Prescription Drug Coverage
Prescription Drug Coverage
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How to Contact Social Security or Medicaid for Extra Help
People with limited income and resources may qualify for “Extra Help”. If you qualify, you get help paying for any Medicare drug plan’s monthly premium, yearly deductible, and prescription co-payments. This “Extra Help” also counts toward your out-of-pocket costs.
You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify for getting “Extra Help”, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week; or
- The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778. For additional information on extra help from the Social Security Administration you can also visit their website: Extra Help with Medicare Prescription Drug Plan Costs | SSA; or
- Your State Medicaid Office (See Evidence of Coverage for contact information).
Prescription Drug Benefits
A formulary (drug list) is a list of covered drugs selected by Florida Complete Care in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Florida Complete Care will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Florida Complete Care network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Generally, if you are taking a drug on our 2022 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2022 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug:
- New generic drugs. We may immediately remove a brand name drug on our formulary if we are replacing it with a new generic drug that will appear on the same tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.
- If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the Formulary Exception section of this website.
- Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
- Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.
A downloadable copy of our formulary is updated monthly to reflect the removal and addition of drugs noting when it was last updated. To get updated information about the drugs covered by Florida Complete Care, please see the most recently posted formulary below or call Customer Service.
Florida Complete Care covers both brand name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Restrictions on Coverage:
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: Florida Complete Care requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Florida Complete Care before you fill your prescriptions. If you don’t get approval, Florida Complete Care may not cover the drug.
- Quantity Limits: For certain drugs, Florida Complete Care limits the amount of the drug that Florida Complete Care will cover. This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, Florida Complete Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Florida Complete Care may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Florida Complete Care will then cover Drug B.
- Call Customer Service at 1-844-740-0625 (TTY users should call 711)
- Submit Fax Request to 855-633-7673
- Send Mail Requests:
- CVS Caremark
P.O. Box 52000
Phoenix, AZ 85072-2000
- CVS Caremark
2023 Coverage Determination Request Form – English
2023 Coverage Determination Request Form – Spanish
Coverage Determination Online Request
You can find out if your drug is covered or has any additional requirements or limits by looking in the comprehensive formulary that you can download from this website. We have also posted documents that explain our prior authorization and step therapy restrictions. If you have questions about the formulary, any restrictions, or if your medication is not listed, please call Customer Service.
2023 Prior Authorization Criteria – English
2023 Step Therapy Criteria – English
Step Therapy Criteria – Spanish
Prescription Drug Search Tool
2023 Prescription Drug Search Tool
The Florida Complete Care Drug List (Formulary) tool allows you to search drug names to determine 2022 plan coverage for your formulary.
Perform the search via the following steps:
- Search for a Drug
- Select the drug, strength and dosage form and Add to List
- Repeat Steps 1 and 2 for all drugs for which you would like to determine coverage
- Review results, including:
- Drug Name: Name of drug found and applicable strength and dosage form with brand and generic status
- Notes: Details coverage, along with any formulary restrictions on medications such as quantity limits, prior authorizations or step therapy requirements. This column also provides additional information as applicable.
- Forms and Criteria:Provides additional details on coverage as applicable to the medications viewed.
Out-of-network/non- contracted providers are under no obligation to treat Florida Complete Care members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.
If a drug is not covered in the way you would like it to be covered, you can ask us to make an exception to our coverage rules. An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.
There are several types of exceptions that you can ask us to make.
- You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Florida Complete Care limits 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 a greater amount.
Generally, Florida Complete Care will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
Direct Member Reimbursement (DMR)
(Mail your request for payment for Part D prescription drugs, together with any bills or paid receipts to us at this address:
For Part D prescription drug claims:
Medicare Part D Paper Claim
P.O. Box 52066
Phoenix, AZ 85072-2066
You may also call Customer Service to request payment at 1-844-740-0625. We are open 24 hours a day, 7 days a week.
Drug Utilization Review
Florida Complete Care requires participating pharmacies to perform drug utilization review (DUR) each time you fill a prescription. This is designed to analyze drug safety and usage for members based on their profile. The DUR is an important tool that screens for potential drug complications, such as:
- Drug-Drug Interactions
- Drug-Age precautions
- Drug-Gender precautions
- Drug-Pregnancy precautions
- Drug-Allergy precautions
- Incorrect dosage precautions
- Incorrect duration of drug therapy
- Therapeutic duplication
- Excessive use precautions
- Prescription limitations
Compliance Monitoring (Pharmacy)
The drug utilization review serves as a measure to ensure that drug usage criteria are met and satisfy FDA guidelines. Clinical protocols are adopted by the Pharmacy and Therapeutic (P&T) Committee. Based on this review, the attending pharmacist and/or physician can make the most beneficial decision regarding the pharmaceutical care for the patient.
