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.

APPEALS
It is the policy of EnvisionRx Plus to provide an avenue for appeals support in the form of a prescription call center in accordance with guidance from the Centers for Medicare and Medicaid Services (CMS). We will carefully assess the nature of the complaint received by telephone and will promptly determine and inform the enrollee whether the complaint is subject to its grievance or its appeal procedures. [For our complete Appeals Policies and Procedures document, click here].

What is an appeal?
An "appeal" is the type of complaint you make when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug.

GRIEVANCES
It is the policy of EnvisionRx Plus to provide meaningful procedures for timely hearing and resolution of grievances. This policy enables us to use listening and problem - solving skills to resolve the issue presented. The policy also provides a protocol for escalation of grievances when warranted or requested. [For our complete Grievance Policy and Procedures document, click here].

What is a grievance?
A grievance is different from an appeal because usually it will not involve coverage or payment for prescription drugs included in Medicare prescription drug coverage benefits. Instead, the following types of problems might lead to you filing a grievance:

1. If you feel that you are being encouraged to disenroll from EnvisionRx Plus
2. Problems with the customer service you receive
3. Problems with how long you have to spend waiting on the phone or in the pharmacy
4. Disrespectful or rude behavior by pharmacists or other staff
5. Cleanliness or condition of pharmacy
6. If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination
7. You believe our notices and other written materials are difficult to understand
8. Failure to make a decision within the required time frame
9. Failure to forward your case to the independent review entity if we do not make a decision within the required time frame

You may request aggregate numbers of grievances, appeals, and exceptions filed with EnvisionRx Plus by calling Member Services at 866-250-2005 (TTY users may call 1-866-763-9630). Customer Service is open 24 hours a day, 7 days a week.

PLAN TRANSITION PROCESS
As a new or continuing member in 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 your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. We will not pay for a transition supply of medications filled at a Mail Order Pharmacy.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

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 Customer 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.

DISENROLLMENT
Disenrollment from EnvisionRx Plus means ending your membership with us. Disenrollment can be voluntary (your choice) or involuntary (not your own choice). You might leave EnvisionRx Plus because you have decided that you want to leave. You can decide to leave for any reason during specified times [click here for more information].

There are also a few situations where you would be required to leave. For example, you would have to leave EnvisionRx Plus if you move out of our geographic service area or if EnvisionRx Plus no longer offers prescription drug coverage. We are not allowed to ask you to leave the Plan because of your health.

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, please 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 enrolled in the EnvisionRx Plus MTM program.

• You have the following disease states: High Cholesterol, Diabetes, and Hypertension
• Be on at least 5 different covered Part D drugs for these disease states
• Average $1,000/quarter on your total drug spend

It is recommended that you take full advantage of this program if you are selected. You may opt out by calling Member Services at 1-866-250-2005 24 hours a day, 7 days a week. TTY users should call 1-866-763-9630.