MEMBER PORTAL

Our Member Portal Secure Access allows members to view and access their pharmacy-related data. Some of these features include: Access to view and download pharmacy claims, real-time benefit information, a drug pricing tool that will allow you to compare costs and multiple pharmacies, a participating pharmacy locator tool and drug information. Pharmacy and claims data are updated within 15 minutes. As a member of the plan, you can access this information by entering your credentials (member ID and password).
Please use the links below for additional information about the drugs covered by your plan. You may also refer to the search tool below to search for your medications by name.

DRUG LIST / FORMULARY 2024

DRUG SEARCH TOOL

 

Part D Coverage Determinations

A coverage determination means any decision made by Doctors HealthCare Plans as a Medicare Part D sponsor regarding payment or benefit to which you believe you are entitled to. Some drugs on the formulary may have additional requirements or limits where a request for a coverage determination is necessary. Some of these requirements and limits may include:

• Prior Authorization (PA)
• Step Therapy (ST)
• Quantity Limit (QL)

Expedited Coverage Determinations will be made within 24 hours. Standard Coverage Determinations will be made within 72 hours.

You can ask Doctors HealthCare Plans to make an Exception to its coverage rules or to cover a drug even if it is not available on your plan formulary.

 

Prior Authorization (PA)

Some prescription drugs require prior authorization (PA) to be covered. If your prescription drug requires prior authorization, you, your appointed representative, or your prescribing physician or other prescriber will need to request and receive approval in advance from Doctors HealthCare Plans before you fill your prescription. If you don’t get approval, Doctors HealthCare Plans may not cover the drug.

Prior Authorization (PA) Criteria

 

Step Therapy (ST)

With step therapy drugs, Doctors HealthCare Plans requests that you first try certain drugs to treat your medical condition before we cover another drug for that condition. If your drug has a step therapy requirement, your prescribing physician or other prescriber will need to provide a supporting statement to Doctors HealthCare Plans. Approval must be received before you fill your prescription. If you don’t get approval, Doctors HealthCare Plans may not cover the drug.

Step Therapy (ST) Criteria

Step Therapy (ST) Criteria- Part B Drugs Only

 

Quantity Limit (QL)

For certain drugs, Doctors Health Care Plans limits the amount of the drug that will be covered per prescription or for a defined period of time. If you require additional quantities over the limit, your physician will need to provide a supporting statement to Doctors HealthCare Plans. An approval must be received before you fill your prescription for the additional quantity, otherwise the additional quantity may not be covered.

Medications with Quantity Limit (QL)

 

Exceptions

Exceptions also require coverage determination. There are several types of exceptions you can ask us to make:

• You can ask us to cover a drug even if it is not on our formulary.
• You can ask us to cover a formulary drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on your drug.

All exception requests must be supported by a statement by the prescribing physician or other prescriber to demonstrate medical necessity.

 

 

Ways to Request a Coverage Determination

• CALL: Contact Member Services toll-free at 833-342-7463 (TTY: 711), 7 days a week 8 a.m. to 8 p.m.
• ONLINE SUBMISSION: Submit your Coverage Determination request online
• FAX: Download and complete a Coverage Determination form and fax the completed form to 858-357-2614. (English / Español)
• MAIL: Mail the completed request form to the plan’s Pharmacy Department address:

Doctors HealthCare Plans, Inc.
Attn: Pharmacy Department
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134

 

Mail-Order

If you take maintenance medications for long-term conditions like arthritis, asthma, diabetes, high blood pressure or high cholesterol you may have your medications mailed to your home by using a participating mail-order service pharmacy.  See information below:

Mail Order Information English / Español

Mail Order Form – English / Español

 

 

Direct Member Reimbursement

• In-Network Pharmacies

Doctors HealthCare Plans offers national in-network prescription drug coverage. This means that you will pay the same cost sharing amount for your prescriptions in all 50 states and the District of Columbia at any of our in-network pharmacies. You should always present your Member ID card at the pharmacy so the pharmacy can gather the information needed to process your claim electronically. The plan’s in network pharmacies are required to submit your prescription claims. If you do not present your ID card, or if the pharmacy does not submit your claim electronically, you can pay cash and request reimbursement from Doctors HealthCare Plans. You are responsible for your cost-share plus the difference between the cash price and the negotiated rate, if the cash price is higher. Doctors HealthCare Plans will reimburse you the negotiated rate we agreed to pay the pharmacy. Please note, the plan will not pay for any prescriptions that are filled by pharmacies outside the United States.