Florida Complete Care ensures the safety and health of its members through the establishment of effective Quality Assurance measures and systems. We do this to reduce medication errors and adverse drug reactions, and to improve medication utilization. These measures include making sure that providers comply with pharmacy practice standards, drug utilization review, internal medication error identification systems, and medical therapy management programs.
Medication Therapy Management Program
The Florida Complete Care Medication Therapy Management (MTM) Program helps you get the most out of your medications by:
- Preventing or reducing drug-related risks
- Supporting good lifestyle habits
- Providing information for safe medication disposal options
Who qualifies for the MTM Program?
You will be enrolled in the Florida Complete Care MTM Program if you meet one of the following:
- Have coverage limitation(s) in place for medication(s) with a high risk for dependence and/or abuse, or
- Meet the following criteria:
- You have three or more of these conditions:
- Chronic heart failure (CHF)
- Chronic obstructive pulmonary disease (COPD)
- Chronic alcohol & drug dependence
- You take eight or more maintenance medications covered by your plan
- You are likely to spend more than $4,696 in prescription drug costs in 2022
- You have three or more of these conditions:
Your participation in the MTM Program is voluntary and does not affect your coverage. This is not a plan benefit and is open only to those who qualify. There is no extra cost to you for the MTM Program.
How will I know if I qualify for the MTM Program?
If you qualify, we will mail you a letter. You may also receive a call to set up your one-on-one medication review.
What services are included in the MTM Program?
In the MTM Program, you will receive the following services from a health care provider:
- Comprehensive medication review
- Targeted medication review
What is a comprehensive medication review?
The comprehensive medication review is completed with a health care provider in person or over the phone. This review is a discussion that includes all your medications:
- Over-the-counter (OTC)
- Herbal therapies
- Dietary supplements
This review usually takes 20 minutes or less to complete. During the review, you may ask any questions about your medications or health conditions. The health care provider may offer ways to help you manage your health and get the most out of your medications. If more information is needed, the health care provider may contact your prescriber.
At the end of the review, the health care provider will provide you with a summary of what you discussed. The summary will include the following:
- Medication Action Plan. Your plan may include suggestions for you and your
prescriber to discuss during your next visit
- Personal Medication List. This is a list of all the medications discussed
during your review. You can keep this list and share it with your prescribers
- Here is a blank copy of the Personal Medication List – English for tracking your medications.
- Personal Medication List – Spanish
Who will contact me about completing the review?
You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You can choose to complete the review in person or over the phone.
A health care provider may also call you to complete your review over the phone. When they call, you can schedule your review at a time that is best for you.
Why is this review important?
Different prescribers may write prescriptions for you without knowing all the medications you take. For that reason, the MTM Program health care provider will:
- Review all your medications
- Discuss how your medications may affect each other
- Identify any side effects from your medications
- Help you reduce your prescription drug costs
How do I benefit from talking with a health care provider?
By completing the medication review with a health care provider, you will:
- Understand how to safely take your medications
- Get answers to any questions you may have about your medications or health conditions
- Review ways to help you save money on your drug costs
- Receive a Personal Medication List and Medication Action Plan to keep and share with your prescribers and/or caregivers
What is a targeted medication review?
The targeted medication review is completed by a health care provider who reviews your medications at least once every three months. With this review, we mail, fax, or call your prescriber with suggestions about prescription drugs that may be safer or work better for you. As always, your prescriber will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your prescriber decide to change them. We may also contact you by mail or phone with suggestions about your medications.
How can I get more information about the MTM Program?
Please contact us if you would like more information about the Florida Complete Care MTM Program or if you do not want to participate. Our number is 1-833-322-7526, 24 hours a day, 7 days a week. (TTY users, call 711)
How do I safely dispose of medications I don’t need?
The Florida Complete Care MTM Program is dedicated to providing you with information about safe medication disposal. Medications that are safe for you may not be safe for someone else. Unneeded medications should be disposed of as soon as possible. You can discard your unneeded medications through a local safe disposal program or at home for some medications.
- Locating a community safe drug disposal site
A drug take back site is the best way to safely dispose of medications. To find drug take back sites near you, visit the website below and enter your location:https://apps2.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e2s1
Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs, and other ways for safe disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you.
