Members

Prescription Drug Information

Prescription Drug Information

How to use the Health Choice Pathway Formulary (List of Covered Drugs)

What is a Formulary (List of Covered Drugs)?

A formulary is a list of drugs that are covered by Health Choice Pathway. The formulary contains a wide range of drugs and includes both generics and brand name drugs. All the drugs on the formulary are approved by the Food and Drug Administration (FDA). For the most recent list of drugs or other questions, please contact Member Services at 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week.

What if my medication is not on the Health Choice Pathway Formulary?

We want to make sure you have the medications you need. If a drug is not covered and you would like it to be covered, you can ask us to make an exception. If your doctor thinks it is important for you to be on a drug that is not on our formulary, you and your doctor can submit a formulary exception request. If we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor is required to explain the medical reasons why you need the medication. Also, some drugs have certain restrictions, such as a quantity limit or step therapy. If your doctor does not think your drug should have a restriction, you and your doctor can submit a formulary exception request.

***You can request a Pharmacy Coverage Determination or Exception online by visiting our Prior Authorization/Pre-Certification Portal.

Additional information about medications can be accessed by logging into the CVS Caremark website. Click here to access caremark.com.

  • Learn about drug interactions
  • Learn about drug side effects
  • Learn whether generic substitutes are available for specific brand name drugs
  • Find a pharmacy in the Health Choice network
  • Register to use the CVS Mail Service Pharmacy or order a refill by mail
  • Click here to find a Pharmacy

 

Note:
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

CVS Caremark Mail Service Pharmacy

As a value-added service to our members, Health Choice Pathway offers members the option of ordering their prescriptions by mail. If you take prescription medications on a regular basis for allergies, high blood pressure, diabetes, arthritis, or other ongoing conditions, consider home delivery. It’s a service available at no additional cost to you.

When you order prescription drugs through CVS Caremark, you may order up to a 100-day supply of most medications. 

Generally, it takes 14 days to process your order and ship it to you. However, sometimes your mail order may be delayed. If for some reason your order cannot be delivered within 14 days, a pharmacy representative may contact you.

Benefits of Home Delivery

  • You can skip the trip to a participating pharmacy – your prescriptions are delivered directly to your home.
  • You don’t have to pay for home delivery – standard shipping of your prescriptions is free.
  • You only need to order refills once every three months – you get up to a 100-day supply of your medication with each order. (**except opioids)
  • You can speak to a pharmacist anytime, day or night – the Pharmacy never closes.
  • You can order refills from home – by phone, fax, mail or Internet. To order a refill by mail, click here
  • You can access the Caremark member web portal at https://www.caremark.com/

For more information about getting your prescriptions delivered to your home from the Pharmacy, please call Member Services at 1-800-656-8991, TTY  711, 8 a.m. – 8 p.m., 7 days a week. Or, you may e-mail Member Services at comments@HealthChoiceAZ.com.

What if Health Choice Pathway Denies Coverage for a Prescription Drug?

What to do if you have complaints

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage.

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Health Choice Pathway or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint.
Following is a brief explanation of grievances, coverage determinations, and appeals.

For detailed information about these processes and how to file a grievance, coverage determination, and/or appeal please visit the Evidence of Coverage Chapter 9.

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Health Choice Pathway or one of our network pharmacies that do not relate to coverage for a prescription drug.

For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

What is a coverage determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug.

Coverage determinations include exceptions requests. You have the right to ask us for an exception if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

What is an appeal?

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

For a detailed explanation of Health Choice Pathway Complaints and Grievances Procedure; how to request a Coverage Determination; and how to find out more information about Part D Appeals procedures and exception processes, please refer to your Health Choice Pathway Evidence of Coverage Chapter 9, or click on the links at the top of the page.

How do I request an exception to the Health Choice Pathway Formulary?

You can ask Health Choice Pathway to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Health Choice Pathway limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

If you are requesting an exception, your doctor or other prescribers must give us the medical reasons for the drug exception you are requesting. Your doctor can call, mail, or fax the statement to our plan, or submit it online. If the statement is received over the phone and the plan needs more information in writing to support the request, we may ask your doctor to submit additional information before making a decision. 

The statement can be faxed or mailed to:

Health Choice Pathway
Attn: Pharmacy Prior Authorization Requests
410 N 44th Street, Suite 900
Phoenix, AZ 85008
Fax: 1-877-424-5690

Exception requests may be submitted online at https://HealthChoice.PromptPA.com. (**Note: by clicking this link, you are leaving the Health Choice Pathway website)

Prior Authorizations

For certain drugs, you or your doctor need to get prior approval from Health Choice Pathway before we will agree to cover the drug for you. This is called prior authorization. Sometimes plan approval is required so we can be sure that your drug is covered by Medicare. Sometimes the requirement for getting approval in advance helps guide the appropriate use of certain drugs. If prior approval is not obtained, your drug might not be covered. The drugs that require prior approval can be identified in your Health Choice Pathway Formulary. Those are the drugs with the “PA” symbol in the Restrictions column.

