Prescription Drug Benefit

Georgia Health Advantage provides Medicare Part D prescription drug coverage.

For your convenience, there is a complete list of all covered drugs in the plan (a comprehensive formulary). Our Online Drug List (Formulary) lists the Part D drugs covered by Georgia Health Advantage. Our formulary is designed to cover the drugs most needed to treat the special needs of our Members.

If the drug you are taking is not on the list of covered drugs, read your Evidence of Coverage to find out what you can do. This includes instructions for both new and current Members.

If you would like help managing your prescription drugs, read about our Medication Therapy Management program and its eligibility requirements. You can also see a sample of the Personal Medication List.

How to Request a Coverage Determination, Redetermination, or Grievance

A coverage determination is decision made by our plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it.

If a drug is not covered on our plan, you can ask Georgia Health Advantage to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if Georgia Health Advantage turns down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Georgia Health Advantage will then consider your request.

A coverage determination may be requested by any of the following:

    • You or your representative may request a coverage determination.
    • Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.

A coverage determination may be requested for any of the following:

    • Covering a Part D drug for you that is not on Georgia Health Advantage’s List of Covered Drugs (Formulary).
      • You may ask Georgia Health Advantage for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your Georgia Health Advantage’s List of Covered Drugs (Formulary).
      • You may ask for an exception if your network pharmacy can’t fill a prescription as written.
    • Removing a restriction on Georgia Health Advantage’s coverage for a covered drug.
      • You may ask for an exception if you or your prescriber believe that a coverage rule (such as a prior authorization) should be waived.
    • Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception).
      • You may ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believe you can’t take any of the lower tier drugs for the same condition. Applies if your plan has multiple tiers for your Part D Drugs.
    • Request for payment.
      • You may ask us to pay for a prescription that you already paid for.

Your doctor or other prescriber must give Georgia Health Advantage a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescriber when you ask for the exception.

Georgia Health Advantage can accept or deny your request.

If Georgia Health Advantage approves your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If Georgia Health Advantage says no to your request for an exception, you can ask for a review of Georgia Health Advantage’s decision by making an appeal. If your health requires a quick response, you must ask Georgia Health Advantage to make a “fast decision”.

A redetermination is also known as an appeal. If Georgia Health Advantage denies a member’s coverage determination/exception, the member may appeal the decision to Georgia Health Advantage by requesting a redetermination.

You, your representative or a prescriber can request a coverage determination by phone or in writing.

    • Phone: Contact Member Services Department at our toll-free number at 1-844-917-0645; TTY 711. Our hours are between 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.
    • Mail: Envision Rx Options, ATTN: Coverage Decision, 2181 E. Aurora Road, Suite 201, Twinsburg, Ohio 44087, faxing us at 1-877-503-7231
    • Online: https://envision.promptpa.com

What Is a Grievance?

A grievance is a type of complaint that does not involve payment or denial of services by Georgia Health Advantage or a Contracting Medical Provider. For example, you would file a grievance if:

    • You have a problem with things such as the quality of your care during a hospital stay;
    • You feel you are being encouraged to leave your plan;
    • Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room;
    • Waiting too long for prescriptions to be filled;
    • The way your doctors, network pharmacists or others behave;
    • Not being able to reach someone by phone or obtain the information you need; or
    • Lack of cleanliness or the condition of the office.

Who Can File a Grievance?

A grievance may be filed by any of the following:

    • You may file a grievance.
    • Your authorized representative.

Why File a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with Georgia Health Advantage or a Network Participating Provider or Pharmacy, especially if such complaints result from misinformation, misunderstanding, or lack of information.

Can I Expedite a Grievance?

Yes. If you disagree with Georgia Health Advantage’s decision to extend the timeframe on your organization determination or reconsideration, or Georgia Health Advantage’s decision to process your expedited request as a standard request. In such cases, you may file an expedited grievance and receive a response within twenty-four (24) hours of receipt.

Where can a Grievance Be Filed?

You may file a standard grievance in writing directly to: Georgia Health Advantage Appeals and Grievances Department, 201 Jordan Road, Suite 200, Franklin, TN 37067 by faxing 1-844-280-5360 or over the phone by contacting our Member Services Department at our toll-free number at 1-844-917-0645; TTY 711. Our hours are between 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx.

Forms and Links

This section provides specific information of particular importance to our Georgia Health Advantage Members receiving Part D drug benefits. Below are links to forms applicable to Part D grievances, coverage determinations (including exceptions) and appeals processes.

Request for a Medicare Prescription Drug Coverage Determination

A Member, a Member’s representative, or a Member’s prescriber may use this model form to request a coverage determination, including an exception, from Georgia Health Advantage.

Request for a Medicare Prescription Drug Redetermination (Appeals)

A Member, a Member’s representative, or a Member’s prescriber may use this model form to request a redetermination (appeal) from Georgia Health Advantage.

Online link to Request a Medicare Prescription Drug Coverage Determination or Redetermination.

A Member, a Member’s representative, or a Member’s prescriber may use this link to request a coverage determination or redetermination, from Georgia Health Advantage.

Best Available Evidence Policy

Federal regulations at 42 CFR § 423.800 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 in 2006. 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.

For more information, please view the best available evidence (BAE) policy.

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