Prescription Drug Coverage

2018 Prescription Drug Formulary Information

2018

A prescription drug formulary is a list of medications the MedStar Medicare Choice plans covers.

MedStar Medicare Choice (HMO) 2018 Prescription Drug Comprehensive Formulary

MedStar Medicare Choice Dual Advantage (HMO SNP) 2018 Prescription Drug Comprehensive Formulary

MedStar Medicare Choice Care Advantage (HMO SNP) 2018 Prescription Drug Comprehensive Formulary

 

Some of the drugs that MedStar Medicare Choice covers may require you and your doctor to get prior approval. The document below will advise you of which drugs require prior authorization.

​2018

Prior Authorization Requirements MedStar Medicare Choice (HMO) 

Prior Authorization Requirements MedStar Medicare Choice Dual Advantage (HMO SNP) 

Prior Authorization Requirements MedStar Medicare Choice Care Advantage (HMO SNP) 

 

In some cases, MedStar Medicare Choice requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. The document below will advise you of which drugs require step therapy.

2018

Step Therapy Requirements MedStar Medicare Choice (HMO) 

Step Therapy Requirements MedStar Medicare Choice Dual Advantage (HMO SNP) 

Step Therapy Requirements MedStar Medicare Choice Care Advantage (HMO SNP) 


Participating Pharmacy Information

MedStar Medicare Choice gives you access to a large network of retail chain and independent pharmacies. As a member, you can take advantage of 65,000 pharmacies nationwide. 

2018 Medstar Medicare Choice Pharmacy Directory 

 

2017 Prescription Drug Formulary Information

A prescription drug formulary is a list of medications the MedStar Medicare Choice plans covers.

MedStar Medicare Choice (HMO) 2017 Prescription Drug Comprehensive Formulary

MedStar Medicare Choice Dual Advantage (HMO SNP) 2017 Prescription Drug Comprehensive Formulary

MedStar Medicare Choice Care Advantage (HMO SNP) 2017 Prescription Drug Comprehensive Formulary

MedStar Medicare Choice may add or remove prescription drugs from our formulary during the year. The document below will advise you of these changes.

2017

60-Day Formulary Change Notice MedStar Medicare Choice (HMO)  

60-Day Formulary Change Notice MedStar Medicare Choice Dual Advantage (HMO SNP)  

60-Day Formulary Change Notice MedStar Medicare Choice Care Advantage (HMO SNP)  

Some of the drugs that MedStar Medicare Choice covers may require you and your doctor to get prior approval. The document below will advise you of which drugs require prior authorization.

​2017

Prior Authorization Requirements MedStar Medicare Choice (HMO) 

Prior Authorization Requirements MedStar Medicare Choice Dual Advantage (HMO SNP) 

Prior Authorization Requirements MedStar Medicare Choice Care Advantage (HMO SNP) 

In some cases, MedStar Medicare Choice requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. The document below will advise you of which drugs require step therapy.

2017

Step Therapy Requirements MedStar Medicare Choice (HMO) 

Step Therapy Requirements MedStar Medicare Choice Dual Advantage (HMO SNP) 

Step Therapy Requirements MedStar Medicare Choice Care Advantage (HMO SNP) 


Participating Pharmacy Information

MedStar Medicare Choice gives you access to a large network of retail chain and independent pharmacies. As a member, you can take advantage of 65,000 pharmacies nationwide. 

2017 Medstar Medicare Choice Pharmacy Directory


Help for Prescription Drug Costs (LIS Premium Summary Table)

People with limited incomes may qualify for extra help to pay their prescription drug costs. If you qualify, Medicare could pay for up to 75 percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or late enrollment penalty. Many people are eligible for these savings and don’t even know it. Please click below to receive the low income subsidy information for your region.

