Prescription Drugs

If you do not see your drug listed on the formulary or your drug is listed on the formulary with restrictions, you have two options:

• You can ask the Pharmacy Help Desk for a list of similar drugs that are covered in the formulary. When you receive the list, work with your provider to see if these alternatives will work for you. You can reach the Pharmacy Help Desk at 1-800-927-6048 (TTY: 711). They are open 24 hours a day, 7 days a week.
• You or your provider can request an exception. See below for information about how to request an exception.

You can ask us to make an exception to our coverage rules. Some covered drugs may have additional requirements or limits on coverage, see the Utilization and Quality Assurance Program section below for more information.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You or your prescriber should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You or your prescriber can request an expedited (fast) exception 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 a supporting statement from your doctor or other prescriber.

You or your prescribing physician can request to initiate a coverage determination. You can request it by either:

• Phone by calling the Pharmacy Help Desk 1-800-927-6048 (TTY: 711); 24 hours a day, 7 days a week.

• Download the Coverage Determination Request for Medicare Prescription Drugs (see below)
• Fax: 1-877-239-4565; or
• Mail:
  Express Scripts
  Attn: Medicare Reviews
  P.O. Box 66571
  St Louis, MO 63166-6571

Optima Community Complete Request for Drug Coverage Determination

Better therapeutic outcomes for members with multiple conditions

Our Medication Therapy Management Program (MTMP) is focused on improving therapeutic outcomes for Medicare Part D members. This program is administered by Express Scripts, our pharmacy benefits manager. Optima Medicare members can participate in this program at no cost. There is no change to insurance benefits, co-pays/coinsurance, prescription coverage, or available doctors or pharmacies while in this program.

To qualify for MTMP, a member must meet all of the following criteria:

• Members must have filled eight (8) or more chronic Part D medications; and
• Members must have at least three (3) of the following chronic conditions: asthma; chronic obstructive pulmonary disease (COPD); congestive heart failure (CHF); depression; diabetes, dyslipidemia, HIV/AIDs, hypertension, osteoporosis, and/or rheumatoid arthritis; and
• Members may likely incur an annual spend equal to or greater than $4,935 for 2023 for all covered chronic Part D medications.
  OR
• Are in a Drug Management Program to help better manage and safely use medications such as opioids and benzodiazepines

The success of our MTMP is built upon our proven experience using a wide range of services designed to help members with multiple conditions by:

• Ensuring they take their medications correctly
• Improving medication adherence
• Detecting potentially harmful medication uses or combinations of medications
• Educating members and health care providers

Our programs are evidence-based and can integrate both pharmacy and medical data when available, and are built upon multiple measures that demonstrate positive clinical outcomes for members like you. Pharmacists, physicians, and PhDs develop, manage and evaluate the programs for effectiveness.

One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their health care provider.

Comprehensive Medication Review (CMR)

The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of MTMP. If you meet the criteria outlined above, you will receive an MTMP Enrollment Mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members’ prescribers may receive a member-specific report.

The CMR includes three components:

1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or "behind the scenes" by a qualified provider and/or using computerized, clinical algorithms.
2. An interactive, person-to-person consultation performed by a qualified provider at least annually to all MTM-eligible members.
3. An individualized, written summary of the consultation for the member, including but not limited to, a personal medication list (PML), reconciled medication list, action plan, and recommendations for monitoring, education, or self-management.

Personal Medication List

Optima Health has contracted with Express Scripts to deliver MTM services to eligible members. If you would like more information or do not want to take part in the program, please call the Express Scripts MTM Department at 1-844-866-3730 (TTY: 711), Monday through Friday from 9:00 a.m. to 7:00 p.m. Central Standard Time.

Optima Medicare works with physicians to make sure members get the most appropriate, safe and cost-effective drugs. The plan's Utilization Management and Quality Assurance program is designed to assure adverse drug events and drug interactions are avoided and ensure optimum medication use. The Utilization Management and Quality Assurance program is provided at no additional cost to members or providers.

Utilization Management and Quality Assurance programs incorporate tools to encourage appropriate and cost-effective use of Part D drugs. These tools include prior authorization, quantity limits, additional charges and clinical interventions. Other tools may be used if necessary.

• PA = Prior Authorization. Optima Medicare requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from Optima Medicare before you fill your prescriptions. If you don’t get approval, Optima Medicare may not cover the drug.
• ST = Step Therapy. In some cases, Optima Medicare requires you to first try certain drugs to treat your medical condition. For example, if Drug A and Drug B both treat your medical condition, Optima Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Optima Medicare will then cover Drug B.
• QL = Quantity Limits. For certain drugs, Optima Medicare limits the amount of the drug that it will cover. This may be in addition to a standard one-month or three-month supply.
• AN = Additional Charge. If you obtain a brand name drug when a generic equivalent is available, you will be required to pay the difference between the cost of the generic drug (which is paid by Optima Medicare) and the cost of the brand name drug in addition to the appropriate brand copay.

See Optima Medicare's formulary for drugs that have prior authorization requirements, step therapy, quantity limits or where additional charges may apply.

As part of the Utilization Management and Quality Assurance program, all prescriptions are screened by systems to detect and address the following:

• drug-drug interactions that are clinically significant
• duplication of drugs (taking more than one drug in the same drug class)
• inappropriate drugs
• incorrect drug
• patient-specific drug contraindications
• over-utilization of drugs
• under-utilization of drugs
• abuse or misuse of drugs.

A review of prescriptions is performed before the drug is dispensed. These are concurrent drug reviews and are clinical edits at the point-of-sale (at the pharmacy counter).

Retrospective drug utilization reviews identify inappropriate or medically unnecessary care. Optima Medicare performs periodic reviews of claims data to evaluate prescribing patterns and drug use that may indicate inappropriate use.

Physicians treating patients who are receiving potentially inappropriate drug therapy will receive provider-specific reports detailing the patient's drug utilization. The providers receive educational materials explaining the report and the intervention it addresses. The reports identify individual patients who may require evaluation, the reason for the report and options for the provider to consider.

When you join our Plan as a new member, you may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. You should talk with your doctor to determine what is best for your care. During the first 90 days of your new membership, Optima Medicare may provide a temporary supply of a drug which is not on our formulary or which has restrictions. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary refill supply for the drug during the first 90 days of the new plan year.

We will provide a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy for a Part D drug that is not on our formulary or that is subject to restrictions, such as prior authorization or step therapy. You can only receive one temporary 30-day supply as part of our transition process. After you receive the temporary 30-day supply, we will provide you with a written notice explaining the steps you can take to request an exception and how to work with your doctors if you should switch to a drug we cover.

For Members in a Long-Term Care Facility (like a nursing home)

If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary transition supply (unless you have a prescription written for fewer days). The first supply will be for a maximum of 98-days, or less if your prescription is written for fewer days. If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan, when that member is a resident of a long-term-care facility. If a new member, who is a resident of a long-term-care facility and has been enrolled in our Plan for more than 90 days, needs a drug that isn’t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 34-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. This is in addition to the initial transition supply provided.

If a current member transitions to a different level of care, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days) and cover more than one refill during the first 90 days if the member transitions into a long-term care facility. If the transition is out of a long-term care facility, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when the member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.