NTDSNPCH5CY20244122023_CS508ClearedX

<Plan name> MEMBER HANDBOOK

_Chapter 5: Getting your outpatient prescription drugs

Introduction

This chapter explains rules for getting your outpatient prescription drugs. These are drugs that your provider orders for you that you get from a pharmacy or by mail-order. They include drugs covered under Medicare Part D and [Insert name of Medicaid program]. [Plans with no cost-sharing, delete the next sentence.] Chapter 6 of your Member Handbook tells you what you pay for these drugs. Key terms and their definitions appear in alphabetical order in the last chapter of your Member Handbook.

We also cover the following drugs, although they are not discussed in this chapter:

• Drugs covered by Medicare Part A. These generally include drugs given to you while you are in a hospital or nursing facility.

• Drugs covered by Medicare Part B. These include some chemotherapy drugs, some drug injections given to you during an office visit with a doctor or other provider, and drugs you are given at a dialysis clinic. To learn more about what Medicare Part B drugs are covered, refer to the Benefits Chart in Chapter 4 of your Member Handbook.

• In addition to the plan’s Medicare Part D and medical benefits coverage, your drugs may be covered by Original Medicare if you are in Medicare hospice. For more information, please refer to Chapter 5, Section F “If you are in a Medicare-certified hospice program.”

Rules for our plan’s outpatient drug coverage

[If coverage includes Medicaid drugs, please add language as needed for Medicaid.] We usually cover your drugs as long as you follow the rules in this section.

You must have a doctor or other provider write your prescription, which must be valid under applicable state law. This person often is your primary care provider (PCP). [Plans may modify or delete the next sentence as appropriate.] It could also be another provider if your PCP has referred you for care.

Your prescriber must not be on Medicare’s Exclusion or Preclusion Lists [insert as applicable: or any similar Medicaid lists].

You generally must use a network pharmacy to fill your prescription.

Your prescribed drug must be on our plan’s List of Covered Drugs. We call it the “Drug List” for short.

• If it is not on the Drug List, we may be able to cover it by giving you an exception.

• Refer to Chapter 9 [insert reference, as applicable] to learn about asking for an exception.

Your drug must be used for a medically accepted indication. This means that use of the drug is either approved by the Food and Drug Administration (FDA) or supported by certain medical references. Your doctor may be able to help identify medical references to support the requested use of the prescribed drug. [Plans should add definition of “medically accepted indication” as appropriate for Medicaid-covered drugs and items.]

[Plans should refer to other parts of the Member Handbook using the appropriate chapter number, section, and/or page number. For example, "refer to Chapter 9, Section A, page 1." An instruction [insert reference, as applicable] appears with many cross references throughout the Member Handbook. Plans may always include additional references to other sections, chapters, and/or member materials when helpful to the reader.]

[Plans must update the Table of Contents to this document to accurately reflect where the information is found on each page after plan adds plan-customized information to this template.]

Table of Contents

A. Getting your prescriptions filled 4

A1. Filling your prescription at a network pharmacy 4

A2. Using your Member ID Card when you fill a prescription 4

A3. What to do if you change your network pharmacy 4

A4. What to do if your pharmacy leaves the network 4

A5. Using a specialized pharmacy 5

A6. Using mail-order services to get your drugs 5

A7. Getting a long-term supply of drugs 8

A8. Using a pharmacy not in our plan’s network 9

A9. Paying you back for a prescription 9

B. Our plan’s Drug List 9

B1. Drugs on our Drug List 10

B2. How to find a drug on our Drug List 10

B3. Drugs not on our Drug List 10

B4. Drug List cost-sharing tiers 11

C. Limits on some drugs 12

D. Reasons your drug might not be covered 13

D1. Getting a temporary supply 14

D2. Asking for a temporary supply 15

D3. Asking for an exception 15

E. Coverage changes for your drugs 16

F. Drug coverage in special cases 18

F1. In a hospital or a skilled nursing facility for a stay that our plan covers 18

F2. In a long-term care facility 18

F3. In a Medicare-certified hospice program 18

G. Programs on drug safety and managing drugs 19

G1. Programs to help you use drugs safely 19

G2. Programs to help you manage your drugs 19

G3. Drug management program for safe use of opioid medications 20

1. Getting your prescriptions filled

A1. Filling your prescription at a network pharmacy

In most cases, we pay for prescriptions only when filled at any of our network pharmacies. A network pharmacy is a drug store that agrees to fill prescriptions for our plan members. You may use any of our network pharmacies.