2018 Low Income Subsidy Table 

2017 Low Income Subsidy Table

For eligibility information, to sign up for extra help, or to inquire about your low-income subsidy status contact

  • 1-800-MEDICARE (800-633-4227). TTY/TDD users should call 877-486-2048, 24 hours a day, 7 days a week.
  • The Social Security Administration at 800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 800-325-0778.You can also visit their website at www.socialsecurity.gov/prescriptionhelp.
  • Your state Medicaid or Medical Assistance Office.

In some cases Medicare may not give MedStar Medicare Choice the correct low-income subsidy information for an eligible individual. Medicare created the Best Available Evidence policy so that plan sponsors could readdress cost-sharing for those beneficiaries once the original information was found to be incorrect.

Best Available Evidence (BAE) Policy


Prescription Drug Authorizations, Exceptions, Redeterminations, and Grievances to the MedStar Medicare Choice Prescription Drug Formulary

MedStar Medicare Choice members may ask for a coverage determination, redetermination, or appeal for a Part D prescription drug. Use the links below to learn more.

What should I do before talking to my doctor about changing my prescription drugs or requesting an exception to the MedStar Medicare Choice prescription drug formulary?

As a new member to 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 we will pay for your prescription. You should talk to your doctor to decide if you should switch to another drug that we cover or request a formulary exception. During the first 90 days that you are a member of our plan, we may cover a limited amount of your current non-formulary drug therapy in certain cases while you talk to your doctor to determine the right course of action for you. Please select the appropriate link below to learn more.

Online Form:

  • Please select the appropriate coverage determination and exception form from above.
  • Have your physician or other prescriber assist in completing the form.
  • Save the form on your computer.

If you do not wish to save personal health information on your computer, please use one of the other methods provided on this page.

Use the online form provided below to upload the document and submit to MedStar Medicare Choice.

2018

If you reside in the District of Columbia or Maryland

MedStar Medicare Choice Evidence of Coverage – Appeals and Grievances and Coverage Determination Information

MedStar Medicare Choice Dual Advantage Evidence of Coverage – Appeals and Grievances and Coverage Determination Information- Coming Soon

MedStar Medicare Choice Care Advantage Evidence of Coverage – Appeals and Grievances and Coverage Determination Information

2017

If you reside in the District of Columbia or Maryland

MedStar Medicare Choice Evidence of Coverage – Appeals and Grievances and Coverage Determination Information

MedStar Medicare Choice Dual Advantage Evidence of Coverage – Appeals and Grievances and Coverage Determination Information

MedStar Medicare Choice Care Advantage Evidence of Coverage – Appeals and Grievances and Coverage Determination Information


Part D Prescription Drug Appeals and Grievances Information

To learn more about Part D prescription drug appeals and grievances information, please select the appropriate link below

2018

If you reside in the District of Columbia or Maryland

MedStar Medicare Choice Evidence of Coverage – Part D Prescription Drug Appeals and Grievances Information

MedStar Medicare Choice Dual Advantage Evidence of Coverage – Part D Prescription Drug Appeals and Grievances Information- Coming Soon

MedStar Medicare Choice Care Advantage Evidence of Coverage – Part D Prescription Drug Appeals and Grievances Information

2017

If you reside in the District of Columbia or Maryland

MedStar Medicare Choice Evidence of Coverage – Part D Prescription Drug Appeals and Grievances Information

MedStar Medicare Choice Dual Advantage Evidence of Coverage – Part D Prescription Drug Appeals and Grievances Information

MedStar Medicare Choice Care Advantage Evidence of Coverage – Part D Prescription Drug Appeals and Grievances Information

Members can request a coverage determination, exception, redetermination or appeal by completing and signing one of the forms below and mailing, faxing or emailing it to MedStar Medicare Choice, or by calling our Member Services Department. Please contact us using one of the methods listed. You may also call our Member Services Department to get information about this process, to check on the status of your request, or to obtain an aggregate number of appeals and grievances for our plan.

