1-877-266-1484 and ask if your drug is covered. Once we receive a statement from your doctor, we must make a coverage determination. We must make coverage determinations and notify the affected member within 72 hours of receiving the request or sooner if their health condition requires more immediate action. If immediate action is necessary, you or your physician can request that we review your situation in 24 hours. To request a coverage determination you can call Express Scripts, Inc. at 1-877-697-7244 or TTY 1-800-899-2114 for the hearing or speech impaired, or your physician can call Express Scripts Inc. at
1-800-417-8164. You can also fill out the coverage determination form below and mail it to Express Scripts, Inc., P.O. Box 390007, Bloomington, MN 55439. Attn: MED-D Accounts. Note: if we approve your exception request for a non-formulary drug, you cannot request an exception to the co-payment we require you to pay for the drug. Often Express Scripts will not have all of the information it needs to make a coverage determination. In those cases, an extra two weeks is allowed to gather all necessary supporting documentation.
For further information, please refer to Section 12 of your Evidence of Coverage.
Coverage Determination Request Form >
Who May Ask for a Coverage Determination?
You or someone you name to act for you (your appointed representative)
may request a coverage determination (including exception). You can name a relative, friend, advocate, attorney, doctor, or
someone else to act for you. Others may already be authorized under State
law to act for you. Please fill out the Appointment of Representative form and
send it to us with your request. You can call us at: 1-877-464-4365
(TTY/TDD 1-800-852-7897) if you need help filling out the form or want to
learn more about appointing a representative.
Appointment of Representative form >
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Grievances and Appeals
Grievances
A grievance is a complaint about any problem you had with Healthfirst Plans or one of our network pharmacies that does not relate to coverage for a prescription drug. Grievances do not relate to payment for or approval of a prescription drug, which are known as coverage determinations. If you (your appointed representative) have a grievance, please call Express Scripts Member Services at 1-800-266-1484 or TTY 1-866-753-8556 for the hearing or speech impaired. We will try to resolve any complaint over the phone. You may also send your grievance to:
Express Scripts, Inc.,
Attn: Director of Grievances
P.O. Box 66517
St. Louis, Missouri 63166-6517
All grievances will be acknowledged promptly and in writing. The Appeals & Grievances Department will research your issues and respond to you in writing once it has completed its investigation.
Expedited Grievances
If you are grieving the decision by Express Scripts not to expedite an initial determination or an appeal. You can request an expedited grievance. Express Scripts will respond to you within 24 hours.
Prescription Drug Coverage Appeals
Once Express Scripts notifies you of a decision, you may or may not agree with it. You (or your authorized representative) can ask us to reconsider our decision. This is known as filing an appeal. Much like coverage determinations, there is a fast track and routine process for handling appeals. The chart below explains how these different time frames work.
You have a right to appeal if you think Express Scripts:
- Decided not to cover a drug, vaccine, or other Part D benefit
- Decided not to reimburse you for a Part D drug that you paid for
- Reimburse you less than you feel you should have received
- Ask you to pay a different cost-sharing amount than you think you are required to pay for a prescription
- Denied your exception request
- Made a coverage determination you disagree with.
We will consider your appeal thoroughly and promptly. The time frames listed above will give you an idea of when you can expect a response from Express Scripts. It is important to let us know as soon as possible that you wish to file an appeal. If you wish to file a standard appeal, you must send written request within sixty (60) days from the date of the notice of coverage determination to:
Express Scripts, Inc.,
Pharmacy Appeals - Part D
Mail Route: BL0390
6625 West 78th Street
Bloomington, MN 55439
To request a fast appeal, you may call Express Scripts at
1-800-344-3405, extension 2373022 or TTY 1-800-899-2114 for the hearing or speech impaired.
If you are concerned about the quality of care you have received, for example, you believe our pharmacist provided you with the incorrect dose of a prescription; you may also file a complaint with the Healthcare Quality Strategies (QIO), through their hotline at 1-800-624-4557 or (1-732-238-5570). Quality Improvement Organizations are groups of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. The Quality Improvement Organization review process is designed to help stop any improper medical practices.
Who May Ask for a Grievance or an Appeal?
You or someone you name to act for you (your appointed representative)
may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at: 1-866-889-2527 (TTY/TDD 1-800-852-7897) if you need help filling out the form or want to learn more about appointing a representative.
Appointment of Representative form >
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Medication Therapy Management Program (MTMP)
Medicare and Healthfirst Medicare Plan want to make sure that you are getting the most out of your prescription drug use. To help you get the safest, most effective and affordable prescription drugs, certain members may join Healthfirst MTMP. This program was designed and is managed by licensed pharmacists to improve the way prescription drugs are used.
Participating in Medication Therapy Management program will help you to:
- Improve the way you use your prescription drugs
- Make sure you get the most out of the prescription drugs you are taking
- Reduce your risk for harmful drug events
- Avoid possible interactions between your prescription drugs
To be eligible to participate in MTMP you must meet certain eligibility criteria. You must take multiple prescription drugs, have certain medical condition(s) such as Asthma, Chronic Obstructive Pulmonary Desease (COPD), Diabetes, Dyslipidemia, Heart Failure or Hypertension and have significant costs for your prescription drugs. We will contact you by mail, if you are eligible to participate in this program. You are not required to participate in MTMP if you do not wish to do so.
If you have any questions about Healthfirst Medication Therapy Management program, you may call Express Scripts 24 hours per day, 7 days per week at 1-877-697-7244. TTY users should call
1-800-899-2114.
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Pharmacy Access Information
Healthfirst has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. We have a national network of more than 56,000 pharmacies that work with Express Scripts – Healthfirst pharmacy vendor. There are 1,800 network pharmacies in our service area. To find a pharmacy near you, please visit our Find a Provider page.
Filling your prescriptions when you travel or are outside of the plan’s service area
We encourage you to use our network pharmacies at all times to fill your prescriptions. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. We will cover your prescription at an out-of-network pharmacy, if you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service or if your are trying to fill a covered prescription drug that is not regularly stocked at an in-network
retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). You will be allowed to fill each prescription at an out-of-network pharmacy for the reasons listed above up to three (3) times within each calendar year. After a prescription has been filled three (3) times at an out-of-network pharmacy, you will be required to pay the full cost of any additional prescriptions filled at an out-of-network pharmacy.
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How do I submit a paper claim?
When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription.
To submit a paper claim, you must send Express Scripts a copy of the receipt for the prescription drugs from the pharmacy where you bought them and a completed paper claim form. Please send your paper claim to the following address: Express Scripts, Inc., Attn: MED-Accounts, PO Box 390007, Bloomington, MN 55439-0873. For more information, please call Express Scripts at 1-877-697-7244 (TTY 1-800-899-2114), 24 hours a day, 7 days a week.
Prescription Claim Form >
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