Medicare Part D

Part D Prescription Drug Coverage Information

Members and Providers
The sections below provide helpful information and forms about your Medicare Part D prescription drug plan benefits and how to access them .

Select Care Drug List
Some of your drugs may be covered at no cost to you. Click here to view the Select Care drug list to see if your drugs qualify.

 

Pharmacy Network Information

Baptist Health Plan Advantage (HMO) gives you access to a large network of retail chain and independent pharmacies. As a member, you can take advantage of more than 65,000 pharmacies nationwide.

  • Find a network pharmacy or download the pharmacy directory by clicking here.
  • Click the appropriate link to locate a long-term care or home infusion pharmacy.
  • Mail order pharmacies: To get information about filling your prescriptions by mail, please call our Member Services department.
  • Telephone: 855.859.1738
  • TTY/TDD: Dial 711 (Kentucky Relay)

Mail Order Pharmacy

  • Express Scripts, Inc.
    P.O. Box 66567
    St. Louis, MO 63166
    888.289.1405

You can get prescription drugs shipped to your home through our network mail order delivery program.

For refills of your mail order prescriptions, you have the option to sign up for an automatic refill program. Under this program, we will start to process your next refill automatically when our records show that you should be close to running out of your drug. We will contact you prior to shipping each refill to make sure you are in need of more medication. You can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use the auto refill program, please contact us 30 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time. To opt out of the automatic refill program, please contact us by calling our toll-free number, 1-888-289-1405 or TTY/TDD 1-800-899-2114.

Typically you should expect to receive your prescription drugs within 14 days from the time that the mail order pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at toll free 1-888-289-1405 or TTY/TDD 1-800-899-2114.
Mail Order Form.

 

Formulary Resources

A prescription drug formulary is a list of drugs a Medicare Advantage plan covers. The Baptist Health Plan Advantage (HMO) formulary includes thousands of brand-name and generic medications. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

These drugs have been approved for coverage by the health plan and are also reviewed and approved by the Centers for Medicare and Medicaid Services (CMS), the agency that administers the Medicare Program.

You may search our prescription drug formulary in several ways:

  • You can use the alphabetical list to search by the first letter of your medication
  • You can search by typing part of the generic (chemical) or brand (trade) names
  • You can search by selecting the therapeutic class of the medication you are looking for
  • Searchable Formulary

To download a pdf version of the Baptist Health Plan Advantage (HMO) Comprehensive Formulary click the link below:

  • Baptist Health Plan Advantage (HMO) Comprehensive Formulary
  • Baptist Health Plan Advantage (HMO) may add or remove prescription drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug and/or move a drug to a higher cost-sharing tier, we will notify you of the change on the website at least 60 days before the date that the change becomes effective.

Utilization Management

For certain prescription drugs, Baptist Health Plan Advantage (HMO) has additional requirements for coverage or limits on coverage. These requirements and limits ensure that members use these drugs in the most effective way and control drug costs. A team of doctors and pharmacists developed these requirements and limits. Examples of utilization management tools are described below:

  • Prior Authorization – Some of the drugs Baptist Health Plan Advantage (HMO) covers may require you to obtain prior approval. This means that approval is required prior to coverage. If you do not get approval, we may not cover the drug. Click on the link below to view any drugs that require prior authorization. You may also view the Prior Authorization list here.
  • Quantity Limits – For certain drugs, Baptist Health Plan Advantage (HMO) limits the amount of the drug that we will cover per prescription or for a defined period of time. Click here to view the drugs that have quantity limits.
  • Step Therapy – In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. This is called step therapy. For example, if Drug A and Drug B both effectively treat a medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. Click the link below to see a list of drugs that require step therapy. You may also view the Step Therapy document here.
  • Generic Substitution – When there is a generic version of a brand-name drug available, network pharmacies will automatically give you the generic version, unless your doctor has told Baptist Health Plan Advantage (HMO) that you must take the brand-name drug and has obtained a prior authorization.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination).

To confirm for Prior Authorization, Quantity Limits, Step Therapy, and/or Generic Substitution, click here on the Searchable Formulary.

Drug Utilization Review

We conduct drug utilization reviews for our members to make sure that they are getting safe and appropriate medications. These reviews are especially important for members who go to more than one doctor and/or pharmacy for their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

  • Possible medication errors
  • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Drugs that are potentially inappropriate because of the member’s age or gender
  • Possible harmful interactions between drugs you are taking
  • Drug allergies
  • Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with you and your doctor to correct the problem.

 

Part D Resources

Transition Process

For Non-Long Term Care Residents:
For any drug that you are currently taking that is not on our formulary, or that requires additional authorization, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you fill the prescription at a network pharmacy. If you are given this temporary supply, please speak to your doctor before you use the entire supply so you and your doctor can select a formulary alternative or request an exception. We will not pay for this drug beyond your first 30-day supply unless you have been approved for a formulary exception.

For Long-Term Care Residents:
If you are a resident of a long-term care facility, we will cover a temporary transition supply up to 31 days. We will cover additional refills if needed for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or is subject to additional authorization, but you are past the first 90 days of membership in our plan, we will cover up to a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception or work with your physician to select a formulary alternative.

For Members Moving from Home to a Long-Term Care Facility or From a Long-Term Care Facility to Home:
If your level of care changes (e.g. entering a long term-care facility or going home after a stay in a long-term care facility), Baptist Health Plan Advantage (HMO) again provides transitional supplies of non-formulary or otherwise restricted medications. For the first month after being discharged from a long-term care facility, you can get at least a 31-day supply of your current medications to allow time for you and your physician to switch to a formulary alternative or request an exception.