To find a network pharmacy, look in the Provider and Pharmacy Directory, visit our website or contact Member Services [insert if applicable: or your care coordinator].

A2. Using your Member ID Card when you fill a prescription

[Plans may add language to describe use of Medicaid card as directed by the state if applicable.] To fill your prescription, show your Member ID Card at your network pharmacy. The network pharmacy bills us for [plans with cost-sharing, insert: our share of the cost of] your covered prescription drug. [Plans with no cost-sharing, delete the next sentence:] You may need to pay the pharmacy a copay when you pick up your prescription.

If you don’t have your Member ID Card with you when you fill your prescription, ask the pharmacy to call us to get the necessary information.

If the pharmacy can’t get the necessary information, you may have to pay the full cost of the prescription when you pick it up. Then you can ask us to pay you back [insert if the plan has cost-sharing: for our share]. If you can’t pay for the drug, contact Member Services right away. We will do everything we can to help.

• To ask us to pay you back, refer to Chapter 7 of your Member Handbook.

• If you need help getting a prescription filled, contact Member Services [insert if applicable: or your care coordinator].

A3. What to do if you change your network pharmacy

[Plans in which members do not need to take any action to change their pharmacies may delete the following sentence.] If you change pharmacies and need a prescription refill, you can [insert as applicable: either ask to have a new prescription written by a provider or] ask your pharmacy to transfer the prescription to the new pharmacy if there are any refills left.

If you need help changing your network pharmacy, contact Member Services [insert if applicable: or your care coordinator].

A4. What to do if your pharmacy leaves the network

If the pharmacy you use leaves our plan’s network, you need to find a new network pharmacy.

To find a new network pharmacy, look in the Provider and Pharmacy Directory, visit our website, or contact Member Services [insert if applicable: or your care coordinator].

A5. Using a specialized pharmacy

Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include:

• Pharmacies that supply drugs for home infusion therapy. [Plans may insert additional information about home infusion pharmacy services in the plan’s network.]

• Pharmacies that supply drugs for residents of a long-term care facility, such as a nursing facility.

• Usually, long-term care facilities have their own pharmacies. If you’re a resident of a long-term care facility, we make sure you can get the drugs you need at the facility’s pharmacy.

• If your long-term care facility’s pharmacy is not in our network or you have difficulty getting your drugs in a long-term care facility, contact Member Services. [Plans may insert additional information about LTC pharmacy services in the plan’s network.]

• Pharmacies that serve the Indian Health Service/Tribal/Urban Indian Health Program. Except in emergencies, only Native Americans or Alaska Natives may use these pharmacies. [Plans may insert additional information about I/T/U pharmacy services in the plan’s network.]

• Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special handling, provider coordination, or education on their use. (Note: This scenario should happen rarely.)

To find a specialized pharmacy, look in the Provider and Pharmacy Directory, visit our website, or contact Member Services [insert if applicable: or your care coordinator].

A6. Using mail-order services to get your drugs

[Plans that do not offer mail-order services, replace the information in this section with the following sentence: Our plan does not offer mail-order services.]

[Include the following information only if your mail-order service is limited to a subset of all formulary drugs, adapting terminology as needed: For certain kinds of drugs, you can use our plan’s network mail-order services. Generally, drugs available through mail-order are drugs that you take on a regular basis for a chronic or long-term medical condition.] [Insert if plan marks mail-order drugs in formulary: Drugs available through our plan’s mail-order service are marked as mail-order drugs in our Drug List.] [Insert if plan marks non-mail-order drugs in formulary: Drugs not available through our plan’s mail-order service are marked with [plans should indicate how these drugs are marked] in our Drug List.]

Our plan’s mail-order service [insert as appropriate: allows or requires] you to order [insert as appropriate: at least a <number of days>-day supply of the drug and no more than a <number of days>-day supply or up to a <number of days>-day supply or a <number of days>-day supply]. A <number of days>-day supply has the same copay as a one-month supply.

