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Medicare Part D

Alignment Health Plan offers Medicare Advantage plans with built-in prescription drug coverage, or Medicare Part D. Medicare Part D helps pay for outpatient prescription drugs, vaccines and some supplies not covered by Medicare Part A or Part B.

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Search our Part D Network

  • Find a Drug
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    A drug formulary is a complete list of all the prescription drugs that are covered by Alignment Health Plan during the covered benefit year. For your prescription drug to be covered, your drug must be included in this comprehensive list. Visit our Member Forms and Resources to view an electronic drug formulary or Request Plan Materials to have a printed list be mailed to you. You can also search for a specific medicine name or condition. Learn more

    Drug Search


Prescription Drug Benefit Information

  • Plan Premiums, Deductibles and Cost Sharing
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    To learn more about our Part D prescription drug benefits, please review the plan’s Summary of Benefits. The document highlights applicable premiums, copayments, coinsurance and deductibles. Please refer to the Evidence of Coverage for a complete explanation of benefits.

    Find Evidence of Coverage

  • Out-of-Network Coverage
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    We cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

    • If you are unable to get a covered drug in a timely manner within our service area, because there are no network pharmacies within a reasonable driving distance that provide 24-hour service
    • If you are trying to fill a covered prescription drug that is not regularly stocked at a network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals)
    • If you are traveling outside of our service area and run out of, lose, or become ill and need a covered drug
    • If you are provided a covered drug while in an emergency department, provider-based clinic, outpatient surgery or other outpatient setting and unable to get the drug filled at a network pharmacy
    • If you are evacuated or displaced from your residence, due to a federally- declared disaster or other public health emergency declaration, and unable to get the covered drug at a network pharmacy

    In these situations, please check first with Member Services to see if there is a network pharmacy nearby. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

    How do you ask for reimbursement from the plan?
    If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. Please refer to your plan’s Evidence of Coverage for a complete explanation of how to ask the plan to pay you back.

  • Quality Assurance Policy
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    We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

    We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

    • Possible medication errors
    • Drugs that may not be necessary because you are taking another drug to treat the same medical condition
    • Drugs that may not be safe or appropriate because of your age or gender
    • Certain combinations of drugs that could harm you if taken at the same time
    • Prescriptions written for drugs that have ingredients you are allergic to
    • Possible errors in the amount (dosage) of a drug you are taking
    • Unsafe amounts of opioid pain medications

    If we see a possible problem in your use of medications, we will work with your provider to correct the problem.

  • Step Therapy Criteria
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    In some cases, Alignment Health Plan may require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called step therapy, which is a managed care approach to taking prescription drugs.

    View Criteria


Part D Resources and Links

  • Grievance, Coverage Determination or Appeal Process
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    The process for coverage decisions and appeals can be found in Chapter 9 of your evidence of coverage (EOC). This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Please refer to Chapter 9 of your EOC for a full description of the process.

    Find Evidence of Coverage

    You can also access this information by downloading Chapter 9 here: English | Spanish

  • Appointment of Representative Form
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    When you are asking for a coverage decision or making an appeal, you can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. The Appointment of Representative form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. Contact Member Services to send us the signed form.

    View Form

  • Request Drug Coverage Determination Form
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    A coverage decision is a decision that Alignment Health Plan makes about benefits and coverage or about the amount the plan will pay for medical services or drugs. An initial coverage decision about Part D drugs is called a “coverage determination.” Learn more

    To request an initial coverage decision about Part D drugs over the web, please complete our Coverage Determination Form.

    Coverage Determination Form

  • Low Income Subsidy (LIS) Levels
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    If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

    View LIS Levels

  • Transition Process
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    This procedure describes the standard process that Alignment Health Plan, its divisions and subsidiaries, and its pharmacy benefit manager (PBM), use to develop and maintain the Medicare Transition Program.

    Learn More