FIDA Prescription Drugs
Part D Quality Assurance
Drug Utilization Review
We conduct drug utilization reviews for all of our participants to make sure that they are receiving safe and appropriate care. These reviews are especially important for participants who have more than one doctor prescribing their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems, such as:
- Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
- Drugs that are inappropriate because of your age or gender
- Possible harmful interactions between drugs you are taking
- Drug allergy contraindications
- Drug dosage errors or duration of drug therapy
- Clinical abuse and misuse of medications
- Over-utilization and under-utilization of medications
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
Medication Therapy Management Program (MTMP)
Our MTM program is a FREE service that is offered by Elderplan FIDA Total Care for participants who meet our selected criteria described below. Please note that this program is not considered a benefit.
Under our MTM program, you will have access to the following free services:
- A telephone consultation with a pharmacist to review your current prescriptions and over-the-counter medications – the pharmacist will call you to talk about any medication-related issues you may be experiencing and to create a specific medication action plan (MAP), that you can share with your doctor.
- Each eligible MTM participant’s drug information is analyzed for potential drug—drug interactions, possible adverse effects of medications, or gaps in care. Every quarter, we automatically enroll qualified participants in the MTM program so they may begin receiving this extra support. Eligible MTM participants will receive a letter notifying them that they have been auto-enrolled into the MTM Program. As an MTM participant, you are also eligible to receive a comprehensive medication review (CMR). We will offer you CMR participation by mail and in some cases by phone. The CMR will give you the opportunity to review all of your current medications with a pharmacist. This is a one-on-one conversation by phone that takes about 30 minutes. After completing the CMR, you will be mailed a personal medication list (PML) and a medication action plan (MAP). The PML will include your current prescription medications, over-the-counter medications and dietary and herbal supplements.
Advantages of the MTM Program include:
- Ability to identify and reduce the chance for medication errors
- More information about your current medication therapy
- Opportunity to save money by reducing duplicative therapy and offering affordable formulary alternative availability if applicable
- Chance to identify and educate you on the side effects of the drugs you are taking and discuss ways to reduce those effects
For more information about the MTM program and to schedule your free medication review with a pharmacist, please call the number on your MTM welcome letter. You can also call Elderplan FIDA Total Care Participant Services at 1-855-462-3167, 8 a.m. to 8 p.m., 7 days a week (TTY 711) for additional information.
Drug Management Programs
For certain formulary drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our participants use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits to help us to provide quality coverage to our participants:
- Prior Authorization: We require you to get prior authorization for certain drugs. This means that providers will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug. See “Formulary Product Prior Authorization Approval Criteria” below.
- Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 30 tablets per prescription for Pioglitazone tablets.
- Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
- Generic Substitution: When there is a generic version of a brand name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand name drug or writes “DAW” on the prescription.
You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary. If your drug is subject to one of these additional restrictions or limits and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).
While a Medicare Prescription Drug Plan can cover off-label uses of a prescription drug, we cover the off-label use only in cases where the use is supported by certain reference book citations. Congress specifically listed the reference books that list whether the off-label use would be permitted. These compendia are: (1) American Hospital Formulary Service Drug Information; (2) United States Pharmacopoeia-Drug Information; and (3) the DRUGDEX Information System; and (4) Medscape. If the use is not supported by one of these reference books (known as compendia), then the drug would be considered a non-Part D drug and would not be covered by Elderplan.
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our participants use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits to help us provide quality coverage to our participants:
Elderplan FIDA Total Care (Medicare-Medicaid Plan)
For certain drugs, Elderplan FIDA Total Care (Medicare-Medicaid Plan) limits the amount of a drug you can get. For example, Elderplan FIDA Total Care provides 30 tablets for 30 days for pioglitazone tablets. This may be in addition to a standard one-month or three-month supply. Please check our downloadable formulary or the searchable formulary link posted on our website to see if your drug has a Quantity Limit restriction.
If you have any questions regarding Quantity Limits, call our Pharmacy Benefit Manager (PBM) CVS/caremark at 1-866-443-0935 or Participant Services at 1-855-462-3167. The TTY number for the hearing impaired is 711. Participant Services is available seven days a week between the hours of 8:00 a.m. and 8:00 p.m.
2019 Prior Authorization Approval List: English
Certain drugs need authorization from Elderplan FIDA Total Care before you fill your prescription. Please click on the Prior Approval List link to see if you meet the criteria for you to receive authorization for your drug. You can also go to the searchable formulary to see if your drug needs prior authorization.
If you have any questions regarding prior authorizations, call our Pharmacy Benefit Manager (PBM) (PBM) at CVS/caremark at 1-866-443-0935 or Participant Services at 1-855-462-3167, or the TTY number for the hearing impaired, 711, seven days a week between the hours of 8:00 a.m. and 8:00 p.m.
