Policies and Procedures
EnvisionRx Plus regards seriously its responsibility as a provider of prescription drug benefits to beneficiaries with Medicare coverage, including those that participate in medication therapy management and drug and/or utilization management. As such, we are committed to managing the provision of these benefits with integrity, and applying sound policies and procedures for appeals, coverage determinations, exceptions, and grievances.
This page will provide you with the necessary information for understanding your rights, privileges, and benefits under EnvisionRx Plus.
GRIEVANCES, COVERERAGE DETERMINATIONS, & APPEALS
Click here to view the EnvisionRx Plus Grievances and Appeals policy.
You can appoint a representative to act on your behalf by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website at http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp. Please note by clicking on this link, you will be leaving the EnvisionRx Plus website.
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.
BEST AVAILABLE EVIDENCE POLICY
Best Available Evidence Policy: http://www.cms.hhs.gov/prescriptiondrugcovcontra/17_Best_Available_Evidence_Policy.asp
Please note by clicking on this link, you will be leaving the EnvisionRx Plus website
DISENROLLMENT
Disenrollment from EnvisionRx Plus means ending your membership with us. Disenrollment can be voluntary or involuntary. Click here for more information.
FILLING PRESCRIPTIONS OUTSIDE THE NETWORK
Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. We will only cover prescriptions filled at an out-of-network pharmacy in the event of an emergency.
To ensure that EnvisionRxPlus will allow an out of network pharmacy before you fill your prescription, call Member Services to see if there is a network pharmacy in your area, where you can fill your prescription. If you do go to an out-of-network pharmacy due to a health emergency, you may have to pay the full cost (rather than paying just your co-payment), when you fill your prescription. In the event of using an out-of-network pharmacy for an emergency, you can ask us to reimburse you for our share of the cost by submitting a claim form. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy’s price is higher than what a network pharmacy would have charged. Regardless of the amount, we can only reimburse you the amount that we would have paid if you had the prescription filled at a network pharmacy. Even though you may not receive the full amount you paid in reimbursement, the amount that you paid may still be counted towards your $4,700 required out-of-pocket costs in reaching the catastrophic stage.
To submit a paper claim when an out-of-network pharmacy is used in the case of an emergency, download and print the form, or call Member Services at 866-250-2005 (TTY users may call 711) to request a paper claim form. This form must be completed and returned along with your original paper receipt from the pharmacy within the first 90 days of receiving your prescription. This receipt is the one that normally is attached to the bag and shows the National Drug Code, Quantity, Days Supply, Date Filled, and your cost for the medication. If you do not have a copy of your pharmacy receipt, you can ask your pharmacy to reprint a copy for you. Mail the reimbursement form and the receipts within 90 days to the address below:
EnvisionRx Plus
Attn: Member Reimbursement Department
PO Box 1298
Twinsburg, OH 44087
MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM
A Medication Therapy Management (MTM) Program is a program that EnvisionRx Plus offers to qualifying members. The goal of EnvisionRx Plus’ MTM program is to help raise awareness of the importance of your current medication regimen in managing your disease states. All members who meet the following criteria will be automatically enrolled in the EnvisionRx Plus MTM Program:
- Have at least 3 of the following disease states: High Cholesterol, Diabetes, Hypertension or Bone Disease-Arthritis-Osteoporosis
- Be on at least 8 different covered part D drugs
- Average $750/quarter on your total drug spend
It is recommended that you take full advantage of this program if you are selected. This is an added service that is at no additional cost to you. For additional information or to opt out of the program, call Member Services at 1-866-250-2005 24 hours a day, 7 days a week. TTY users should call 711.
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