Filling prescriptions by mail

To get [insert if applicable: order forms and] information about filling your prescriptions by mail, [insert instructions].

Usually, a mail-order prescription arrives within <number of days> days. [Insert plan’s process for members to get a prescription if the mail-order is delayed.]

Mail-order processes

Mail-order service has different procedures for new prescriptions it gets from you, new prescriptions it gets directly from your provider’s office, and refills on your mail-order prescriptions.

1. New prescriptions the pharmacy gets from you

The pharmacy automatically fills and delivers new prescriptions it gets from you.

[Plans should include the appropriate information below from the following options, based on (1) whether the plan will automatically process new prescriptions consistent with the policy described in the December 12, 2013, CMS memorandum entitled “Clarification to the 2014 Policy on Automatic Delivery of Prescriptions,” and 2016 Final Call Letter and (2) whether the plan offers an optional automatic refill program consistent with the policy described in the 2020 Final Call Letter. Plan sponsors who provide automatic delivery through retail or other non-mail means have the option to either add or replace the word “ship” with “deliver” as appropriate.]

[For new prescriptions received directly from health care providers, insert one of the following two options.]

[Plan sponsors that do not automatically process new prescriptions from provider offices, insert the following:]

2. New prescriptions the pharmacy gets from your provider’s office

After the pharmacy gets a prescription from a health care provider, it contacts you to find out if you want the medication filled immediately or at a later time.

• This gives you an opportunity to make sure the pharmacy is delivering the correct drug (including strength, amount, and form) and, if needed, allows you to stop or delay the order before [plans with cost-sharing for drugs, insert: you are billed and] it is shipped.

• Respond each time the pharmacy contacts you, to let them know what to do with the new prescription and to prevent any delays in shipping.

[Plan sponsors that do automatically process new prescriptions from provider offices, insert the following:]

2. New prescriptions the pharmacy gets from your provider’s office

The pharmacy automatically fills and delivers new prescriptions it gets from health care providers, without checking with you first, if:

• You used mail-order services with our plan in the past, or

• You sign up for automatic delivery of all new prescriptions you get directly from health care providers. You may ask for automatic delivery of all new prescriptions now or at any time by [insert instructions].

[Plans with no cost-sharing for drugs, delete the following sentence:] If you get a prescription automatically by mail that you do not want, and you were not contacted to find out if you wanted it before it shipped, you may be eligible for a refund.

If you used mail-order in the past and do not want the pharmacy to automatically fill and ship each new prescription, contact us by [insert instructions].

If you never used our mail-order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy contacts you each time it gets a new prescription from a health care provider to find out if you want the medication filled and shipped immediately.

• This gives you an opportunity to make sure the pharmacy is delivering the correct drug (including strength, amount, and form) and, if necessary, allows you to cancel or delay the order before [plans with cost sharing for drugs, insert: you are billed and] it is shipped.

• Respond each time the pharmacy contacts you, to let them know what to do with the new prescription and to prevent any delays in shipping.

To opt out of automatic deliveries of new prescriptions you get directly from your health care provider’s office, contact us by [insert instructions].

[For refill prescriptions, insert one of the following two options.]

[Plans that do not offer a program that automatically processes refills, insert the following:]

3. Refills on mail-order prescriptions

For refills, contact your pharmacy [insert recommended number of days] days before your current prescription will run out to make sure your next order is shipped to you in time.

[Plans that do offer a program that automatically processes refills, insert the following:]

3. Refills on mail-order prescriptions

For refills of your drugs, you have the option to sign up for an automatic refill program [optional: called <name of auto refill program>]. Under this program we start to process your next refill automatically when our records show you should be close to running out of your drug.

• The pharmacy contacts you before shipping each refill to make sure you need more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed.

• If you choose not to use our auto refill program, contact your pharmacy [insert recommended number of days] days before your current prescription will run out to make sure your next order is shipped to you in time.

To opt out of our program [optional: insert name of auto refill program instead of “our program”] that automatically prepares mail-order refills, contact us by [insert instructions].

[All plans offering mail-order services, insert the following:]

Let the pharmacy know the best ways to contact you so they can reach you to confirm your order before shipping. [Insert instructions on how members should provide their communication preferences.]

