Frequently Asked Questions

 

Medicare Part D Common Questions

Click on the questions in below to view the answers. Expand all questions.

  1. Q.

    Does Alignment Health Plan (AHP) HMO offer Prescription Drug Coverage?
    1. A.

      Yes, AHP HMO is a Medicare Advantage Plan with Part D coverage. AHP HMO has formed a network of pharmacies. You can use any pharmacy in our network. The pharmacies in our network can change any time. You can call our Member Services Department and ask for a current Pharmacy Network List.

  1. Q.

    What is the cost of prescriptions as a member of Alignment Health Plan (AHP) HMO?
    1. A.

      Alignment Health Plan (AHP) HMO offers up to a 30-day supply of generic medications at a $0 copayment and preferred brand name medications at a $15.00 copayment and non-preferred brand name medications at a $60.00 copayment. We also provide some over-the-counter medications exclusively for your use. These over the counter drugs are provided at no cost to you. To find out which drugs our plan covers, refer to your formulary.

      If you qualify for additional assistance under the Low Income Subsidy (LIS), you will pay your LIS copayments. If you go to a pharmacy that is not in our network, you might have to pay more for your prescriptions. You also might have to follow special rules before getting your prescription in order for the prescription to be covered under the plan. For more information about the pharmacy network, please call our Member Services Department.

      Members stay in the Coverage Gap Stage until their out-of-pocket costs reach $4,750. CMS defines the Coverage Gap Stage as the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,750 in covered drugs during the covered year. The Explanation of Benefits (EOB) we send to you will help you keep track of how much you and the plan have spent for your drugs during the year. After you leave the Coverage Gap Stage, we will continue to provide some prescription drug coverage until your yearly out-of-pocket costs reach a maximum amount that Medicare has set. In 2013, that amount is $4,750. All formulary generic drugs are covered through the gap. until your yearly out-of-pocket drug costs reach $4,750.

  1. Q.

    What if I have a limited income and resources?
    1. A.

      There is extra help for people with limited income and resources. Almost 1 in 3 people with Medicare will qualify for extra help and Medicare will pay for almost all of their prescription drug costs. Medicare may be able to pay your medicare drug plan costs so that you get your outpatient prescription drugs for little or no cost. View this calendar-year income subsidy totals:

  1. Q.

    What is Medicare prescription drug coverage?
    1. A.

      Medicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Medicare prescription drug coverage provides protection for people who have very high drug costs.

  1. Q.

    Who can get Medicare prescription drug coverage?
    1. A.

      Everyone with Medicare is eligible for this coverage, regardless of income and resources, health status, or current prescription expenses.

  1. Q.

    When can I get Medicare prescription drug coverage?
    1. A.

      You may sign up from October 15, 2012 to December 7, 2012. If you join by December 31, 2012, your coverage will start January 1, 2012, and you won't miss a day of coverage. If you don't sign up for Part D benefits when you are first eligible or by December 31, 2012, you may pay a penalty. Your next opportunity for Annual Enrollment Period will be, October 15, 2013 to December 7, 2013.

  1. Q.

    How does Medicare prescription drug coverage work?
    1. A.

      Your decision about Medicare prescription drug coverage depends on the kind of health care coverage you have now. There are two ways to get Medicare prescription drug coverage.

      You can join a Medicare prescription drug plan or you can join a Medicare Advantage Plan or other Medicare Health Plans that offer drug coverage. Whatever plan you choose, Medicare drug coverage will help you by covering brand-name and generic drugs at pharmacies that are convenient for you.

      Like other insurance, if you join, you will pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay part of the cost of your prescriptions, including a copayment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible.

  1. Q.

    Why should I get Medicare prescription drug coverage?
    1. A.

      Medicare prescription drug coverage provides greater peace of mind by protecting you from unexpected drug expenses. Even if you don't use a lot of prescription drugs now, you should still consider joining. As we age, most people need prescription drugs to stay healthy. For most people, joining now means protecting yourself from unexpected prescription drug bills in the future.

  1. Q.

    Can I fill a prescription outside of Alignment Health Plan's Network?
    1. A.

      Yes, Alignment Health Plan (AHP) HMO has network pharmacies outside of the service area where you can get your drugs covered as a member of our plan. Generally, we only cover drugs filled at an out of network pharmacy in limited circumstances when a network pharmacy is not available. Before you fill a prescription at an out of network pharmacy, please call member services to ask if there is a network pharmacy available.

  1. Q.

    What is Alignment Health Plan HMO's process for reimbursement?
    1. A.

      If you must use an out-of-network pharmacy (generally, out of the plan service area) you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost. Send a copy of your receipt to AHP HMO and ask that your portion be reimbursed to you.

      For more information about reimbursement from the plan, please contact Member Services or refer to your Evidence of Coverage (EOC) Chapter 7, Section 2.1 for requesting reimbursement from the plan.

  1. Q.

    Does Alignment Health Plan HMO cover home infusion therapy?
    1. A.

      Yes, Alignment Health Plan HMO will cover home infusion therapy if:

      • Your Prescription Drug is on our Plan formulary
      • You have followed all required coverage rules, and our Plan has approved your prescription for home infusion therapy
      • Your prescription is written by a doctor, and
      • You get your home infusion services from a Plan network pharmacy
      Please refer to Find a Pharmacy for more information or contact member services.

  1. Q.

    Can Alignment Health Plan HMO's formulary change at any time?
    1. A.

      We may add or remove drugs from the formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. If we remove drugs from the formulary, add prior authorizations, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, and you are taking the drug affected by the change, we will notify you of the change at least 60 days before the date that the change becomes effective. If we don't notify you of the change in advance, you will get a 60 day supply of the drug when you request a refill of the drug. However, if a drug is removed from our formulary because the drug has been recalled from the market, we will not give 60 days notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members about the change as soon as possible.

  1. Q.

    Does Alignment Health Plan HMO require prior authorization for specific prescriptions?
    1. A.

      For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. We require you to get prior authorization for certain drugs. This means that your PCP or specialist will need to get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug.

      Download a Prior Authorization Form

  1. Q.

    Does Alignment Health Plan HMO cover non-formulary medications?
    1. A.

      If your prescription is not listed on the formulary, you should first contact Member Services to be sure it is not covered. If Member Services confirms that we do not cover your drug, you have three options:

      • You can ask your doctor if you can switch to another drug that is covered by us. If you would like to give your doctor a list of covered drugs that are used to treat similar medical conditions, please contact Member Services.

      • You can ask us to make an exception for us to cover your drug.

        Download a non-formulary medication request form to take to your PCP or Specialist

      • You can pay out-of-pocket for the drug and request that the plan reimburse you by means of an exceptions request. This does not obligate the plan to reimburse you if the exception request is not approved.
  1. Q.

    Does Alignment Health Plan HMO allow Prescription Coverage Determinations?
    1. A.

      The first decision made by a plan regarding the prescription drug benefits an enrollee is entitled to receive under the plan, including a decision not to provide or pay for a Part D drug, a decision concerning an exception request, and a decision on the amount of cost sharing for a drug.