Policies & Procedures
Policies & Procedures
Out-of-Network Coverage:
Generally, RxAmerica covers drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Our objective is to minimize the need for beneficiaries to seek services out-of-network by contracting with pharmacies across all Medicare regions, and by contracting with numerous retail pharmacy chains. The following are circumstances when we will consider coverage of prescriptions out-of-network:
- member is traveling outside service area, becomes ill and cannot access a network pharmacy;
- member is unable to obtain a covered Medicare 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 hours a day, seven days a week;
- member is prescribed an orphan or specialty drug that is not regularly stocked at an accessible network pharmacy;
- a pharmacy is not available in an area where a National Emergencies Act and/or a Public Health Emergency declaration have been announced.
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
Medication Therapy Management Program (MTMP) Members of our plan with complicated medication therapy may qualify for our Medication Therapy Management Program (MTMP). The MTMP will help you and your doctors get the most benefit from your medications.
Who qualifies for MTMP?
You will be automatically enrolled in this program if you:
take eight (8) or more medications every day have three (3) or more long-term health conditions, such as diabetes, asthma or high blood pressure and spend more than $3,000 a year on medications If you are selected, this program is available at no extra cost to you.
How will I know if I’m selected?
Once you are selected, you will receive an invitation for a personal phone call with one of our pharmacists to review your medications. After your phone call, you will begin receiving newsletters in the mail. These newsletters will include information on new drugs, tips for staying healthy and other information to help you get the most out of your medication therapy.
How does it work?
This program works with you and your doctor to make sure you are receiving safe and effective medication therapy. Specially trained pharmacists will review your medications with your doctor ways to help you better manage your medications and also avoid possible adverse events. In addition, you will be invited to review all of your medications with one of our pharmacists who can answer any questions you may have.
To make sure we are providing the highest quality and best possible service, all parts of this program are constantly reviewed for quality purposes and to assure compliance with our standard operating procedures. Our clinical pharmacists base their discussions with your doctor on the US Food and Drug Administration (FDA) approved drug information, national clinical guidelines and other CMS-approved sources. Our suggestions to your doctor are developed by CVS Caremark pharmacists and reviewed by CVS Caremark and outside doctors every year to assure that the highest quality, best and most accurate information possible is provided.
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.
Disclaimers
Medicare beneficiaries may enroll in RxAmerica through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.medicare.gov. For more information contact RxAmerica at 1-800-429-6686 from 8 a.m. to 8 p.m. (local time), seven days a week. TTY users can call 1-877-279-0371.
You may contact 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048, 24 hours a day/7 days a week for more information about Medicare benefi ts and services including general information regarding the health or Part D benefi t, and plan ratings for all Medicare Part D plans.
Medicare Beneficiaries enrolled in an MA PFFS plan that includes Medicare prescription drugs or any MA coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO, or MA PFFS plan if they enroll in a PDP; and
Enrolled in a private fee-for-service plan ( PFFS) that does not include Medicare prescription drug coverage, an MA Medicare Savings Account (MSA) plan or an 1876 Cost plan may enroll in a PDP and will not be automatically disenrolled from the PFFS, MSA or 1876 Cost Plan.
Notice of Formulary Change:
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.