A7. Getting a long-term supply of drugs

[Plans that do not offer extended-day supplies, replace the information in this section with the following sentence: Our plan does not offer long-term supplies of drugs.]

You can get a long-term supply of maintenance drugs on our plan’s Drug List. Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition. [Insert if applicable: When you get a long-term supply of drugs, your copay may be lower.]

[Delete if the plan does not offer extended-day supplies through network pharmacies.] Some network pharmacies allow you to get a long-term supply of maintenance drugs. A <number of days>-day supply has the same copay as a one-month supply. The Provider and Pharmacy Directory tells you which pharmacies can give you a long-term supply of maintenance drugs. You can also call [insert if applicable: your care coordinator or] Member Services for more information.

[Delete if plan does not offer mail-order service.] [Insert as applicable: For certain kinds of drugs, you or You] can use our plan’s network mail-order services to get a long-term supply of maintenance drugs. Refer to Section A6 [insert reference, as applicable] to learn about mail-order services.

A8. Using a pharmacy not in our plan’s network

Generally, we pay for drugs filled at an out-of-network pharmacy only when you aren’t able to use a network pharmacy. [Insert as applicable: We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.]

We pay for prescriptions filled at an out-of-network pharmacy in the following cases:

[Plans should insert a list of situations when they cover prescriptions out of the network (e.g., during a declared disaster) and any limits on their out-of-network policies (e.g., day supply limits, use of mail-order during extended out-of-area travel, authorization or plan notification).]

In these cases, check with [insert if applicable: your care coordinator or] Member Services first to find out if there’s a network pharmacy nearby.

A9. Paying you back for a prescription

[Plans may add language to reflect that the organization is not allowed to reimburse members for Medicaid-covered benefits.] If you must use an out-of-network pharmacy, you must generally pay the full cost [plans with cost-sharing, insert: instead of a copay] when you get your prescription. You can ask us to pay you back [plans with cost-sharing, insert: for our share of the cost].

To learn more about this, refer to Chapter 7 of your Member Handbook.

2. Our plan’s Drug List

We have a List of Covered Drugs. We call it the “Drug List” for short.

We select the drugs on the Drug List with the help of a team of doctors and pharmacists. The Drug List also tells you the rules you need to follow to get your drugs.

We generally cover a drug on our plan’s Drug List when you follow the rules we explain in this chapter.

[Plans that offer indication-based formulary design must include: If we cover a drug only for some medical conditions, we clearly identify it on our Drug List and in Medicare Plan Finder along with the specific medical conditions covered.]

B1. Drugs on our Drug List

[States should modify this section to accurately reflect the coverage in the state.] Our Drug List includes drugs covered under Medicare Part D and some prescription and over-the-counter (OTC) drugs and products covered under [Insert name of state Medicaid program].

[Insert either of the two sentences: “Our Drug List includes brand name drugs and generic drugs.” OR “Our Drug List includes brand name drugs, generic drugs, and biosimilars.”]

A brand name drug is a prescription drug that is sold under a trademarked name owned by the drug manufacturer. Brand name drugs that are more complex than typical drugs (for example drugs that are based on a protein) are called biological products. On our Drug List, when we refer to “drugs” this could mean a drug or a biological product.

Generic drugs have the same active ingredients as brand name drugs. [Insert if applicable: Since biological products are more complex than typical drugs, instead of having a generic form, they have alternatives that are called biosimilars.] Generally, generic drugs [Insert if applicable: and biosimilars] work just as well as brand name drugs [Insert if applicable: or biological products] and usually cost less. There are generic drug substitutes [Insert if applicable: or biosimilar alternatives] available for many brand name drugs [Insert if applicable: and some biological products]. Talk to your provider if you have questions about whether a generic or a brand name drug will meet your needs.

Our plan also covers certain OTC drugs and products. Some OTC drugs cost less than prescription drugs and work just as well. For more information, call Member Services.

B2. How to find a drug on our Drug List

To find out if a drug you take is on our Drug List, you can:

• [Insert if applicable: Check the most recent Drug List we sent you in the mail.]

• Visit our plan’s website at <web address>. The Drug List on our website is always the most current one.

• Call [insert if applicable: your care coordinator or] Member Services to find out if a drug is on our Drug List or to ask for a copy of the list.

