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Prescription Drug Frequently Asked Questions (FAQs)

What if my drug is not on the drug list (formulary)?

First, contact Member Services and ask if your drug is covered. If Member Services says your drug is not covered, you have two options:

  • You can ask Member Services for a list of similar drugs that are covered by AmeriHealth Caritas VIP Care Plus. When you receive the list, show it to your provider and ask him or her to prescribe a similar drug that is covered by AmeriHealth Caritas VIP Care Plus.
  • You can ask us to make an exception and cover your drug. For more information, please see the section below titled, "How do I request an exception to the AmeriHealth Caritas VIP Care Plus drug list?"

What is a coverage determination?

A coverage determination is any decision (an approval or denial) that AmeriHealth Caritas VIP Care Plus makes when you ask for coverage or payment of a drug that you believe AmeriHealth Caritas VIP Care Plus should provide.

  • You or your primary care provider (PCP) and other prescribers can ask for a coverage determination.
  • You can also appoint someone (such as a relative) to request a coverage determination for you.
  • You can ask for a standard coverage determination. AmeriHealth Caritas VIP Care Plus will give you a decision in 72 hours.
  • You can also ask for a fast (also called "expedited") coverage determination if you or your PCP or other prescriber believes that your health could be seriously harmed by waiting up to 72 hours for a decision. AmeriHealth Caritas VIP Care Plus will give you a decision in 24 hours.

How to contact us when you are asking for a coverage decision about your Part D prescription drugs:

Request for Medicare prescription drug coverage determination

Submit a request online or fill out the paper form (PDF).

Fax, urgent: 1-855-829-2870.
Fax, standard: 1-855-825-2749.
Call: 1-888-667-0318.
Write:

AmeriHealth Caritas VIP Care Plus
Attn: Prior Authorization
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

What can I do if my coverage determination is denied?

If AmeriHealth Caritas VIP Care Plus denies your coverage determination, you have the right to request a redetermination appeal. Please see Request for Redetermination of Medicare Prescription Drug Denial or read your member handbook (PDF) for information about your appeal and grievance rights.

Can the drug list change?

Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year. However, there are two exceptions. We may remove a drug from our formulary when a new, less expensive generic drug becomes available or when new information is released that a drug is unsafe or doesn’t work. Please check the webpages for the most up to date version of the drug list.

If we remove drugs from our formulary or add prior authorization requirements, quantity limits, or step therapy restrictions on a drug, we must tell affected members there is a change at least 30 days before the change happens. Or we will tell the member about the change when they request a refill of the drug, and the member will receive a 30-day supply of the drug.

If the Food and Drug Administration (FDA) says a drug on our formulary is unsafe or the drug's manufacturer removes the drug from the market, we will remove the drug from our formulary and provide notice to members who take the drug.

What is prior authorization?

Prior authorization means that you will need to get approval from AmeriHealth Caritas VIP Care Plus before you fill your prescriptions for some drugs. If you do not get approval, AmeriHealth Caritas VIP Care Plus may not cover the drugs. You can find out which drugs require prior authorization by reviewing the AmeriHealth Caritas VIP Care Plus drug list. Usually, your PCP or other prescribers will have to give us information about your medical condition or previous prescriptions to receive prior authorization.

Enrollees and providers: Use the Coverage Determination Request Form (PDF) or the online Coverage Determination Form.

Mail or fax the completed form to:

Fax, urgent: 1-855-829-2870.
Fax, standard: 1-855-825-2749.

AmeriHealth Caritas VIP Care Plus

How do I request an exception to the AmeriHealth Caritas VIP Care Plus drug list?

Prior authorization exception

You and/or your primary care provider (PCP) or other prescriber can request an exception to the AmeriHealth Caritas VIP Care Plus drug list. Generally, your PCP or other prescriber must provide a statement of medical necessity that explains why the listed drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Enrollees and providers: Use the Coverage Determination Request Form (PDF).

Mail or fax the completed form to:

Fax, urgent: 1-855-829-2870.
Fax, standard: 1-855-825-2749.

AmeriHealth Caritas VIP Care Plus
Attn: Prior Authorization
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

How do I get reimbursed for my prescription expenses?