Coverage Determinations

If you would like Health Choice Pathway to make a decision on a Part D drug, such as a formulary exception, you, your doctor, or your Appointed Representative may request a Coverage Determination from the plan over the phone, by fax, by mail, or online. You may choose to complete the Coverage Determination Request form found below or you may submit your request in another format. When Health Choice Pathway makes a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug. The decision by a dispensing pharmacist not to fill a prescription is not considered a denial by Health Choice Pathway.

Coverage determinations include:

  • Prior authorizations by Health Choice Pathway before a pharmacy may dispense certain drugs,
  • Limits set by Health Choice Pathway on the quantity (amount) of certain drugs that can be dispensed,
  • A decision to pay a claim for a drug you paid for,
  • A decision whether a prescribed drug is medically necessary, appropriate, or used for an FDA-approved indication, and
  • A request for an “exception” to the formulary as discussed above.

You, your authorized representative, or your prescribing physician may request a coverage determination. Most decisions are made within 72 hours unless your health is in jeopardy and a request is made for a fast-track decision. Fast-track decisions are made within 24 hours of the request when the prescriber has provided the clinical information necessary for review.

To request a Coverage Determination, please call 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week.

You have the option of submitting your request in writing or online. You may mail or fax your written request for a Coverage Determination to:

Health Choice Pathway
Attn: Pharmacy Prior Authorization Requests
410 N 44th Street, Suite 900
Phoenix, AZ 85008
Fax: 1-877-424-5690

Requests may be submitted online at https://HealthChoice.PromptPA.com. (**Note: by clicking this link, you are leaving the Health Choice Pathway website)

If coverage is denied, you will be notified and receive a written explanation with a notice of appeal rights.

Redeterminations

If we deny part or all of the Coverage Determination and you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug, you may ask us to reconsider our decision. This is called an “appeal” or “request for redetermination”.

Note:
You cannot request a Redetermination/Appeal if we have not issued a Coverage Determination.

How you make your appeal depends on whether you are requesting reimbursement for a Part D drug you already received and paid for, OR authorization of a Part D benefit (that is, a Part D drug that you have not yet received).

If your appeal concerns a decision we made about authorizing a Part D benefit that you have not yet received, then you and/or your doctor will first need to decide whether you need a standard or fast Redetermination. The procedures for deciding on a standard or fast Redetermination are the same as those described for a standard or fast Coverage Determination.

Please be assured, when we receive your request to reconsider the Coverage Determination, we give the request to healthcare professionals at our organization who were not involved in making the original Coverage Determination. This helps ensure that we give your request a fresh look.

How to Request a Redetermination

You must make your Redetermination (appeal) request to Health Choice Pathway within 60 calendar days from the notice of denial of the initial coverage determination. Requests, standard or expedited,  may be made orally or in writing. You may choose to complete the Redetermination form found below or you may submit your signed request in another format.

To request an expedited Redetermination, please call 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week.

An enrollee, or the appointed representative, or the prescribing physician may use the form below to request a Coverage Determination or Redetermination request from the plan.

Coverage Determination Request Form
Solicitud de determinación de cobertura de medicamentos con receta

Redetermination Request Form
Solicitud de redeterminación de la denegación de medicamentos con receta de Medicare

You have the option of submitting your request in writing or online. You may mail or fax your written request for a Redetermination to:

Health Choice Pathway
Attn: Pharmacy Prior Authorization Requests
410 N 44th Street, Suite 900
Phoenix, AZ 85008
Fax: 1-877-424-5690

Requests may also be submitted online at https://HealthChoice.PromptPA.com. (**Note: by clicking this link, you are leaving the Health Choice Pathway website)

Medicare Prescription Drug Coverage and Your Rights

You have the right to get a written explanation from Health Choice Pathway if:

  • Your doctor or pharmacist tells you that Health Choice Pathway will not cover a prescription drug in the amount or form prescribed by your doctor.
  • You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.

Health Choice Pathway written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan’s decision.

You also have the right to ask Health Choice Pathway for an exception if:

  • You believe you need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;” or
    You believe you should get a drug you need at a lower cost-sharing amount.

What you need to do:

  • Contact Health Choice Pathway to ask for a written explanation about why a prescription is not covered, or to ask for an exception if you believe you need a drug that is not on your drug plan’s formulary or believe you should get a drug you need at a lower cost-sharing amount.
  • Refer to the Summary of Benefits you received from Health Choice Pathway or call Member Services at 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week.
  • When you contact Health Choice Pathway, be ready to tell them:
    • The name of the prescription drug(s) that you believe you need.
    • The name of the pharmacy or physician who told you that the prescription drug(s) is not covered.

The date you were told that the prescription drug(s) is not covered.

You can find detailed information regarding the Grievance and Appeals processes in your Evidence of Coverage booklet.

You may also call Member Services at 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week for assistance with problem-solving related to your Part D benefits or for questions about processes or appeal status.

Transition Policy

Transition Policy
Política de Transición de la Parte D

When you join Health Choice Pathway you may learn that we do not cover a prescription drug you were taking before you joined our Plan. You may be able to get a temporary supply of the drug that would give you and your doctor time to change to another drug. This is called a transition fill.