[Plans may insert additional ways to find out if a drug is on the Drug List.]

B3. Drugs not on our Drug List

We don’t cover all prescription drugs. Some drugs are not on our Drug List because the law doesn’t allow us to cover those drugs. In other cases, we decided not to include a drug on our Drug List.

[Plans should remove or modify language regarding benefit exclusions when the benefits are covered by the plan under the Medicaid program or as a supplemental benefit.]

Our plan does not pay for the kinds of drugs described in this section. These are called excluded drugs. If you get a prescription for an excluded drug, you may need to pay for it yourself. If you think we should pay for an excluded drug because of your case, you can make an appeal. Refer to Chapter 9 of your Member Handbook for more information about appeals.

Here are three general rules for excluded drugs:

1. Our plan’s outpatient drug coverage (which includes Medicare Part D and [insert name of state-specific Medicaid program] drugs) cannot pay for a drug that Medicare Part A or Medicare Part B already covers. Our plan covers drugs covered under Medicare Part A or Medicare Part B for free, but these drugs aren’t considered part of your outpatient prescription drug benefits.

2. Our plan cannot cover a drug purchased outside the United States and its territories.

3. Use of the drug must be approved by the FDA or supported by certain medical references as a treatment for your condition. Your doctor may prescribe a certain drug to treat your condition, even though it wasn’t approved to treat the condition. This is called “off-label use.” Our plan usually doesn’t cover drugs prescribed for off-label use.

Also, by law, Medicare or [insert name of Medicaid program] cannot cover the types of drugs listed below.

• Drugs used to promote fertility

• Drugs used for the relief of cough or cold symptoms

• Drugs used for cosmetic purposes or to promote hair growth

• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

• Drugs used for the treatment of sexual or erectile dysfunction

• Drugs used for the treatment of anorexia, weight loss or weight gain

• Outpatient drugs made by a company that says you must have tests or services done only by them

B4. Drug List cost-sharing tiers

[Plans that do not use drug tiers should omit this section. Plans may modify this section to reflect the tiering structure].

Every drug on our Drug List is in one of <number of tiers> tiers. A tier is a group of drugs of generally the same type (for example, brand name, generic, or OTC drugs). In general, the higher the cost-sharing tier, the higher your cost for the drug.

[Plans must briefly describe each tier (e.g., Cost-sharing Tier 1 includes generic drugs, or for plans with no cost-sharing in any tier, Tier 1 includes generic drugs). Indicate which is the lowest tier and which is the highest tier.]

To find out which cost-sharing tier your drug is in, look for the drug on our Drug List.

Chapter 6 of your Member Handbook tells the amount you pay for drugs in each tier.

3. Limits on some drugs

For certain prescription drugs, special rules limit how and when our plan covers them. Generally, our rules encourage you to get a drug that works for your medical condition and is safe and effective. When a safe, lower-cost drug works just as well as a higher-cost drug, we expect your provider to prescribe the lower-cost drug.

If there is a special rule for your drug, it usually means that you or your provider must take extra steps for us to cover the drug. For example, your provider may have to tell us your diagnosis or provide results of blood tests first. If you or your provider thinks our rule should not apply to your situation, ask us to make an exception. We may or may not agree to let you use the drug without taking extra steps.

To learn more about asking for exceptions, refer to Chapter 9 of your Member Handbook.

[Plans should include only the forms of utilization management the plan uses. Plans delete any they don’t use and renumber the list accordingly.]

1. Limiting use of a brand name drug when a generic version is available

Generally, a generic drug works the same as a brand name drug and usually costs less. [Insert as applicable: In most cases, if or If] there is a generic version of a brand name drug available, our network pharmacies give you the generic version.

• We usually do not pay for the brand name drug when there is an available generic version.

• However, if your provider [insert as applicable: told us the medical reason that the generic drug won’t work for you or wrote “No substitutions” on your prescription for a brand name drug or told us the medical reason that the generic drug or other covered drugs that treat the same condition will work for you], then we cover the brand name drug.

• [Plans that offer all drugs at $0 cost-sharing, delete the following sentence:] Your copay may be greater for the brand name drug than for the generic drug.