- Mailing medications to accepting drug disposal sites
Medications may be mailed to authorized sites using approved packages. Information on mail-back sites can be found at https://www.deatakeback.com.
- Safe at-home medication disposal
You can safely dispose of many medications through the trash or by flushing them down the toilet. Visit the following website to learn more about safe at-home disposal:https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html
Follow these steps for medication disposal in the trash:
- Remove medication labels to protect your personal information
- Mix medications with undesirable substances, such as dirt or used coffee grounds
- Place mixture in a sealed container, such as an empty margarine tub
Drug Management Program (DMP)
The Florida Complete Care Drug Management Program (DMP) helps members who are at risk for prescription drug abuse to safely manage these pain medications. Opioid pain medications can help with certain types of pain, but have serious risks like addiction, overdose, and death. These risks are increased when opioids are obtained from multiple doctors or pharmacies; when opioids are taken with certain other medications like benzodiazepines (commonly used for anxiety and sleep); and/or when a person taking opioids has a recent history of opioid overdose. If a member gets opioids from multiple doctors or pharmacies, we may talk with their doctors to verify the safe utilization of these medications. After consulting with the doctors if it is concluded that the use of prescription opioids and/or benzodiazepines is not appropriate, we (with the consent of your doctors) may limit coverage of these medications under the DMP by limiting the amount of medication dispensed, by limiting prescribing to a specific prescriber(s), and/or by limiting dispensing of these medication to a specific pharmacy(ies) to better coordinate their health care.
Before you are placed in the drug management program, we will notify you by letter. You’ll be able to let us know which doctors or pharmacies you prefer to use to get your prescription opioids and benzodiazepines, and about any other information you think is important for us to know. After you’ve had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you another letter confirming our decision. You and your doctor can appeal if you disagree with the decision or think we made a mistake.
For more information regarding the DMP Program, please call 1-844-740-0625, 24 hours a day, 7 days a week. (TTY users, call 711)
Note: The safety reviews and Drug Management Program generally won’t apply to you if you have cancer, get hospice, palliative, or end-of-life care, if you live in a long-term care facility or if you have sickle cell disease.
Grievances and Appeals
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision.
When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. Under certain circumstances, you can request an expedited or “fast coverage decision” or fast appeal of a coverage decision. If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.
You can use one of the following methods to request an appeal:
- Call Customer Service at 1-855-344-0930 (TTY 711)
- Submit Fax Request to 1-855-633-7673
- Send Mail Requests to
|CVS Caremark Standard Appeal (Redeterminations) (7 Day TAT)|
|P.O. Box 52000, MC109|
|Phoenix, AZ 85072-2000|
2023 Redetermination Request Form – English
2023 Redetermination Request Form – Spanish
Redetermination Online Request
How to Appoint a Representative
You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative,” to ask for a coverage decision or make an appeal. There may be someone who is already legally authorized to act as your representative under state law.
If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Customer Service and ask for the “Appointment of Representative” form or:
Click here for 2023 Appointment of Representative Form – English (PDF)
Click here for 2023 Appointment of Representative Form – Spanish (PDF)
to download the form. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.
The form is also available on Medicare’s website at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf
The formal name for “making a complaint” is “filing a grievance”. The complaint process is used for certain types of problems only. This includes complaints you make about us or pharmacies related to quality of care, waiting times, and the customer service you receive. This type of complaint does not involve coverage or payment disputes.
Contact us promptly – either by phone or in writing. Usually calling our Customer Service is the first step. If you do not wish to call (or you called and were not satisfied) you can put your complaint in writing and send it to us. The grievance must be made within 60 days after you had the problem you want to grieve about.
We look into your complaint and give you our answer. If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days. If we decide to take an extra 14 days, we will tell you in writing. If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not. If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint.” If you have a “fast complaint,” it means we will give you an answer within 24 hours.
You can submit a complaint about us directly to Medicare. To submit a complaint to Medicare, go to https://www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Information on the aggregate number of Florida Complete Care grievances, appeals and exceptions is available by contacting Customer Service.
Tier Cost Sharing
Cost sharing is the amount that a member has to pay when services or drugs are received. Tier cost sharing is a term that means there is cost sharing for drugs that are classified under specified tier levels. The Florida Complete Care formulary has one tier:
- Tier 1: Formulary- Brand and Generics Drugs
Under certain circumstances, Florida Complete Care can offer a temporary supply of a drug to you when your drug is not on the formulary or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
Part D Transition Guidelines:
Members and situations affected by this transitional fills policy in which Florida Complete Care will apply a transition process are described below:
- New Beneficiaries enrolled into the plan following the annual coordinated election period;
- Newly eligible Medicare Beneficiaries from other coverage;
- The transition of Beneficiaries who switch from one plan to another after the start of a Contract Year;
- Current Beneficiaries affected by negative formulary changes across Contract Year;
- Beneficiaries residing in long-term care (LTC) facilities, including Beneficiaries being admitted to or discharged from an LTC facility.
