2020 Ponce de Leon Blvd, Suite 901. Coral Gables, FL 33134   
  

Prescription Drug Coverage 2019

Doctors HealthCare Plans offers prescription drug coverage in all of its plans. Our formulary provides coverage for a list of medications that are separated into different tiers, where generic drugs usually cost less than the brand and are placed in a lower tier. The Food and Drug Administration (FDA) approves Medicare Part D drugs and rates generic drugs to be as effective and safe as brand name drugs. Some drugs in the formulary may require Prior Authorization, may have Step Therapy requirements or Quantity Limitations.

Please use the following links for more information.

Formulary

Please refer to the search tool below to search for your medications by name.  You can also view an explanation of our Prior Authorization, Quantity Limits and Step Therapy criteria.

Search tool for medications

Part D Coverage Determination

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. A coverage determination is necessary when a formulary medication requires a Prior Authorization, Step therapy and/or Quantity limit.

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 (STP)

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 (STP) Criteria

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, such as Tiering exceptions and Formulary exceptions, also require coverage determination. A tiering exception is when you believe you should get your drug at a lower cost share. A formulary exception is when you believe you need a drug that is not on the plan’s formulary. All exception requests must be supported by a statement by the prescribing physician.

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

There are several ways to which you, your appointed representative, or your prescribing physician or other prescriber can request a coverage determination.

  • Call Member Services toll-free at 833-342-7463 (TTY: 711), 7 days a week 8 a.m. to 8 p.m.;
  • Submit your Coverage Determination request online (Coverage Determination request online)
  • Supporting documentation will need to be submitted by the prescribing physician or other prescriber to demonstrate medical need.
  • Download and complete a Coverage Determination form (English / Spanish) and fax the completed form to 866-291-3725.
  • Mail the completed request form to the plan’s Pharmacy Department address:

Doctors HealthCare Plans, Inc.
ATTN
: Pharmacy Department
2020 Ponce De Leon Blvd., Suite 901
Coral Gables, FL 33134

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 for this online submission. 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 online, 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 needed immediately; 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

Direct Member Reimbursement Claim Form – 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., Suite 901
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

Transition Policy – Spanish

Medication Therapy Management Program

Doctors HealthCare Plans, Inc., offers a Medication Therapy Management (MTM) program to assist our members in unique situations, including individuals who have several complex medical conditions, those who take several drugs at the same time, or those who have very high drug costs.

If you are a member of Doctors HealthCare Plans, Inc., you may be eligible for this program if:

  • You have 3 or more chronic diseases, such as Heart Failure, COPD, Kidney Disease, Alzheimer’s Disease, and/or Osteoporosis; AND
  • You take 8 or more Part D prescription drugs; AND
  • You are likely to incur at least $4,044 annually in Part D medication costs.

The MTM program, which is completely voluntary and free to members, helps ensure that our members are receiving optimal care. If you qualify for the MTM program, you will receive notification of eligibility within 60 days. This notification will provide detailed information about the MTM program as well as our contact information should you have any questions.

One of the key components of the MTM program is our attention to your chronic diseases and the medications you take. A pharmacist will contact you by phone to provide you with a Comprehensive Medication Review (CMR) of all your medications. The pharmacist will work to schedule a time that is convenient for you and your schedule. The CMR typically lasts 15 to 30 minutes, depending on your specific needs and questions. The pharmacist is available to discuss how to best take your medications, your costs, or any problems you’re currently experiencing. Following the CMR, you will receive a written summary of the discussion via mail. This summary will contain a Medication Action Plan (MAP) with recommendations on how to make the best use of your medications; it also includes adequate space for you to take notes or jot down any follow-up questions. You will also receive a Personal Medication List (PML), which will include all the medications you’re currently taking and why you take them. In addition to the CMR, Targeted Medication Reviews (TMR) are conducted throughout the year. During a TMR, the pharmacist or health professional will assess your medication use and monitor for any new potential drug therapy issues. Any recommendations identified as a result of the TMR will be sent to your physician.

If eligible, it’s a good idea to schedule your medication review prior to your annual “Wellness” visit so that you can discuss your Medication Action Plan and Personal Medication List with your physician. Bring your MAP and PML to your next Wellness visit or any discussions with your doctors, pharmacists, or healthcare providers.

If you qualify for the MTM program, we will automatically enroll you and send you information about the program. However, should you decide not to participate, please notify us, and we will withdraw you from the program.

For more information regarding the MTM program, please call 1-800-424-9340 or TTY (for the hearing impaired) at 1-855-405-8233 between 9AM and 6PM EST.

The Doctors HealthCare Plans, Inc., Medication Therapy Management Program is not considered a benefit.

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Last Updated: 11/18/2018

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