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Healthfirst
100 Church Street
New York, NY 10007

Want to become a Healthfirst member? Have a question about our benefits?
Contact us at:

Medicare
1-877-237-1303
TDD/TTY English
1-888-542-3821
TDD/TTY Español
1-888-867-4132
Monday-Friday, 8:30 am to 6 pm

Already a Healthfirst member? For answers to your questions, contact us at:
Medicare
1-888-260-1010
TDD/TTY English
1-888-542-3821
TDD/TTY Español
1-888-867-4132
Monday - Sunday, 8 am to 8 pm

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2014 Medicare Part D Pharmacy Benefits

We want to help you get the best use of your Part D benefits with a Healthfirst Medicare Plan.

This section describes your Part D prescription plan rights including grievances, coverage determinations, exceptions and appeal processes. For more detailed information, refer to Chapter 9 of the Evidence of Coverage.


CVS Caremark is the company Healthfirst uses to manage members’ prescription drug coverage for Medicare.  You will see CVS Caremark listed:

  • On your member ID card;
  • In letters sent to you about your medicines; and
  • In the information listed below.

You can call Member Services at any time (24 hours a day, 7 days a week) at 1-888-260-1010 (TTY users 1-888-542-3821) if you need help with:

  • Picking up or paying for your prescription medicines at the pharmacy;
  • Getting an emergency exception to our approved medicines list (formulary);
  • Obtaining information on the aggregate number of grievances, appeals, and exceptions filed with us; or
  • Any other questions about prescription medicines or supplies you may need.

If you don’t find what you are looking for, please Contact Us.

2014 Medicare Formulary

What is a formulary?

A formulary is a list of prescription drugs (both generic and brand name) that are preferred by your health plan. Your health plan may only pay for medications that are on this "preferred" list, unless your health care provider talks with your health plan and gets prior approval.

> View your full Medicare formulary here

Can my formulary change over the course of the year?

Healthfirst may add or remove drugs from Healthfirst’s Medicare Part D formulary during the year. Before removing drugs from the formulary or adding prior authorization, quantity limits, and/or step therapy restrictions on a drug, Healthfirst will notify members of the change via mail and this website at least 60 days before the date that change becomes effective. Exceptions to this would be when the US Food and Drug Administration (FDA) deems a drug on the formulary to be unsafe or when the drug’s manufacturer removes the drug from the market, in which case Medicare will promptly remove the drug from the Part D formulary.

> View current changes to your formulary

Are there any restrictions to my formulary?

Some of the prescription drugs on the Healthfirst Medicare Plan formulary have restrictions on when or how they may be accessed. You can look up individual drugs on our formulary and see if any of these restrictions apply. If you prefer, you can look on the lists available below that show all of the drugs on our formulary that require prior authorization, quantity limits, or step therapy.


Prior Authorization
This means that your provider will need to contact us before you fill your prescription. If we don’t get the necessary information to satisfy the prior authorization, we may not cover the drug.

Drugs covered under Medicare Part B or D
Some drugs may be covered under Medicare Part B or D depending upon the circumstances.  Information may need to be submitted describing the use and setting of the drug to make the determination.

> Download a full list of drugs that require prior authorization


Quantity Limits

This means that we limit the quantity of the drug we will cover.

The symbol (QL, units/days supply) in the Notes column indicates that quantities dispensed may be limited.  The quantity allowed is listed following the QL symbol and may be read as “units per days supply.”

For example, on page 49 the drug NEXIUM 2 is listed with the symbol QL (30 ea / 30 days). This means that this drugs availability is limited to a quantity of 30 per 30 days supply of the drug.  

If your prescription for any of these medications exceeds the maximum quantity listed, you and your doctor will need to request a formulary exception.

The list of drugs that require quantity limits is found on the current formulary.

View your full Medicare formulary here


Step Therapy

In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.  

For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

> Download a full list of drugs that require step therapy

Pharmacy Transition Process

What is the Transition Process for new and current members who’s drugs are no longer covered?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited.

