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 & APPEALS
Click here to view the EnvisionRx Plus Grievances and Appeals policy.
Plan Transition Process
As a new member in our plan you may be taking medications that are not on our formulary. In this case, 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). 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
Within the first 90 days of coverage with EIC, we will provide new members a one-time temporary fill for at least 30 day supply of non-formulary medication (unless the prescription is written for fewer days). LTC Members
Within the first 90 days of coverage with EIC, a new EIC enrollee residing in a Long Term Care (LTC) facility will be provided a temporary supply of non-formulary medications. 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, for up to a 93 day supply within the first 90 days of coverage. Transition Across Plan Years
The list of covered formulary medications is subject to change from 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. In the first 90 days of the plan year, EIC will provide a temporary supply of the requested non-formulary prescription drug when the member has had a prescription for the medication filled within the past 120 days. EIC will mail enrollees a transition notice that they must either switch to a drug on the applicable EIC formulary or get an exception to continue taking the non-formulary medication. Emergency Transitions
If you are past your 90-day transition period, we may still provide to you an emergency supply of non-formulary medications. This will occur on a case by case basis, when it has been identified that an exception request or appeal has been filed but it has not been completed by the end of the transition period.
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 and TTY users should call 866-763-9630 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.
BEST AVAILABLE EVIDENCE POLICY
Best Available Evidence Policy: http://www.cms.hhs.gov/prescriptiondrugcovcontra/17_Best_Available_Evidence_Policy.asp
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.
Before you fill your prescription in these situations, 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 for the reasons listed below, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. 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. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage. To submit a paper claim,
download and print the form, or call Member Services at 866-250-2005 (TTY users may call 1-866-763-9630) to request a paper claim form. This form must be completed and returned along with your original paper receipts from the pharmacy for your medications to:
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 1-877-878-6410 24 hours a day, 7 days a week. TTY users should call 1-877-878-6412.
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