Resources, training and tools to help you.
EnvisionInsurance is committed to making the coverage determination and appeals process as easy as possible. Fax authorization or coverage determination forms to 1-877-503-7231, submit electronic requests for coverage determination or call 1-866-250-2005 (TTY 711) for assistance.
The Centers for Medicare and Medicaid Services (CMS) does not allow Medicare Part D plans to accept coverage determination criteria from Pharmacists; however, EnvisionInsurance is committed to streamlining this process. If needed, you can download coverage determination forms to provide to prescribers or contact our help desk to have criteria forms faxed directly to them. You can also search our covered drugs or drug pricing tool to find lower-cost alternatives for your patients.
Further, the Affordable Care Act includes provisions to close the Medicare Part D prescription drug coverage gap (also known as the "donut hole") to make prescription drugs more affordable for people with Medicare. We provide information to help pharmacists assist their patients in understanding the program.
The Social Security Act and regulations governing Medicare from the Centers for Medicare and Medicaid Services (CMS) require that:
- Part C and Part D sponsors must have an effective compliance program which includes measures to prevent, detect and correct Medicare non-compliance as well as measures to prevent, detect and correct fraud, waste, and abuse.
- Sponsors must have effective training for employees, managers and directors, as well as their first tier, downstream, and related entities. (42 C.F.R. §422.503 and 42 C.F.R. §423.504)
To comply with these regulations we provide access to those training tools in Resources under Provider Support.
Medicare Part D requires pharmacies to post conspicuously (or distribute) the Medicare Prescription Drug Coverage and Your Rights notice (CMS-1047). This form must either be posted conspicuously at the pharmacy or distributed to any beneficiary who disagrees with the information provided by a Pharmacist.
Understanding High Risk Medications
We are committed to improving the quality of our members’ health. The adapted Beers' Criteria (CMS Guidelines for Potentially Inappropriate Medications in the Elderly) identifies medications noted by an expert panel to have potential risks that outweigh potential benefits of the drug. The criteria are appropriate for persons older than 65 years of age, regardless of their level of frailty. High Risk Medications (HRMs) are medications that either are considered ineffective in most patients over 65 years of age or pose unnecessarily high risks when safer treatment alternatives may be available.
Please note: By clicking some of the links above you are leaving the EnvisionInsurance website.
Understanding and Reporting Fraud, Waste & Abuse
If you identify potential FWA activities involving EnvisionInsurance members, pharmacies, or other prescribers you may report the suspicions by contacting one of the following:
FWA Hotline: 1-866-417-3069
Member Service: 1-866-250-2005. TTY, call 711.
Medicare: 1-800-MEDICARE (1-800-633-4227). TTY, call 1-877-486-2048.