2. Getting plan approval in advance

For some drugs, you or your doctor must get approval from our plan before you fill your prescription. If you don’t get approval, we may not cover the drug.

3. Trying a different drug first

In general, we want you to try lower-cost drugs that are as effective before we cover drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, we may require you to try Drug A first.

If Drug A does not work for you, then we cover Drug B. This is called step therapy.

4. Quantity limits

For some drugs, we limit the amount of the drug you can have. This is called a quantity limit. For example, we might limit how much of a drug you can get each time you fill your prescription.

To find out if any of the rules above apply to a drug you take or want to take, check our Drug List. For the most up-to-date information, call Member Services or check our website at <web address>. If you disagree with our coverage decision based on any of the above reasons you may request an appeal. Please refer to Chapter 9 of the Member Handbook.

4. Reasons your drug might not be covered

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

• Our plan doesn’t cover the drug you want to take. The drug may not be on our Drug List. We may cover a generic version of the drug but not the brand name version you want to take. A drug may be new, and we haven’t reviewed it for safety and effectiveness yet.

• Our plan covers the drug, but there are special rules or limits on coverage. As explained in the section above [insert reference, as applicable], some drugs our plan covers have rules that limit their use. In some cases, you or your prescriber may want to ask us for an exception.

There are things you can do if we don’t cover a drug the way you want us to cover it.

D1. Getting a temporary supply

In some cases, we can give you a temporary supply of a drug when the drug is not on our Drug List or is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

To get a temporary supply of a drug, you must meet the two rules below:

1. The drug you’ve been taking:

• is no longer on our Drug List or

• was never on our Drug List or

• is now limited in some way.

2. You must be in one of these situations:

• [Plans omit this scenario if the plan allows current members to ask for formulary exceptions in advance for the following year. Plans omit this scenario if the plan was not operating in the prior year.] You were in our plan last year.

• We cover a temporary supply of your drug during the first [insert time period (must be at least 90 days)] days of the calendar year.

• This temporary supply is for up to [insert supply limit (must be the number of days in plan’s one-month supply)] days.

• If your prescription is written for fewer days, we allow multiple refills to provide up to a maximum of [insert supply limit (must be the number of days in plan’s one-month supply)] days of medication. You must fill the prescription at a network pharmacy.

• Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.

• You are new to our plan.

• We cover a temporary supply of your drug during the first [insert time period (must be at least 90 days)] days of your membership in our plan.

• This temporary supply is for up to [insert supply limit (must be the number of days in plan’s one-month supply)] days.

• If your prescription is written for fewer days, we allow multiple refills to provide up to a maximum of [insert supply limit (must be the number of days in plan’s one-month supply)] days of medication. You must fill the prescription at a network pharmacy.

• Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.

• You have been in our plan for more than [insert time period (must be at least 90 days)] days, live in a long-term care facility, and need a supply right away.

• We cover one [insert supply limit (must be at least a 31-day supply)]-day supply, or less if your prescription is written for fewer days. This is in addition to the temporary supply above.

• [If applicable, plans insert their transition policy for current members with changes to their level of care.]

D2. Asking for a temporary supply

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

When you get a temporary supply of a drug, talk with your provider as soon as possible to decide what to do when your supply runs out. Here are your choices:

• Change to another drug.

Our plan may cover a different drug that works for you. Call Member Services to ask for a list of drugs we cover that treat the same medical condition. The list can help your provider find a covered drug that may work for you.

OR

• Ask for an exception.

You and your provider can ask us to make an exception. For example, you can ask us to cover a drug that is not on our Drug List or ask us to cover the drug without limits. If your provider says you have a good medical reason for an exception, they can help you ask for one.

[Plans that do not allow current members to ask for an exception prior to the beginning of the following contract year may omit this paragraph:]

D3. Asking for an exception

If a drug you take will be taken off our Drug List or limited in some way next year, we allow you to ask for an exception before next year.

• We tell you about any change in the coverage for your drug for next year. Ask us to make an exception and cover the drug for next year the way you would like.

• We answer your request for an exception within 72 hours after we get your request (or your prescriber’s supporting statement).

To learn more about asking for an exception, refer to Chapter 9 of your Member Handbook.