You should talk to your doctor to decide if you should:

  • Switch to a drug that we cover; or
  • Request a formulary exception so that we will cover the drug you currently take.

We may cover your drug in certain cases during the first 90 days you are a member of the plan to give you and your doctor time to discuss options.

For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription written for fewer days) while you pursue a formulary exception.

> Transition Policy (English  Español  中文

Pharmacy Exceptions and Coverage Determinations

What do I need to know about coverage determinations?

When CVS Caremark receives a request for payment or to provide a Part D drug to a member, CVS Caremark must determine whether or not the request is necessary and appropriate and what your part of the cost is for the drug. These actions by CVS Caremark are known as “coverage determinations.”

Coverage determinations include exception requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary), or believe you should get a drug at a lower copay.

Before you request a drug determination, please call Member Services at 1-888-260-1010, 24 hours a day, 7 days a week, TTY/TDD members 1-888-542-3821 and ask if your drug is covered. If you request an exception, your doctor must provide a statement to support your request. Once we receive a statement from your doctor, we must make a coverage determination and notify the affected member within 72 hours of receiving the request, or sooner if their health condition requires more immediate action. If immediate action is necessary, you or your physician can request that we review your situation in 24 hours.

We accept request for a coverage determination by mail, email, phone, or fax.

CVS Caremark Part D Services

MC109

P.O. Box 52000

Phoenix, AZ 85072-2000

1-888-260-1010

(TTY 888-542-3821)

24 hours a day, 7 days a week

Fax: 1-855-633-7673

MedicareCoverageDeterminations@caremark.com

Note: Often CVS Caremark will not have all of the information it needs to make a coverage determination. In those cases, an extra 2 weeks is allowed to gather all necessary supporting documentation. In addition, if we approve your exception request for a non-formulary drug, you cannot request an exception to the copay you must pay for the drug.

Part D Coverage Determination Request Form

The Part D Coverage Determination form is also available by visiting the CMS website.
* Please note that clicking on this link will take you away from the Healthfirst website.

Who may ask for a coverage determination?

You or someone you name to act for you (your appointed representative) may request a coverage determination (including exception). You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at: 1-888-260-1010, 7 days a week, 8am – 8pm, TTY/TDD members call 1-888-542-3821 if you need help filling out the form, or want to learn more about appointing a representative..

> Appointment of Representative form (English / Español / 中文)

The Appointment of Representative form is also available by visiting the CMS website.
* Please note that clicking on this link will take you away from the Healthfirst website.

2014 Pharmacy Appeals and Grievances

What is a grievance?

A grievance is a complaint about any problem you had with Healthfirst Medicare Plans or one of our network pharmacies that does not relate to coverage for a prescription drug. Grievances do not relate to payment for or approval of a prescription drug, which are known as coverage determinations. If you (your appointed representative) have a grievance, please call Member Services at 1-888-260-1010, or TTY 1-888-542-3821 for the hearing or speech impaired, 24 hours a day, 7 days a week. We will try to resolve any complaint over the phone.

You may also send your grievance to the following address:

CVS Caremark

Grievances Department

MC121

P.O. Box 53991

Phoenix, AZ 85072-3991

Fax: 1-866-217-3353

All grievances will be acknowledged promptly and in writing once the Appeals & Grievances Department has completed its investigation.

Expedited grievances
If you are complaining about the decision by CVS Caremark not to expedite an initial determination or an appeal, you can request an expedited grievance. CVS Caremark will respond to you within 24 hours.

What is an appeal?

Once CVS Caremark notifies you of a coverage determination decision, you may or may not agree with it. You (or your authorized representative) can ask us to reconsider our decision. This is known as filing an appeal. There is a fast track and routine process for handling appeals similar to coverage determination requests.

The information below explains how these different time frames work.

You have a right to appeal if you think CVS Caremark:

  • Decided not to cover a drug, vaccine, or other Part D benefit;
  • Decided not to reimburse you for a Part D drug that you paid for;
  • Reimbursed you less than you feel you should have received;
  • Asks you to pay a different cost-sharing amount than you think you are required to pay for a prescription;
  • Denied your exception request;
  • Made a coverage determination you disagree with.