  • Fax: 855-434-8762
  • Phone: Call our Member Services Department at 855-222-1041, from 8 a.m. to 8 p.m., seven days a week*. TTY/TDD users should call 855-250-5604.
  • Mail: MedStar Medicare Choice
    ATTN: Appeals and Grievances
    P.O. BOX 689
    Pittsburgh, PA 15230-0689


Medicare Prescription Drug Determination Request Forms

MedStar Medicare Choice members should have their prescribing physician fill-out the following forms.

MedStar Medicare Choice Prescription Drug Coverage Determination/Exception Request Form

MedStar Medicare Choice Dual Advantage Prescription Drug Coverage Determination/Exception Request Form

MedStar Medicare Choice Care Advantage Prescription Drug Coverage Determination/Exception Request Form

Coverage Determination and Exceptions requests sent by email which contain Protected Health Information (PHI) should be sent securely. All requests submitted by email are immediately received by MedStar Medicare Choice Pharmacy Services and processed according to the turnaround times provided in your Evidence of Coverage.

Fax: 855-862-6517

 

Mail: MedStar Medicare Choice Pharmacy Services

 

Attn: Pharmacy Services
950 N. Meridian Street 
Suite 600
Indianapolis, IN 46204

If you or your prescriber submit a request for coverage that is denied and you do not agree with our decision, you may request an appeal (redetermination). Use the link below to view this form and have your physician or other prescriber assist in completing this document. Please note, a physician supporting statement is required for all exceptions requests.

MedStar Medicare Choice Medicare Prescription Drug Coverage Redetermination Request Form

MedStar Medicare Choice Dual Advantage Medicare Prescription Drug Coverage Redetermination Request Form

MedStar Medicare Choice Care Advantage Medicare Prescription Drug Coverage Redetermination Request Form

Fax: 855-432-8762

Mail: MedStar Medicare Choice Pharmacy Services
950 N. Meridian Street 
Suite 600
Indianapolis, IN 46204

A MedStar Medicare Choice member can appoint a person to act on his/her behalf. Print the form below, complete the required fields, and fax or mail it to us. Once we receive this completed request we will verify it, adjust our records accordingly, and speak to your appointed representative. If you have any questions, please call our Member Services Department at 855-222-1041, from 8 a.m. to 8 p.m., seven days a week.* TTY/TDD users should call 855-250-5604.

Fax: 855-434-8762
Mail: MedStar Medicare Choice
P.O. BOX 65
Pittsburgh, PA 15230-9922

Appointment of Representative Form

 

MedStar Medicare Choice Prescription Drug Transition Policy

For Non-Long-Term Care Residents

For any drug that you are currently taking that is not on our formulary, or that requires additional authorization, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you fill the prescription at a network pharmacy. If you are given this temporary supply, please speak to your doctor before you use the entire supply so you and your doctor can select a formulary alternative or request an exception. We will not pay for this drug beyond your first 30-day supply unless you have been approved for a formulary exception.

For Long-Term Care Residents

If you are a resident of a long-term care facility, we will cover a temporary transition supply up to 31 days. We will cover additional refills if needed for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or is subject to additional authorization, but you are past the first 90 days of membership in our plan, we will cover up to a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception or work with your physician to select a formulary alternative.

For Members Moving from Home to a Long-Term Care Facility or From a Long-Term Care Facility to Home

If your level of care changes (e.g., entering a long term-care facility or going home after a stay in a long-term care facility), MedStar Medicare Choice again provides transitional supplies of non-formulary or otherwise restricted medications. For the first month after being discharged from a long-term care facility, you can get at least a 31-day supply of your current medications to allow time for you and your physician to switch to a formulary alternative or request an exception.


Pharmacy Claim Reimbursement

If you are a MedStar Medicare Choice member, complete the form below to apply for reimbursement for Part D prescription drugs.

Prescription Drug Reimbursement Claim Form

H9915_18_4039 - Pending CMS Approval

Last Updated Date: 10/17/17