Prescription Drug Authorization

As a new member to 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 have trouble getting it. (For example, you may need prior authorization from us before the drug can be covered.). If the drug you are taking is not on our formulary, you should talk to your doctor to decide if you should switch to another drug that we cover or request a formulary exception. During the first 90 days that you are a member of our plan, we may cover a limited amount of your current non-formulary drug therapy in certain cases while you talk to your doctor to determine the right course of action for you. Please note there are some exclusions from coverage required under Medicare, including:

  • Non-prescription drugs (also called over-the-counter drugs)
  • Drugs when used to promote fertility
  • Drugs when used for the relief of cough or cold symptoms
  • Drugs when used for cosmetic purposes or to promote hair growth
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
  • Drugs when used for treatment of anorexia, weight loss, or weight gain
  • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

For a detailed listing of all exclusions, please see section 7.1 in chapter 5 of the Evidence of Coverage (EOC).

View the Baptist Health Plan Advantage (HMO) Comprehensive Formulary.

To request a prior authorization or check the status of a prior authorization request submitted by your physician or other prescriber please contact us at 855.859.1738.

Coverage Determinations, Redeterminations, Exceptions and Grievances

Members can request a coverage determination, exception, redetermination or appeal by a variety of methods such as calling our Member Services department or mailing, faxing or emailing one of the forms below to Baptist Health Plan Advantage (HMO). Please contact us using one of the methods listed. You may call our Member Services Department at 855.859.1738. TTY users should dial 711 (Kentucky Relay) to get information about this process, to check on the status of your request, or to obtain an aggregate number of appeals and grievances for our plan.

The Medicare program also offers forms to Medicare beneficiaries for prescription drug determination or appeal requests. Use the link below to view this information on the Medicare website.

  • Coverage Determination Request Form
  • Request for Redetermination Form
  • For Medicare Enrollees: CMS Coverage Determination Request Form
  • For Medicare Providers: CMS Coverage Determination Request Form
  • Centers for Medicare & Medicaid (CMS) Complaint Form

Coverage Determinations and Exceptions Contact Information:

  • Fax: 844.443.7933
  • Phone: 855.859.1738
  • Email: MedicarePartD@evolenthealth.com
  • Mail:
    Baptist Health Plan Advantage
    Attn: Pharmacy Services
    950 North Meridian St., Suite 600
    Indianapolis, IN 46204

Redetermination (Appeals) Contact Information:

  • Fax: 844.443.7933
  • Phone: 855.859.1738
  • Mail:
    Baptist Health Plan Advantage
    Attn: Pharmacy Services
    950 North Meridian St., Suite 600
    Indianapolis, IN 46204

Coverage Redetermination, Determination and Exceptions requests sent by email which contain Protected Health Information (PHI) should be sent securely. All requests submitted by email are immediately received by Baptist Health Plan Advantage (HMO) Pharmacy Services and processed according to the turnaround times provided in your Evidence of Coverage.
Online Form:

  • Please select the appropriate coverage redetermination or determination and exception form from above.
  • Have your physician or other prescriber assist in completing the form.
  • Save the form on your computer. If you do not wish to save personal health information on your computer, please use one of the other methods provided on this page.
  • Use the online form provided below to upload the document and submit to Baptist Health Plan Advantage (HMO).

 

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Grievances:
At Baptist Health Plan, we value our members and the quality of care and service you receive is our top priority. We encourage you to let us know right away if you have questions, concerns, or problems related to covered services or the care you receive while you are a member of Baptist Health Plan Advantage (HMO). You may call our Member Services Department at 855.859.1738. TTY users should dial 711 (Kentucky Relay), to report a grievance, get information about this process, check on the status of your request, or obtain an aggregate number of appeals and grievances for our plan.

Hospice Coverage Determination Information:
Hospice Providers should utilize the link below to request a coverage determination or exception. This form should be used prior to the submission of a prescription drug claim to prevent rejection at point-of-sale when a drug in any of the following classes is prescribed for a condition that is not related to the members’ terminal illness.

  • Analgesics
  • Antinauseants (antiemetics)
  • Laxatives
  • Antianxiety drugs (anxiolytics)

Hospice Provider Coverage Determination/Exception Request Form

If you or your prescriber submit a request for coverage that is denied and you do not agree with our decision, you may request an appeal (redetermination). Use the link below to view this form and have your physician or other prescriber assist in completing this document. Please note, a physician supporting statement is required for all exceptions requests.

Request for Redetermination Form

Appointment of Representative

A Baptist Health Plan Advantage (HMO) member can appoint a person to act on his/her behalf. Print the form below, complete the required fields, and fax or mail it to us. Once we receive this completed request we will verify it, adjust our records accordingly, and speak to your appointed representative.

Appointment of Representative Form

 

 

Helpful Forms

Below please find important forms to help you manage your Baptist Health Plan Advantage (HMO) prescription drug coverage.

  • Appointment of Representative Form
  • For Medicare Enrollees: Coverage Determination Request Form
  • For Medicare Providers: Coverage Determination Request Form
  • Medicare Prescription Drug Claim Form
  • Mail Order Pharmacy Form

 

Best Available Evidence (BAE)

Federal regulations at 42 CFR § 423.800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.

To address these situations, CMS created the best available evidence (BAE) policy in 2006.

This policy requires Baptist Health Plan to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate.

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Last Updated: 11/01/2017, 12:05 pm