If you need help asking for an exception, contact Member Services [insert if applicable: or your care coordinator].

5. Coverage changes for your drugs

Most changes in drug coverage happen on January 1, but we may add or remove drugs on our Drug List during the year. We may also change our rules about drugs. For example, we may:

• Decide to require or not require prior approval (PA) for a drug (permission from us before you can get a drug).

• Add or change the amount of a drug you can get (quantity limits).

• Add or change step therapy restrictions on a drug (you must try one drug before we cover another drug).

For more information on these drug rules, refer to Section C.

If you take a drug that we covered at the beginning of the year, we generally will not remove or change coverage of that drug during the rest of the year unless:

• a new, cheaper drug comes on the market that works as well as a drug on our Drug List now, or

• we learn that a drug is not safe, or

• a drug is removed from the market.

To get more information on what happens when our Drug List changes, you can always:

• Check our current Drug List online at <web address> or

• Call Member Services at the number at the bottom of the page to check our current Drug List.

Some changes to our Drug List happen immediately. For example:

• [Plans that otherwise meet all requirements and want the option to immediately replace brand name drugs with their generic equivalents must provide the following advance general notice of changes: A new generic drug becomes available. Sometimes, a new generic drug comes on the market that works as well as a brand name drug on our Drug List now. When that happens, we may remove the brand name drug and add the new generic drug, but your cost for the new drug stays the same [insert if applicable, for example, if the plan’s Drug List has differential cost-sharing for some generics: or will be lower.]

When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.

• We may not tell you before we make this change, but we send you information about the specific change we made once it happens.

• You or your provider can ask for an “exception” from these changes. We send you a notice with the steps you can take to ask for an exception. Refer to Chapter 9 of your Member Handbook for more information on exceptions.]

• A drug is taken off the market. If the FDA says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we take it off our Drug List. If you are taking the drug, we tell you. [Plans include information advising members what to do after they are notified (e.g., contact the prescribing doctor, etc.).]

We may make other changes that affect the drugs you take. We tell you in advance about these other changes to our Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.

• [Plans that want the option to immediately substitute a new generic drug, insert: We add a generic drug that is not new to the market and

• Replace a brand name drug currently on our Drug List or

• Change the coverage rules or limits for the brand name drug.]

• [Plans that are not making immediate generic substitutions insert: We add a generic drug and

• Replace a brand name drug currently on the Drug List or

• Change the coverage rules or limits for the brand name drug.]

When these changes happen, we:

• Tell you at least 30 days before we make the change to our Drug List or

• Let you know and give you a [insert supply limit (must be at least the number of days in the plan’s one-month supply)]-day supply of the drug after you ask for a refill.

This gives you time to talk to your doctor or other prescriber. They can help you decide:

• If there is a similar drug on our Drug List you can take instead or

• If you should ask for an exception from these changes. To learn more about asking for exceptions, refer to Chapter 9 of your Member Handbook.

We may make changes to drugs you take that do not affect you now. For such changes, if you are taking a drug we covered at the beginning of the year, we generally do not remove or change coverage of that drug during the rest of the year.

For example, if we remove a drug you are taking [insert if applicable: increase what you pay for the drug,] or limit its use, then the change does not affect your use of the drug [insert if applicable: or what you pay for the drug] for the rest of the year.

6. Drug coverage in special cases

F1. In a hospital or a skilled nursing facility for a stay that our plan covers

If you are admitted to a hospital or skilled nursing facility for a stay our plan covers, we generally cover the cost of your prescription drugs during your stay. You will not pay a copay. Once you leave the hospital or skilled nursing facility, we cover your drugs as long as the drugs meet all of our coverage rules.

[Plans with no cost-sharing, delete this paragraph:] To learn more about drug coverage and what you pay, refer to Chapter 6 of your Member Handbook.

F2. In a long-term care facility

Usually, a long-term care facility, such as a nursing facility, has its own pharmacy or a pharmacy that supplies drugs for all of their residents. If you live in a long-term care facility, you may get your prescription drugs through the facility’s pharmacy if it is part of our network.

Check your Provider and Pharmacy Directory to find out if your long-term care facility’s pharmacy is part of our network. If it is not or if you need more information, contact Member Services.

F3. In a Medicare-certified hospice program

Drugs are never covered by both hospice and our plan at the same time.