The transition process is applicable to:
- Part D drugs that are not on the Part D formulary
- Part D drugs that are on Part D formulary but require prior authorization, exceed quantity limits or require step therapy
The transition process allows for medical review of Non-formulary Drug requests, and when appropriate, a process for switching new Part D Sponsor Beneficiaries to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination.
In certain instances, drug utilization management edits are applied during the beneficiary’s transition period. These edits are limited to:
- Edits to help determine Part A or B versus Part D coverage;
- Edits to prevent coverage of non-Part D drugs (i.e., excluded drugs or formulary drugs being dispensed for an indication that is not medically accepted); and
- Edits to promote safe utilization of a Part D drug
Our transition processes will apply to all new prescriptions for a non-formulary drug. If we are unable to make a distinction between a new prescription and an ongoing prescription for a non-formulary drug at the point-of-sale, we will provide the enrollee with a transition fill.
The Pharmacy & Therapeutics (P&T) Committee is an advisory committee responsible for reviewing clinical information regarding medications and making formulary recommendations. The P&T Committee is comprised of primary-care and specialty physicians, as well as pharmacists. We have procedures for medical review of non- formulary drug requests and, when appropriate, a process for switching new members to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination. The P&T Committee’s involvement ensures that transition decisions appropriately address situations involving members stabilized on drugs that are not the formulary (or that are on the formulary but require prior authorization, exceed quantity limits, or require step therapy) and which are known to have risks associated with any changes in the prescribed regimen.
Florida Complete Care will charge cost-sharing for a temporary supply of drugs provided under our transition process. For non-LIS eligible enrollees, this cost-sharing is consistent with cost-sharing that we would charge for non-formulary drugs approved under a coverage exception and the same cost sharing for formulary drugs subject to utilization management edits provided during the transition that would apply once the utilization management criteria are met. Cost-sharing for transition supplies for low-income subsidy (LIS) eligible members can never exceed the statutory maximum co-payment amounts.
Within the first 90 days of coverage for a new member under a Part D plan, we will provide a temporary fill when our new member requests a refill of a non-formulary drug, including Part D drugs that are on Part D formulary but require prior authorization, exceed quantity limits, or require step therapy under this medication utilization management policy.
- This 90-day timeframe applies to retail, home infusion, long term care and mail order pharmacies.
- Since certain members may join a plan at any time during the year, this requirement will apply beginning on a member’s first effective date of coverage, and not only to the first 90 days of the contract year.
- If an enrollee leaves a plan and re-enrolls during the original 90-day transition period, the transition period begins again with the new effective date of enrollment. However, if there is no gap in coverage, there is no new transition period.
- This 90-day timeframe assists those beneficiaries transitioning from other prescription drug coverage who obtained extended (i.e., 90-day) supplies of maintenance drugs prior to the last effective date of their previous coverage.
- Outpatient Setting (Retail Pharmacies) – The temporary supply of non-formulary Part D drugs, including Part D drugs that require prior authorization, exceed quantity limits, or require step therapy, must be for at least a month’s supply of medication.
- Long-Term Care (LTC) Setting – The temporary supply of non-formulary Part D drugs, including Part D drugs that require prior authorization, exceed quantity limits, or require step therapy, for a new member in a LTC facility for at least a month’s supply consistent with the dispensing increments (unless the prescription is written for less), with refills provided if needed during the first 90 days of a beneficiary’s enrollment in our plan, beginning on the enrollee’s effective date of coverage.
Emergency Supply for Current Members
- During the first 90 days after a member’s enrollment, he/she will receive a transition supply. However, to the extent that a member in an LTC setting is outside his/her 90-day transition period, we will provide an emergency supply of non-formulary Part D drugs, including Part D drugs that are on the formulary that would otherwise require prior authorization, exceed quantity limits, or require step therapy, while an exception or prior authorization is requested.
- These emergency supplies of non-formulary Part D drugs will be for at least 31 days of medication, regardless of dispensing increments, unless the prescription is written by a prescriber for less than 31 days.