• Out-of-Network Pharmacies

You may need to use pharmacies outside of the plan network under special circumstances. The plan will reimburse medications filled at an out-of-network pharmacy if: there are no open in-network pharmacies for a covered drug urgently needed; the medication is a specialty drug that is not usually kept in stock by in network pharmacies; prescription is for a medical emergency; you get a covered prescription drug from an institutional based pharmacy while a patient in an emergency room, provider based clinic, outpatient surgery clinic, or other outpatient setting; you are evacuated from your home due to state, federal, or public health emergency and don’t have access to an in-network pharmacy; or if you were eligible for Medicaid, without having been enrolled, at the time the prescription was filled.

For a reimbursement request, you will need to pay full cost for the covered drug and submit a Direct Member Reimbursement Claim Form. Please note, reimbursement may not cover your full cost for the covered drug. We will notify you of our decision (and make payment when appropriate) no later than 14 calendar days after receiving your request.

Direct Member Reimbursement Claim Form – English / Spanish

You can mail a written reimbursement request along with any bills, receipts and/or medical record documentation; Or mail a completed Direct Member Reimbursement Claim Form request to:

Doctors HealthCare Plans, Inc.
Attn: Pharmacy Department
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134

 

Transition Policy

The purpose of providing a transition is to promote continuity of care and avoid interruptions in drug therapy. If your prescription drugs are not on the formulary or are limited on the formulary because it has utilization management requirements, such as prior authorization, step therapy or quantity limits, Doctors HealthCare Plans may cover your drug in certain cases during the first 90 days you are a member of our plan.

For more information, please review below:

Transition Policy – English / Español

 

Medication Therapy Management Program

To find out more information about MTM through our partner, MedWatchers.

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a MTM program.  MTM is a service offered by Doctors HealthCare Plans, Inc. at no additional cost to you!  The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit.  This 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 Doctors HealthCare Plans, Inc.’s MTM program, you must meet one of the two following criteria:

1. Be an At-Risk Beneficiary as defined by the CMS clinical guidelines under the Drug Management Program, OR
2. Meet ALL of the following criteria:
   
   1. Have at least 3 of the following conditions or diseases: Alzheimer’s Disease, Osteoporosis, End-Stage Renal Disease (ESRD), Chronic Heart Failure (CHF), Asthma, COPD, or HIV/AIDS, AND
   2. Take at least 8 covered Part D medications, AND
   3. Are likely to have medication costs of covered Part D medications greater than $5,330 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, your caregiver, your pharmacist, and/or your doctor if we detect a potential problem.
• Comprehensive medication review: at least once per 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 pharmacies operated by MedWatchers.  The CMR may also be provided in person or via telehealth at your provider’s office, pharmacy, or long-term care facility.  If you or your caregiver are not able to participate in the CMR, this review may be completed directly with your provider.  These services are provided on behalf of Doctors HealthCare Plans, Inc. 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:
  • Recommended To-Do List (TDL): The list 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.

To obtain a blank copy of the Personal Medication List (PML) that can help you and your health care providers keep track of the medications you are taking, click here for Personal Medication List (PML). 

If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please contact our Member Services Department at 786-460-3427 or Toll-Free: 1-833-342-7463  TTY 711, 7 days a week, 8 am to 8 pm. 

 

Drug Management Program

Prescription opioid pain medications—like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine—can help treat pain after surgery or after an injury, but they carry serious risks, like addiction, overdose, and death. These risks increase the higher the dose you take, or the longer you use these pain medications, even if you take them as prescribed.  Your risks also increase if you take certain other medications, like benzodiazepines (commonly used for anxiety and sleep), or get opioids from multiple doctors and pharmacies.  Doctors HealthCare Plans is dedicated to helping you use prescription opioid pain medications more safely.

Doctors HealthCare Plans, Inc. offers a drug management program (DMP) to help members who are at risk for prescription drug abuse to safely manage these pain medications.  If you get opioids from multiple doctors or pharmacies, we may talk with your doctors to verify the safe utilization of these medications.  After consulting with your doctors if it is concluded that your use of prescription opioids and/or benzodiazepines is not appropriate, we (with the consent of your doctors) may limit your coverage of these medications under the DMP by limiting the amount of medication dispensed, by limiting prescribing to a specific prescriber(s), and/or by limiting dispensing of these medication to a specific pharmacy(ies) to better coordinate your health care.

Before Doctors HealthCare Plans places you in our DMP, we will notify you by letter.  You will be able to tell the plan which doctor(s) or pharmacy(ies) you prefer to use to get your prescription opioids and/or benzodiazepines, and about any other information you think is important for the plan to know.  After you’ve had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you another letter confirming our conclusion. You and your prescriber can appeal if you disagree with our decision or think we made a mistake.

Note: The safety reviews and Drug Management Programs generally won’t apply to you if you have cancer, get hospice, palliative, or end-of-life care, if you live in a long-term care facility or if you have sickle cell disease.

For more information regarding the DMP Program, please call 833-342-7463 (TTY: 711) 7 days a week 8 a.m. to 8 p.m.