• You may be enrolled in a Medicare hospice and require a pain, anti-nausea, laxative, or anti-anxiety drug that your hospice does not cover because it is not related to your terminal prognosis and conditions. In that case, our plan must get notification from the prescriber or your hospice provider that the drug is unrelated before we can cover the drug.

• To prevent delays in getting any unrelated drugs that our plan should cover, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription.

If you leave hospice, our plan covers all of your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, take documentation to the pharmacy to verify that you left hospice.

Refer to earlier parts of this chapter that tell about drugs our plan covers. Refer to Chapter 4 of your Member Handbook for more information about the hospice benefit.

7. Programs on drug safety and managing drugs

G1. Programs to help you use drugs safely

Each time you fill a prescription, we look for possible problems, such as drug errors or drugs that:

• may not be needed because you take another drug that does the same thing

• may not be safe for your age or gender

• could harm you if you take them at the same time

• have ingredients that you are or may be allergic to

• have unsafe amounts of opioid pain medications

If we find a possible problem in your use of prescription drugs, we work with your provider to correct the problem.

G2. Programs to help you manage your drugs

[If plan has more than one medication therapy management program update language to reflect this.] Our plan has a program to help members with complex health needs. In such cases, you may be eligible to get services, at no cost to you, through a medication therapy management (MTM) program. This program is voluntary and free. This program helps you and your provider make sure that your medications are working to improve your health. A pharmacist or other health professional will give you a comprehensive review of all of your medications and talk with you about:

• how to get the most benefit from the drugs you take

• any concerns you have, like medication costs and drug reactions

• how best to take your medications

• any questions or problems you have about your prescription and over‑the‑counter medication

Then, they will give you:

• A written summary of this discussion. The summary has a medication action plan that recommends what you can do for the best use of your medications.

• A personal medication list that includes all medications you take, how much you take, and when and why you take them.

• Information about safe disposal of prescription medications that are controlled substances.

It’s a good idea to talk to your doctor about your action plan and medication list.

• Take your action plan and medication list to your visit or anytime you talk with your doctors, pharmacists, and other health care providers.

• Take your medication list with you if you go to the hospital or emergency room.

MTM programs are voluntary and free to members who qualify. If we have a program that fits your needs, we enroll you in the program and send you information. If you do not want to be in the program, let us know, and we will take you out of it.

If you have questions about these programs, contact Member Services [insert if applicable: or your care coordinator].

G3. Drug management program for safe use of opioid medications

Our plan has a program that can help members safely use their prescription opioid medications and other medications that are frequently misused. This program is called a Drug Management Program (DMP).

If you use opioid medications that you get from several doctors or pharmacies or if you had a recent opioid overdose, we may talk to your doctors to make sure your use of opioid medications is appropriate and medically necessary. Working with your doctors, if we decide your use of prescription opioid [insert if applicable: or benzodiazepine] medications is not safe, we may limit how you can get those medications. Limitations may include:

• Requiring you to get all prescriptions for those medications from [insert: a certain pharmacy or certain pharmacies] and/or from [insert: a certain doctor or certain doctors]

• Limiting the amount of those medications we cover for you

If we think that one or more limitations should apply to you, we send you a letter in advance. The letter explains the limitations we think should apply.

You will have a chance to tell us which doctors or pharmacies you prefer to use and any information you think is important for us to know. If we decide to limit your coverage for these medications after you have a chance to respond, we send you another letter that confirms the limitations.

If you think we made a mistake, you disagree that you are at risk for prescription drug misuse, or you disagree with the limitation, you and your prescriber can make an appeal. If you make an appeal, we will review your case and give you our decision. If we continue to deny any part of your appeal related to limitations to your access to these medications, we automatically send your case to an Independent Review Organization (IRO). (To learn more about appeals and the IRO, refer to Chapter 9 of your Member Handbook.)

The DMP may not apply to you if you:

• have certain medical conditions, such as cancer or sickle cell disease,

• are getting hospice, palliative, or end-of-life care, or

• live in a long-term care facility.

If you have questions, please call <plan name> at <toll-free phone and TTY numbers>, <days and hours of operation>. The call is free. For more information, visit <web address>. 1