Pharmacy & Part D Coverage


Coverage Determinations

A coverage determination, also known as a coverage decision, is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. If you are not sure if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

If UCA makes a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.


There are four different types of situations that involve coverage decisions and appeals:

  • Your medical care: How to ask for a coverage decision or make an appeal
  • Your Part D prescription drugs: How to ask for a coverage decision or make an appeal
  • How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon
  • How to ask us to keep covering certain medical services if you think your coverage is ending too soon” (Applies to these services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services).

You can ask someone to act on your behalf. Use the “Appointment of Representative” form under Related Documents below.

Denial of a Coverage Request

If we deny your coverage request, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made. See the Redetermination of Prescription Drug Coverage Denial Request Form below.

 

For more information on coverage decisions, appeals and complaints – please review your Evidence of Coverage booklet, Chapter 9.

Related Documents

Appointment of Representative Form English Español

Prescription Drug Coverage Determination Request Form English Español

Redetermination of Prescription Drug Coverage Denial Request Form English Español


Drug Transition Process

Under certain circumstances, UCA can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.


To be eligible for a temporary supply, you must meet the two requirements below:

  1. The change to your drug coverage must be one of the following types of changes:

    1. The drug you have been taking is no longer on the plan’s Drug List.

    2. The drug you have been taking is now restricted in some way (Section 4 in this chapter tells about restrictions). 

  2. You must be in one of the following situations:

    1. For those members who were in the plan last year and aren’t in a long-term care (LTC) facility

    2. For those members who are new to the plan and aren’t in a long-term care (LTC) facility

    3. For those members who were in the plan last year and reside in a long-term care (LTC) facility

    4. For those members who are new to the plan and reside in a long-term care (LTC) facility

    5. For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away

To ask for a temporary supply, call our Customer Care Center at (877) 874-3930. TTY users dial 711.


Extra Help Program

Medicare’s “Extra Help” Program is known as the Low Income Subsidy (LIS) Rider.

What is it?

If you qualify for extra help, you’ll get a Low Income Subsidy (LIS) rider or notice from University Care Advantage telling you how much help you’ll get next year towards your drug plan premium, deductible, and copayments.

As a member of our Plan, you will receive the same coverage as someone who is not getting extra help. Your membership in our Plan will not be affected by the extra help. This also means that you must follow all the rules and procedures in the Evidence of Coverage. You must also continue to pay your Medicare Part B premium.

When should I get it?

You should get it in September.

Who sends it?

University Care Advantage will send you your LIS Rider if you qualify for extra help.

What should I do if I get this notice?

Keep this with your Evidence of Coverage (EOC), so you can refer to it if you have questions about your costs. Medicare or Social Security will periodically review your eligibility to make sure that you still qualify for extra help with your Medicare prescription drug plan costs. Your eligibility for extra help might change if there is a change in your income or resources, if you get married or become single, or you lose Medicaid. You will be notified if your status changes.

If you have any questions about your LIS Rider, please contact our Customer Care Center at (877) 874-3930, 8 a.m. to 8 p.m., 7 days a week, TTY users should dial 711.

Related Documents

LIS Premium Table English Español 


Medication Therapy Management

About the MTM Program

If you are enrolled in University Care Advantage (UCA) and have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program. MTM is a service offered by University Care Advantage at no additional cost to you.

The MTM program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.


To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program. Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.

 

To qualify for our MTM program, you must meet ALL of the following criteria: 

  • Have at least 2 of the following conditions or diseases: Chronic Heart Failure (CHF), Diabetes, Dyslipidemia, Hypertension, Asthma, Chronic Obstructive Pulmonary Disease (COPD), AND

  • Take at least 7 covered Part D medications that are chronic/maintenance medications, AND

  • Are likely to have medication costs of covered Part D medications greater than $3,507 per year.

 

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications: 

  • Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, by phone or mail, and/or your doctor if we detect a potential problem.

  • Comprehensive medication review: at least once a year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This review, or CMR, is provided to you confidentially via telephone by SinfoniaRx, which provides this service on behalf of University Care Advantage. This review requires about 30 minutes of your time. Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors. This summary includes:

  • Medication Action Plan (MAP): The action plan has steps you should take to help you get the best results from your medications. 
  • Personal Medication List (PML): The medication list will help you keep track of your medications and how to use them the right way.

 

The Personal Medication List (PML) can help you and your health care providers keep track of the medications you are taking, see document below.

 

If you take many medications for more than one chronic health condition, contact UCA to see if you’re eligible for our MTM program.

Related Documents

Personal Medication List


Part D Coverage

Your Coverage

Generally, our plan only covers Medicare Parts A, B, and D services and drugs.


In addition to your coverage for Part D drugs, University Care Advantage also covers some drugs under the plan’s medical benefits.

 

  • Medicare Part A: Through its coverage of Medicare A benefits, our plan generally covers drugs you are given during covered stays in the hospital or in a skilled nursing facility.

  • Medicare Part B: Through its coverage of Medicare Part B benefits, our plan covers drugs including certain chemotherapy drugs, certain drug injections you are given during an office visit, and drugs you are given at a dialysis facility.

 

In addition to the drugs covered by Medicare, some prescription drugs are covered for you under your AHCCCS (Medicaid) benefits. You can learn more about prescription drug coverage under your Medicaid benefits by contacting your Medicaid health plan.


Utilization Management & Quality Assurance

Quality Assurance

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use prescription drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work medically just as well as a higher cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost-sharing.


Utilization Management

Our utilization management program includes prior authorization, step therapy, and quantity limits. Our program applies these tools to ensure safe and cost-effective use of drugs on our plan’s drug formulary.

  • Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

  • Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover.

  • Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

Related Documents

Prior Authorization Drug List

Step Therapy Drug List