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Pharmacy and prescription drugs

  • Formulary
  • Medication Therapy Management Program
  • Drug coverage determinations
  • Exceptions, limitations and coverage determinations
  • Part D Transition Program
Formulary information

Sharp Advantage provides Medicare prescription drug coverage under an approved formulary. The formulary or drug list is a list of covered drugs provided by Sharp Advantage. The formulary drugs are selected because they are believed to be a necessary part of a quality treatment program.

Sharp Advantage covers both brand name and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. The formulary is updated regularly. Please review your prescriptions to ensure they are covered.

You may view the formulary in the Drug List below. To search for a specific drug, press control “F” and enter the name of the drug, and press enter.

2017 Individual drug list – Sharp Advantage comprehensive formulary
2017 Individual drug list – Sharp Advantage comprehensive formulary in Spanish

2017 Group drug list – Sharp Advantage comprehensive formulary
2017 Group drug list – Sharp Advantage comprehensive formulary in Spanish

Pharmacies may have been added or removed from our network. We also list pharmacies that are in our network but are outside your plan’s service area. Sharp Advantage’s contracted pharmacy network meets or exceeds the Centers for Medicare and Medicaid Services requirements for pharmacy access. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

Here is the Provider and Pharmacy Directory for your review. To search for a specific pharmacy, open the PDF, then press control “F” and enter the name of the pharmacy, and press enter.

2017 Individual - Provider and pharmacy directory
2017 Individual - Provider and pharmacy directory addendum
2017 Individual - Provider and pharmacy directory in Spanish

2017 Group – Provider and pharmacy directory
2017 Group - Provider and pharmacy directory addendum
2017 Group – Provider and pharmacy directory in Spanish


What is the Medication Therapy Management Program

The Medication Therapy Management Program (MTMP) is provided by Sharp Advantage to make sure that members are using the drugs that work best in treating their medical conditions. As part of the MTMP, qualified members receive a one-on-one medication review with a pharmacist or licensed pharmacy intern under the direct supervision of a pharmacist followed by targeted medication reviews on a quarterly basis. The program is offered to you at no extra cost. This MTMP is not considered a benefit.

 


How you qualify for the program

Sharp Advantage determines, by looking at your monthly medication claims information, if you are eligible for the program. To qualify for the MTMP, you must meet all three of the following criteria:

  1. Have two of the six following conditions:
    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia (abnormal cholesterol)
    • Hypertension
    • Asthma
    • Chronic Obstructive Pulmonary Disease (COPD)
  2. And are taking seven or more chronic (Part D) drugs in a 30-day period,
  3. And are likely to pay annual Part D medication costs of $3,919.


How you are notified of your MTMP eligibility

Once eligible, you will receive a letter of your eligibility that invites you to make a telephone appointment to have a one-on-one medication review. Your letter will give you an explanation of the program, and gives you instructions if you want to opt-out of the program.

You may request a medication review by returning the appointment form enclosed with the letter or calling the toll free number in the letter. You may also Contact us for assistance.

 


How MTMP works

As part of your medication review, (which takes around 15 to 30 minutes), you will:

  • Go over by phone the medicines you are currently taking with the pharmacist or the licensed pharmacy intern under the supervision of a pharmacist
  • Make sure with the pharmacist or the licensed pharmacy intern under the supervision of a pharmacist that your medicines are safe for you
  • Ask any questions you may have about your medicines
  • Discuss lower-cost alternatives for your medicines
  • Discuss any concerns you have about your medicines
  • Learn ways to keep track of your medicines
  • Receive a summary of your medication review that includes the Personal Medication List and a Medication Action Plan. You can take these to your doctor for further medication management.
  • Have your medications reviewed quarterly.

For your convenience, a blank medication list may be printed by clicking the link below. Please use the form to keep track of all your prescriptions and over-the-counter medications.

Blank medication list form


Call with questions

To learn more or get additional information, please Contact us.


Exceptions & prior authorization

Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s supporting statement. You can request an expedited (fast) request if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing doctor’s supporting statement.

Exceptions are also called coverage determinations. Members can request an exception to the Sharp Advantage cost-sharing structure, to the formulary, or to obtain a formulary drug that is subject to a utilization management restriction (e.g., step therapy, prior authorization, quantity limit) that you or your prescriber believes should not apply. Once an exception is approved, it is approved for the remainder of the plan year. This means we cannot require a member to request approval for a refill or new prescription to continue using a Part D prescription drug already approved under the exceptions process, for the remainder of the plan year. In order to keep the exception in place for the whole year, the member must remain enrolled in Sharp Advantage, the member’s physician or other prescriber must continue to prescribe the drug and the drug must continue to be safe for treating the member’s condition.

When an exception request is approved, we will give the member a written approval letter and clearly state the date that coverage will end.

Should Sharp Advantage change the formulary or the cost-sharing status of a drug during the plan year, we will give written notice to affected enrollees at least 60 days in advance of the change becoming effective. If we are unable to give a 60-day advance notice, we will provide a 60-day supply of the drug impacted by the change and give written notice at the time of your refill.

Please Contact us with any questions.

See below for the Medicare Prescription Drug Coverage Determination Request Form. You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).