If you receive a temporary fill for a drug, we will send you a letter explaining that the drug was filled under the Transition process. The letter will explain the action you can take to get approval for the drug or how to switch to another drug on the plan formulary.

If you are a new member and are taking a Part D drug that is not on the formulary, or the drug is subject to a utilization management requirement (such as step therapy, prior authorization, or a quantity limit), we will cover a temporary supply during the first 90 days of your membership in Health Choice Pathway. This temporary supply will be for a maximum of 31 days and must be filled at a network pharmacy.

If you live in a Long Term Care facility, we will cover a temporary supply during the first 90 days of your membership in the plan. We will allow you to refill your prescription until we have provided you with up to a 98-day supply (unless the prescription is written for less) during your transition period.

If you are an existing member who was on the plan last year are taking a Part D drug that was removed from the formulary, or the drug now has a new utilization requirement or limitation at the beginning of the new year, we will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of 31 days unless the prescription is written for fewer days. The prescription must be filled at a network pharmacy.

You may also be eligible to receive a transition supply if you experience a level of care change. This is a change from one treatment setting to another. Examples of a level of care change include:

  • A discharge from a hospital to your home
  • Anyone that has ended their skilled nursing stay
  • Anyone that has ended a stay in a long term care facility and returns to the community
  • A discharge from a psychiatric hospital

It is important that you understand that the transition fill is a temporary supply of this drug. Before this supply ends, you should speak to our Plan and/or your physician regarding whether you should change the drug(s) you are currently taking or request an exception from our Plan to continue coverage of the drug. You, your authorized representative, or your provider can ask for an exception request.

To access additional information on the coverage determination and exception process, click here.

If you have any questions regarding the transition process or your temporary supply, you may call us at 1-800-656-8991, TTY 711, 8 a.m. to 8 p.m., 7 days a week.

Health Choice Pathway Medication Therapy Management Program

What is the Medication Therapy Management (MTM) program?

The MTM program is designed to improve the way Health Choice Pathway members take their medication. The plan works with doctors and pharmacists to make sure members get the most medically appropriate, safe, and cost-effective medications.

MTM programs can help:

– Identify potential errors and gaps in your medical care;
– Reduce the risk of medication errors;
– Provide current information on medical practices to help you and your doctor decide the best treatment;
– Help you understand your condition and medications so you can take an active role in managing your healthcare.

Generally, people who are enrolled in an MTM program take multiple medications, have chronic illnesses or diseases or have high drug costs.

The voluntary program is free to all Health Choice Pathway members who meet eligibility requirements. It is not a benefit of Health Choice Pathway plan.

How do I enroll, and what happens in the MTM program?

Health Choice Pathway members who qualify for the program will be sent a letter. Members could also receive a call from a representative of the Health Choice Pathway Quality team. 

Health Choice Pathway members enrolled in the MTM program will receive a yearly Comprehensive Medication Review (CMR) and may receive Targeted Medication Reviews throughout the year. The Comprehensive Medication Review will help to answer questions and identify concerns about:

  • Your prescription medications
  • Over-the-counter medications
  • Herbal therapies and dietary supplements

You will be offered a Personal Medication List to help keep track of your medicines and any issues that were discussed during the Comprehensive Medication Review.

If Health Choice Pathway identifies any emergent or urgent issues, they will be discussed with the member and/or the member’s physician for immediate action. 

This is a sample of the Personal Medication List that is part of the MTM program. If you would like a blank copy or have questions, please call Member Services at 1-800-656-8991, TTY 711, 8 a.m. to 8 p.m, 7 days a week.

Personal Medication List Sample
Lista Personal de Medicamentos

You will be enrolled through the calendar year and can be involved every year that you meet the eligibility requirements.

How would a member disenroll?

  • A member or a member’s appointed representative may disenroll from the MTM program at any time. Please call Member Services at 1-800-656-8991, TTY 711, 8 a.m. to 8 p.m., 7 days a week to get information on how to do this.

 

2021 Low Income Premium Summary Chart

 

 

 

Low -Income Subsidy Category

Deductible

Copayment Up To Out-of-Pocket Threshold*

Copayment Above Out-of-Pocket Threshold*

Institutionalized Full Benefit Dual Eligible; or

Beneficiaries Receiving Home and Community-Based Services

$0

$0

$0

Full Benefit Dual Eligible ≤ 100% FPL

 

$0

$1.30 generic,
$4.00 brand

$0

Full Benefit Dual Eligible > 100% FPL; or

Medicare Saving Program Participant (QMB-only, SLMB-only, or QI); or

Supplemental Security Income (but not Medicaid) Recipient; or

Applicant < 135% FPL with resources ≤$9,360 ($14,800 if married) **

$0

$3.70 generic
$9.00 brand

$0

Applicant < 150% FPL with resources between $9,360- $14,610 ($14,800 – $29,160 if married)**

$92

15%

$3.70 generic,
$9.20 brand

*Out-of-Pocket Threshold is $6,550 for 2021.
** Resource limits displayed include $1,500 per person for burial expenses.


Last Updated: 3/16/2021

 


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