Member Information
Thank you for selecting EnvisionRx Plus as your Medicare Prescription Drug Plan.
The materials in this section will help you understand how your coverage works and how to use your prescription drug card. Please click on the links below to access each of the following EnvisionRx Plus documents:
Evidence of Coverage (EOC)
Provides a thorough description of your benefits under the EnvisionRx Plus prescription drug card and how to access them.
Summary of Benefits
Plan Transition Process
As a new member in our plan you may be taking medications that are not on our drug list (also called a formulary) or medications that are on our formulary but require prior authorization or step therapy under our utilization management rules. If you are taking a medication that is not on our formulary or is on the formulary but requires step therapy, you should ask your doctor to determine if there is an appropriate formulary medication that can be substituted. If your doctor determines that there is no formulary medication that can be substituted for your current therapy, you may request a formulary exception (a request for coverage of a non-formulary medication or a step therapy exception). If you are on a medication that requires prior authorization, we require documentation that you meet the criteria for coverage of the medication. While you and your doctor are determining the right course of action for you, we have the following policy in place to ensure that you are not left without medication coverage.
New Members to Envision at the beginning of the contract year (New Enrollees in EnvisionRx Plus, newly eligible Medicare beneficiaries from other coverage at the beginning of a contract year or Members who switch from one plan to another after the beginning of a contract year) Within the first 90 days of coverage with EIC starting from your effective date of coverage, we will provide new enrollees a one-time temporary 30-day fill (unless you present a prescription written for less than 30 days in which case we will allow multiple fills to provide up to a total of 30 days of medication) of non-formulary medication or medications that require Step Therapy or Prior Authorization (unless the prescription is written for fewer days). LTC Members
Within the first 90 days of coverage with EIC starting from your effective date of coverage, new EIC enrollees residing in a Long Term Care (LTC) facility will be provided a temporary supply of non-formulary medications or medications requiring prior authorization or step therapy. The temporary supply will be for up to 31 days (unless the prescription is written for less than 31 days). In addition, EIC will honor multiple fills of non-formulary medications or medications subject to prior authorization or step therapy, for up to a 93-day supply within the first 90 days of coverage. If you are new to the Long Term Care setting or currently in the Long Term Care Setting and your 90-day transition period has expired, we will provide you with a 31-day emergency supply of non-formulary Part D drugs (unless the prescription presented is written for less than 31 days while an exception or prior authorization is being processed). Additionally, if you are admitted or discharged from a Long Term Care facility, you will have access to early refills if necessary. Transition Across Plan Years
The list of covered formulary medications is subject to change from year to year. For this reason, we have a transition policy in place for current EIC members who are taking a medication that will not be covered in the next plan year or medications that will have step therapy or prior authorization requirements in the new plan year. In the first 90 days of the new plan year, EIC will provide a temporary 30-day supply (unless you present a prescription written for less than 30 days in which case we will allow multiple fills to provide up to a total of 30 days of medication) of the requested non-formulary prescription drug (or drug that has new step therapy or prior authorization requirements) when you have had a prescription for the medication filled within the past 120 days of the date of the attempted fill. In addition, members who were granted an exception in the previous plan year and are staying in the same plan for the new plan year will be allowed a temporary 30-day supply (unless you present a prescription written for less than 30 days in which case we will allow multiple fills to provide up to a total of 30 days of medication). Emergency Transitions/Level of Care Changes
Members who are outside their transition period and experience a level of care change by changing from one treatment setting to another (e.g. long term care to hospital to long term care; hospitals to home; or home to long term care) will be able to receive a 30/31-day supply (30 days in the retail setting and 31 days in the long term care setting) for formulary medication upon admission or discharge from a treatment setting. Members will also be allowed an emergency 30/31-day supply (30 days in the retail setting and 31 days in the long term care setting) transition fill for non-formulary medications, including Part D covered drugs that are on EIC’s formulary but require prior authorization or step therapy. This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from long term care or hospital facilities.
Members who have passed the 90-day transition period may still be provided an emergency supply of non-formulary medications, if approved by us. If approved, members will receive up to a 30-day supply in the retail setting and up to a 31-day supply in the long term care setting. This will occur on a case-by-case basis, when it has been identified that an exception request or appeal has been filed but has not been completed by the end of the transition period. All transition fills for new members, either in the retail setting or in the long term care setting, will process automatically. If you require a transition fill outside of your first 90 days with EnvisionRx Plus, you or your pharmacist should contact Member Services at 866-250-2005, 7 days a week 24, hours a day (TTY users should call 711), so we can implement our transition policy for you.
In the event that you enroll in our plan while living at home, and then become a resident of a long term care facility, you need to contact Member Services at 866-250-2005, 7 days a week 24 hours a day (TTY users should call 711) to let EnvisionRx Plus know that you are now a resident of a LTC facility. This will allow us to implement the long term care transition policy for you.
We will send you written notice via U.S. first class mail within three business days of receiving your transition fill transaction from the pharmacy. This notice will contain an explanation of the temporary nature of that prescription fill; instructions on how to identify an appropriate therapeutic alternative that is on our formulary; an explanation of your right to request a formulary exception; and the procedure for requesting a formulary exception.
If you are a Low Income Subsidy member, you will never pay more than the appropriate copayment amount associated with your Low Income Subsidy Level. For members who do not have Low Income Subsidy status, you will pay the copay/coinsurance associated with our non-preferred brand tier.
Extra Help
People with limited income and resources may qualify for Extra Help. Some people automatically qualify for Extra Help and don’t need to apply. Medicare mails a letter to people who automatically qualify for Extra Help.
If you aren’t getting extra help, you can see if you qualify by calling:
- 1-800-Medicare of TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
- Your State Medicaid Office, or
- The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.
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. View the Extra Help Page and select your State to see what your premium will be.
This information is available for free in other languages. Please contact our customer service number at 1-866-250-2005 for additional information.
Esta información está disponible de forma gratuita en otros idiomas. Por favor de contactar nuestro número de servicio al cliente al 1-866-250-2005 para obtener información adicional.
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