Medicare Part D

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

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.

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.

Prior authorization is required on some drugs before they are covered. If your health plan's drug list requires prior authorization for a specific drug, your doctor must submit a prior authorization request form for approval.

View Criteria and Request Form

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

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

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

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

If Alignment Health Plan denies your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. Learn more

Coverage Redetermination Form

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

Alignment Health Plan has a free voluntary program for members who have multiple medical conditions, take many prescription drugs, and have high drug costs. It is available to you at no cost if you qualify.

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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.

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