2017 Individual - Medicare Prescription Drug Coverage Determination Request Form
2017 Group - Medicare Prescription Drug Coverage Determination Request Form


Formulary exceptions

You, your prescriber, or your Authorized Representative may request a formulary exception by faxing or mailing a completed Medicare Prescription Drug Coverage Determination Form to us.

2017 Individual – Medicare Prescription Drug Coverage Determination Form
2017 Group - Medicare Prescription Drug Coverage Determination Form

You can also fill out a Medicare Prescription Drug Coverage Determination Form online, by clicking here.

You may also Contact us to ask for a coverage determination.

Sharp Advantage uses various tools to ensure the quality of the health care it provides. These tools also extend to providing prescription drug coverage. These tools include‚ but are not limited to: prior authorization criteria‚ clinical edits and quantity limits.


Age limits

Age Limits: Some drugs require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.


Quantity limits

Quantity Limits: For certain drugs, Sharp Advantage limits the amount of the drug we will cover per prescription or for a defined period of time.


Step therapy

In some cases, Sharp Advantage requires you to first try one drug before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. Here are the details of the 2017 step therapy requirements.


Prior authorization

We require you to get prior authorization for certain drugs. You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, the drug may not be covered by Sharp Advantage. Click on the links below to view or download the prior authorization information:
2017 prior authorization information


2017 Opioid Cumulative Dose Program

Sharp Health Plan is required to comply with the Centers for Medicare & Medicaid Services requirements to prevent opioid overuse and protect patient safety. Effective January 1, 2017, Sharp Health Plan will begin the Opioid Cumulative Dose Program for Sharp Advantage members using non-injectable Part D opioid drugs at the pharmacy. The program will have the following features:

  1. For claims from 2 or more prescribers that meet or exceed 120mg morphine-equivalent dosing (MED), pharmacies will be notified to verify dosing.
  2. For claims from 2 or more prescribers that meet or exceed 200mg morphine-equivalent dosing (MED), providers will need to submit a prior authorization request to verify dosing.

Sharp Health Plan will apply the appropriate drug utilization review process to ensure access is maintained for needed medications.

If you have any questions about the new opioid cumulative dose program, please Contact us


Generic substitution

When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher co-pay and/or the difference in cost between the brand and generic medications. Prior authorization criteria‚ clinical step edits and quantity limits may also apply.


Part D Transition Program information

Prescription Drug Transition Process
What to do if your current prescription drugs are not on the formulary or are restricted in some way.

New members
As a new member of a Sharp Advantage plan, insured through Sharp Health Plan, you may currently be taking drugs that are not on our formulary or are on our formulary but coverage is restricted in some way.

Under certain circumstances, you may be able to get a temporary supply of your prescription drug. This will give you and your doctor time to change to another drug or request an exception and ask to cover the drug or remove restrictions from the drug. If the exception is approved, you will be able to obtain the drug you are taking for the specified period of time.

While you are talking with your doctor to determine your course of action, you are eligible to receive an initial 31-day supply of the drug anytime during the first 90 days you are a member of our plan. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31-day supply. The prescription must be filled at a network pharmacy.

After your first 31-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request an exception.

If you are a resident of a long-term care facility, we will cover a temporary supply of your drug during the first 90 days of your membership in our plan. The total supply will be for a maximum of a 98-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 98-day supply. Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.

If you reside in a long-term care facility and need a drug that is not on our formulary or coverage is restricted in some way, 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 for less than 31 days) while you pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that occur after the first 90 days that you are enrolled as a member of our plan. If you are prescribed a drug that is not on our formulary or coverage is restricted in some way, you may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue an exception. This is in addition to the above long-term care transition supply.

Continuing members
As a continuing member in the plan, you receive an Annual Notice of Change (ANOC). We will tell you about any change in the coverage for your drug for next year.

If a drug you are taking will be removed from the formulary or restricted in some way for next year, work with your doctor to find a different drug that we cover. If there is no alternative, you or your doctor can request a formulary exception. We will allow you to request a formulary exception in advance for next year. You may request a formulary exception starting October 15th and we will give you an answer within 72 hours after we receive your request (or your prescriber's supporting statement). If your request is approved, we will cover the drug as of January 1 of the following year for the specified period of time.

If you have not discussed with your doctor to switch to an alternative formulary medication or pursued a formulary exception, you are eligible to receive a temporary 31-day supply of your drug as of January 1of the next benefit year. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31-day supply. The prescription must be filled at a network pharmacy. After your 31-day transition supply, we may not continue to pay for your drug under the transition policy. You are reminded to work with your doctor to find a different drug that we cover or you or your doctor can request an exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that can occur anytime. If you are prescribed a drug that is not on our formulary or coverage is restricted in some way, you are required to use the Plan's exception process. You may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you are a resident of a long-term care facility, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days). If you have any questions about our transition policy or need help asking for a formulary exception, please contact Sharp Health Plan customer care.


 

Sharp Advantage is offered by Sharp Health Plan. Sharp Advantage is an HMO plan with a Medicare contract. Enrollment in Sharp Advantage depends on contract renewal. Read the full disclaimer.

H5386_2017 SA Website Plan and Benefits Approved

Page Last Updated: 10/01/2016