In-network pharmacy claims: Direct member reimbursement

Download the Claim Reimbursement Form (PDF)

Please read the instructions on the form carefully, complete the form, and mail it to:
AmeriHealth Caritas VIP Care Plus
Attn: Direct Member Reimbursement
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

Out-of-network pharmacy claims: Direct member reimbursement

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when an in-network pharmacy is not available. Before you fill your prescription at an out-of-network pharmacy, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. You may also access the AmeriHealth Caritas VIP Care Plus pharmacy directory.

If you do go to an out-of-network pharmacy, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a direct reimbursement claim form. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy, because the out-of-network pharmacy's price may be higher than what an in-network pharmacy would have charged.

You should always submit a claim to us if you fill a prescription at an out-of-network pharmacy, since any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage.

Download the the Claim Reimbursement Form (PDF)

Please read the instructions on the reimbursement form carefully, complete the form, and mail it to:
AmeriHealth Caritas VIP Care Plus
Attn: Prior Authorization
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

What is the AmeriHealth Caritas VIP Care Plus transition policy?

We try to make your drug coverage work well for you, but sometimes a drug might not be covered in the way that you would like it to be. For example:

  • The drug you want to take is not covered by the plan. The drug is not on the drug list. A generic version of the drug is covered, but the brand name version you want to take is not. A drug is new and we have not yet reviewed it for safety and effectiveness.
  • The drug is covered, but there are special rules or limits on coverage for that drug. Some of the drugs covered by the plan have rules that limit their use. In some cases, you or your prescriber may want to ask us for an exception to a rule.

There are things you can do if your drug is not covered in the way that you would like it to be.

  • You can get a temporary supply
    In some cases, the plan can give you a temporary supply of a drug when the drug is not on the drug list or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask the plan to cover the drug.
    To get a temporary supply of a drug, you must meet the two requirements below:
    1. The drug you have been taking:
    • Is no longer on the plan's drug list.
    • Was never on the plan’s drug list.
    • Is now limited in some way.

2. You must be in one of these situations:

  • You were in the plan last year and do not live in a long-term care (LTC facility.
    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 30-day supply for Part D drugs and a 90-day supply for non-Part D drugs. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medicine for Part D drugs and 90 days of medicine for non-Part D drugs. You must fill the prescription at a network pharmacy.
  • You are new to the plan and do not live in an LTC facility.
    We will cover a temporary supply of your drug during the first 180 days of your membership in the plan. This temporary supply will be for a 30-day supply for Part D drugs and a 90-day supply for non-Part D drugs. You must fill the prescription at an in-network pharmacy.
  • You are new to the plan and live in an LTC facility.
    We will cover a temporary supply of your drug during the first 180 days of your membership in the plan. The total supply will be for up to a 31-day supply for Part D drugs and a 31-day supply for non-Part D drugs. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of the number of days allowed. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
  • You have been in the plan for more than 90 days and live in an LTC facility and need a supply right away.
    We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above LTC transition supply.

Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. For example, members who:

  • Enter LTC facilities from hospitals, who are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short-term planning taken into account (often under eight hours).
  • Are discharged from a hospital to home.
  • End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
  • End an LTC facility stay and return to the community.

If a member has more than one change in level of care in a month, the pharmacy must call our plan to request an extension of the transition policy.

To ask for a temporary supply of a drug, call Member Services.

When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:
1. You can change to another drug.
There may be a different drug covered by the plan that works for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. The list can help your provider find a covered drug that might work for you.

2. You can ask for an exception.
You and your provider can ask the plan to make an exception. For example, you can ask the plan to cover a drug even though it is not on the drug list. Or you can ask the plan to cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.

If you need help asking for an exception, you can contact Member Services or your Care Coordinator.

Do you have a prescription mail-order program?

Yes. For certain kinds of drugs, you can use the plan's network mail-order services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan's mail-order service are marked as "mail-order" drugs in our drug list. Our plan's mail-order service requires you to order a 90-day supply. If you use a mail-order pharmacy not in the plan's network, your prescription will not be covered. Usually a mail-order pharmacy order will get to you in no more than 14 days.

However, sometimes your mail-order may be delayed. If you need to start your medications right away, but the mail-order is delayed, ask your provider for a 30-day supply (prescription) to be filled at your local pharmacy.

View the mail order instructions and form (PDF).

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