2019 Step Therapy List: English
Step Therapy is a key part of our prior authorization program that allows us to help your doctor provide you with an appropriate and affordable drug treatment. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second. For example, if Drug A and Drug B both treat your medical condition, Elderplan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Elderplan will then cover B. Please click on the Step Therapy Approval List to see if your drug requires Step Therapy. You can also go to the searchable formulary to see if your drug requires Step Therapy.
If you have any questions regarding Step Therapy, call our Pharmacy Benefit Manager (PBM) at CVS/caremark at 1-866-443-0935 or Participant Services at 1-855-462-3167. The TTY number for the hearing impaired is 711. Participant Services is available seven days a week between the hours of 8:00 a.m. and 8:00 p.m.
Elderplan Part D Transition Process
As a new or continuing Participant in Elderplan FIDA Total Care, you may be taking drugs that are not on our Drug List (formulary) or that are subject to certain utilization management requirements or limitations as described above. Under certain circumstances, Elderplan FIDA Total Care will allow a temporary applicable month’s supply of a drug that is not on our Drug List or has utilization management requirements or limitations.
During the time when you are receiving a temporary supply of a drug, you should talk with your doctor to discuss your options when your temporary supply runs out. After we allow a temporary applicable month’s supply, we generally will not pay for these drugs as part of our transition policy again.
In the case of a drug that you are taking that is not on our formulary, you should talk with your doctor to decide if the alternative drug on our Drug List is right for you or request an exception: English | Español (which is a type of coverage determination) in order to get coverage for the drug. Check the “What is an exception?” section of your Participant Handbook to learn more about how to request an exception. You can also contact our Participant Services listed below.
Please note that our transition policy applies only to those drugs that are “Part D drugs” and that are bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out of network, unless you qualify for out-of-network access.
Elderplan FIDA Total Care will send you a written notice within three (3) business days of the transition fill explaining the following:
- That the transition supply is temporary and may not be refilled unless a coverage determination is requested and approved
- Procedures for requesting a coverage determination, including a formulary exception
- How to work with Elderplan FIDA Total Care and your doctor to identify appropriate alternative drugs on the Drug List (formulary)
- Your right to request a coverage determination which includes a formulary exception, the timeframes for handling the coverage determination, and your right to request an appeal
New Elderplan FIDA Total Care Participants
As a new Elderplan FIDA Total Care Participant, you may currently be taking drugs that are not on the Elderplan FIDA Total Care formulary or are on the formulary with utilization management requirements or limitations. In such cases, anytime during the first 90 days as a new participant, you may be eligible to receive up to a 30-day transition supply of the drug when you go to a network pharmacy.
If you receive a 30-day transition supply, you should talk with your doctor to request a coverage determination for the drug, before finishing the transition supply. Your doctor will have to either address the drug’s utilization management criteria or switch to an appropriate alternative drug that is covered on the formulary. If no appropriate alternative drugs are on the formulary, you or your doctor can request a formulary exception. If the coverage determination is approved, you will be able to receive the drug you are taking for a specified period of time.
Continuing Elderplan FIDA Total Care Participants
As a continuing Elderplan FIDA Total Care Participant in our plan from year to year, you will receive an Annual Notice of Change (ANOC) by September 30. You may notice that a formulary drug you currently take will not be on the new formulary, or the drug will have new utilization management rules in the upcoming year. If this happens, you should talk with your doctor to request a coverage determination. Your doctor will have to either address the drug’s utilization management criteria or switch to an appropriate alternative drug that is covered on the formulary.
If no appropriate alternative drugs are on our formulary, you or your doctor can request a formulary exception. We will provide you with the opportunity to request a formulary exception in advance for the following year. If the coverage determination is approved, you will be able to obtain the drug you are taking for a specified period of time.
For continuing participants subject to a negative formulary change at the beginning of the new plan year, you may be eligible to receive up to a 30-day transition during the first 90 days, if your drug look-back history determines transition fill eligibility. A negative formulary change is when a part D drug has new utilization management rules or one that is no longer on the formulary beginning of the new plan year.
For new and continuing participants, we will allow multiple fills to provide up to a maximum of a 30-day supply if your prescription is written for less. After we allow a (temporary) transition supply, we generally will not pay for these drugs as part of our transition policy again.
Elderplan FIDA Total Care Participants residing in a Long-Term Care Facility
As a new or continuing Elderplan FIDA Total Care Participant in a long-term care facility, we will provide up to a 31-day supply during your 90-day transition window. In the event a prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply. If you are past the transition window, you may also be able to receive an emergency supply of up to 31 days (unless you have a prescription for fewer days). In certain circumstances such as a level of care changes, you may also be eligible for a transition supply. A transition supply for oral brand solids are limited to 14-day fills with exceptions as required by CMS guidance. After we allow a (temporary) transition supply, we generally will not pay for these drugs as part of our transition policy again.
*For an eligible Medicaid drug, Elderplan FIDA Total Care will provide you with a temporary supply of up to a maximum of 90 days during your 90-day transition window.