Level of Care Changes
- The transition process provides for other circumstances that exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on our formulary. These circumstances usually involve the level of care changes for a member that is changing from one treatment setting to another, such as:
- Members who enter LTC facilities from hospitals with a discharge list of medications from the hospital formulary with very short-term planning taken into account (i.e. under 8 hours)
- Members who are discharged from a hospital to a home with very short-term planning taken into account
- Members who 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
- Members who give up hospice status to revert to standard Medicare Part A and B benefits
- Members who end an LTC facility stay and return to the community
- Members who are discharged from psychiatric hospitals with drug regimens that are highly individualized
- These circumstances often result in members and/or providers utilizing the exceptions and/or appeals processes. For these unplanned transitions, we make coverage determinations and re-determinations as expeditiously as the member’s health condition requires.
- Our transition process ensures appropriate medication reconciliation for member upon discharge from LTC facilities or other facilities, so that an effective transition of care can be accomplished.
- Claims data is utilized to determine if the member has experienced a level of care change and allows a transition fill where applicable. When claims data cannot be used to determine a level of care change, a pharmacy may need to call Customer Service to process a point-of-sale override in order to effectuate this type of transition fill.
In certain circumstances, Florida Complete Care will extend the transition period and provide the necessary drugs if the enrollee’s exception request or appeal has not been processed by the end of the minimum transition period. This extension is granted on a case-by-case basis taking into account whether the member’s exception request or appeal has not been processed by the end of the minimum transition period.
Transition Across Contract Years
After members receive their Annual Notice of Change (ANOC) by September 30th of a given year, Florida Complete Care will a transition process for current members at the start of the new contract year or prior to the start of the new contract year.
- Current Enrollees: Where we can identify objective information demonstrating that a meaningful transition has occurred or the enrollee lacks documented ongoing therapy, we do not have to provide access to a transition supply in the new contract year for that member. However, if we are unable to identify such objective evidence, we will provide a transition supply in the new contract year and provide the required transition notice.
- New Enrollees: We also extend the transition policy across contract years where a member enrolls into one of our plans with an effective enrollment date of either November 1st or December 1st and that member needs access to a transition supply. Members with a November 1st or December 1st effective enrollment date will be sent an ANOC as soon as practicable after the effective enrollment date. The ANOC will still serve as advance notice of any formulary or benefit changes in the following contract year.
Florida Complete Care sends written notice within three business days after providing a temporary supply of non-formulary Part D drugs (including Part D drugs that are on the formulary but require prior authorization, exceed quantity limits, or require step therapy). The notice will include:
- An explanation of the temporary nature of the transition supply a Beneficiary has received;
- Instructions for working with the Plan Sponsor and the Beneficiary’s prescriber to satisfy utilization management requirements or to identify appropriate therapeutic alternatives that are on the Sponsor’s formulary;
- An explanation of the Beneficiary’s right to request a formulary exception; and
- A description of the procedures for requesting a formulary exception.
For LTC residents dispensed multiple supplies of a Part D drug in increments of 14-days-or-less, the written notice will be provided within 3 business days after adjudication of the first temporary fill. We will use reasonable efforts to provide notice of transition fill to prescribers to facilitate transitioning of Beneficiaries.
Low-Income Subsidy/Extra Help
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. Florida Complete Care’s premium includes coverage for both medical services and prescription drug coverage.
This table shows you what your monthly plan premium will be if you get extra help.
LIS Premium Summary Form (PDF)
If you aren’t getting extra help, you can see if you qualify by calling Medicare, your State Medicaid Office, or the Social Security Office. (See section titled “How to Contact Social Security or Medicaid for Extra Help”)
Best Available Evidence of Low-Income Subsidy Status
If you believe that you are paying too much for your prescription drugs because Florida Complete Care does not have the correct low-income subsidy status, please call our Member Services Department. We can help you find out if you should be paying less for your prescription drugs because you are eligible for Medicaid and/or the low-income subsidy. Please visit the Centers for Medicare and Medicaid Services website to learn more.
Pharmacy Network and Out-of Network Pharmacy Coverage
Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members. You can use the Pharmacy Directory to find the network pharmacy you want to use. In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies.
You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you can ask either to have a new prescription written by a provider or to have your prescription transferred to your new network pharmacy.
Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility’s pharmacy as long as it is part of our network.
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Please check first with Customer Services to see if there is a network pharmacy nearby. If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost.
Check your Pharmacy Directory to find out if pharmacy is part of our network. If it isn’t, or if you need more information, please contact us at:
Searchable Pharmacy Directory Link