CVS Caremark will consider your appeal thoroughly and promptly. It is important to let CVS Caremark know as soon as possible that you wish to file an appeal. We accept request for a redetermination in any format. If you wish to file a regular appeal (also called a "standard appeal"), you may complete a Request for Redetermination of Medicare Prescription Drug Denial Form and send your request within sixty (60) days from the date of the notice of coverage determination from CVS Caremark to:

CVS Caremark Part D Services

MC109

P.O. Box 52000

Phoenix, AZ 85072-2000

Fax: 1-855-663-7673

MedicareCoverageDeterminations@caremark.com

To request a fast appeal, you may call Member Services at 1-888-260-1010, or TTY 1-888-542-3821 for the hearing or speech impaired, 24 hours a day, 7 days a week.

If you are concerned about the quality of care you have received (for example, you believe our pharmacist provided you with the incorrect dose of a prescription), you may also file a complaint with Island Peer Review Organization (IPRO), at 1-516-326-7767 or TTY 1-516-326-6182 the State's Quality Improvement Organizations, or QIO, which is a group of doctors and health professionals who monitor the quality of care given to Medicare beneficiaries. The QIO review process is designed to help stop any improper medical practices.

> Part D Redetermination Request Form (English / Spanish [Coming Soon])

Who may ask for a grievance or an appeal?

You or someone you name to act for you (your appointed representative) may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at: You can call us at: 1-888-260-1010, 7 days a week, 8am – 8pm, or TTY/TDD members call 1-888-542-3821 if you need help filling out the form or want to learn more about appointing a representative. For further information, please refer to Chapter 9 of your Evidence of Coverage with links provided below.

> Appointment of Representative form (English / Español中文)

The Appointment of Representative form is also available by visiting the CMS website.
* Please note that clicking on this link will take you away from the Healthfirst website.

 

Evidence of Coverage

Healthfirst CompleteCare (HMO SNP)

     English  Español  中文 

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Healthfirst Life Improvement Plan (HMO SNP)

     English  Español  中文 

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Healthfirst Maximum Plan (HMO SNP)

     English  Español  中文 

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Healthfirst Increased Benefits Plan (HMO)

     English  Español  中文 

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Healthfirst 65 Plus Plan (HMO)

     English  Español  中文 

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Healthfirst AssuredCare (HMO SNP)

     English  Español 中文 

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Pharmacy Submitting a Paper Claim

How do I submit a paper claim?

When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. When that happens, you may have to pay the full cost of your prescription and then ask us to pay you back using a paper claim.

To submit a paper claim, you must send CVS Caremark a copy of the receipt for the prescription drugs from the pharmacy where you bought them and a completed paper claim form. Please send your paper claim to the following address:

Paper Claims Department – RxClaim

CVS Caremark

P.O. Box 52066

Phoenix, AZ 85072-2066

For more information, please call Member Services at 1-888-260-1010 (TTY 1-888-542-3821), 24 hours a day, 7 days a week.

> Medicare Prescription Claim Form

Pharmacy Traveling Out-of-Network

How do I fill my prescriptions when I am traveling or when I am outside of the plan services area?

We encourage you to use our in-network pharmacies at all times to fill your prescriptions. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. We will cover your prescription at an out-of-network pharmacy only for certain reasons. For example:

  • 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 an in-network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

Pharmacy Best Available Evidence

What is best available evidence?

Federal regulations specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. To address these situations, CMS created the best available evidence (BAE) policy. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate. Call Healthfirst at 1-888-260-1010 if you are eligible for low income subsidy. 

> Best available evidence policy information
* Please note that clicking on this link will take you away from the Healthfirst website.


Healthfirst Medicare Plan is an HMO plan with a Medicare contract and a contract with the New York Medicaid program. Enrollment in Healthfirst Medicare Plan depends on contract renewal.

H3359_MKT14_18 CMS Approved 10252013