Policies & Procedures
Policies & Procedures
Out-of-Network Coverage:
Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. RxAmerica´s objective is to minimize the need for beneficiaries to seek services out-of-network by contracting with pharmacies across all MMA regions, and by contracting with numerous "top 50" retail pharmacy chains. The following are some circumstances when we would cover prescriptions out-of-network.
- traveling outside service area, become ill and cannot access a network pharmacy
- unable to obtain a covered part D drug in a timely manner within service area because there is not a network pharmacy within a reasonable driving distance that provides service 24/7
- prescribed an orphan or specialty drug that is not regularly stocked at an accessible network pharmacy.
Quality Assurance:
RxAmerica´s primary objective of our Quality Assurance program is to ensure adequate measures and systems to reduce medication error and adverse drug interactions and improve medication use.
Medication Therapy Management (MTM) Program
We offer an MTM program at no additional cost for members who meet certain criteria (multiple conditions, taking many prescription drugs, or high drug costs). We will contact members who qualify for this program. We use the MTM program to help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors. If you are selected to join our MTM program we will send you information about the specific program.
Utilization Management
We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes 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: possible medication errors, duplicate drugs, drugs that are inappropriate because of your age or gender, possible harmful interactions between drugs you are taking, drug allergies, and drug dosage errors. If we identify a medication problem during our drug review, we will work with you and your doctor to correct the problem.
Notice of Formulary Change:
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Coming Soon
Plan Transition Process:
Potential for Contract Termination:
All Medicare Prescription Drug Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
