Drug List or Formulary
A formulary is a list of covered drugs selected by a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Triple-S Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. Check the drugs you are taking on our list in our Medicare Advantage plans.
Notice of Changes to Formulary
Our plan is required to provide notice regarding the removal or change in the preferred or tiered cost sharing status of any Part D drugs included in the formulary.
Notice of changes Effective at 7/1/2017
- Notice of changes Óptimo Plus
- Notice of changes Platino Plus-Platino Ultra-Platino Advance
- Notice of changes Royal-Vital Plus-Royal Plus
Can the Drug List or Formulary change?
We are allowed to make certain changes to our Drug List or Formulary during the year. Changes in the Drug List or Formulary may affect which drugs are covered and how much you will pay when filling your prescription. The kinds of Drug List or Formulary changes we may make include:
- Adding or removing drugs from the Drug List or Formulary.
- Adding preauthorization, quantity limits, and/or step-therapy restrictions on a drug.
- Moving a drug to a higher or lower cost-sharing tier
If we remove drugs from the Drug List or Formulary, we will notify you of the change at least 60 days before the date that the change becomes effective or provide you with a 60-day supply at the pharmacy. If a drug is removed from our Drug List or Formulary because the drug has been recalled from the pharmacies, we will not give 60 days’ notice before removing the drug from the Drug List or Formulary.
What if your drug isn’t on the Drug List or Formulary?
If your drug is not listed in the copy of the Drug List or Formulary that you have at home, visit your plan’s webpage (see column on right) to check the latest version of the Drug List or Formulary, which is updated monthly. In addition, you may contact Member Service Center. If Customer Service confirms that we don’t cover your drug, you have two options:
- Ask your doctor if you can switch to another drug that is covered by us.
- You or your doctor may ask us to make an exception, a type of coverage determination to cover your drug.
¿How do you request an exception?
You and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your doctor says that you have medical reasons that justify asking us for an exception, your doctor can help you request an exception to the rule.
There are different types of exceptions you can request:
- You may ask us to cover your Part D drug even if it is not on our Drug List or Formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
- You may ask us to waive coverage restrictions or limits on your Part D drug. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to provide a higher level of coverage for your Part D drug. This would lower the coinsurance/copayment amount you must pay for your Part D drug.
- You may ask us to waive the coverage restriction if your drug requires to use first other drug before you receives the service.
Generally, we will only approve your request for an exception if the alternative Part D drugs included on the Plan Drug List or Formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and would cause you to have adverse medical effects.
If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision. See your Evidence of Coverage for more information about how request an appeal.
Coverage Determination & Exceptions
¿How do you request a coverage determination?
A coverage determination or an appeal decision happens when Triple-S Advantage does not cover all or part of a vaccine or other drug benefits covered under Medicare Part D.
When we make an initial determination, we are giving our interpretation of how the benefits of prescription drugs in Part D are covered, and how they apply to your specific situation.
You, your prescribing physician, or someone you name to act on your behalf may ask us for an initial determination. The person you name would be your “Appointed Representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your Appointed Representative.
For more information refer to your Evidence of Coverage or contact Customer Service.
As part of the Triple-S Advantage Utilization Management to help control drug plan costs, some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, our plan may not cover the drug.
- Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 9 tablets for 30 days per prescription sumatriptan 100mg tabs. This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, our plan requires 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, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.
- Generic Substitution: Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
- Medication Therapy Management: The Medication Therapy Management Program (MTM) is aimed at improving your health and quality of life by ensuring safe and effective medication use and preventing medication-related issues.
Drugs that Require Preauthorization
Triple-S Advantage will require that you or your physician obtain a preauthorization (prior authorization) for certain medications. This means that you need the approval of Triple-S Advantage before you obtain these medications. If you do not obtain the approval from Triple-S Advantage, Triple-S Advantage will not cover the medication.
List of drugs that require preauthorization
Which Drugs Require Preauthorization?
Our Drug List or Formulary identifies drugs that require preauthorization with the letters PA. If you need more information contact our Customer Service Department at 1-888-620-1919 Monday to Sunday, from 8:00am to 8:00pm. TTY users should call at 1-866-620-2520.
Step Therapy (ST)
In some cases, Triple-S Advantage requires that you first try certain medications to treat your medical condition, before other medications for the same medical conditions are covered. For example, if medication A and medication B both treat your medical condition, Triple-S Advantage may not cover medication B unless you have used medication A first. If medication A does not work for you, then Triple-S Advantage will cover medication B.
When can you request a reimbursement for your medications?
You may submit a paper claim for reimbursement of your drug expenses in the situations described below:
- Drugs purchased out-of-network – when you go to a network pharmacy and use our member’s id card, your claim is automatically submitted to us by the pharmacy.
- Drugs paid for in full when you don’t have your member’s id card with you – if you pay the full cost of the prescription rather than paying just your coinsurance or copayment because you don’t have your member’s id card with you when you fill your prescription, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us.
- Drugs paid for in full in other situations – if you pay the full cost of the prescription rather than paying just your coinsurance or copayment because it is not covered for some reason (for example, the drug is not on the Drug List or Formulary or is subject to coverage requirements or limits) and you need the prescription immediately, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us. In these situations, your doctor may need to submit additional documentation supporting your request.
- Drugs purchased at a lower price – in rare circumstances when you are in a coverage gap or deductible period and have bought a covered Part D drug at a network pharmacy under a special price or discount card that is outside the Plan’s benefit, you may submit a paper claim to have your out-of-pocket expense count towards qualifying you for catastrophic coverage.
- Copayments for drugs provided under a drug manufacturer patient assistance program – if you get help from, and pay copayments under, a drug manufacturer patient assistance program outside our Plan’s benefit, you may submit a paper claim to have your out-of-pocket expense count towards qualifying you for catastrophic coverage.
- To submit a request for reimbursement, you can complete the Reimbursement Form and send it (along with the corresponding receipt) to the address or fax number below.
Departamento de Farmacia
PO Box 11320
San Juan, PR 00922
Fax: (787) 993-3262
How do you submit a paper claim?
Please include your receipt for reimbursement and send it the following address:
PO Box 11320
San Juan, PR 00922
Fax: (787) 993-3262
Your request must include the following:
- Name and contract number of the beneficiary who received the service.
- Date of service
- Stamp or letterhead of pharmacy’s name, address
- Prescription number
- Drug name
- Dispensed quantity
- Amount paid
- Reason for requesting reimbursement
- For services that require a precertification, include a copy of the precertification.
- National Drug Code (NDC)
- National Provider Identifier (NPI) of the physician and pharmacy
How to obtain a temporary supply of your drug?
You may be able to get a temporary supply
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan’s Drug List.
- — or — the drug you have been taking is now restricted in some way (Section 4 in this chapter tells about restrictions).
You must be in one of the situations described below:
For those members who are new or who were in the plan last year and aren’t in a long-term care (LTC) facility:
- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply of medication. The prescription must be filled at a network pharmacy.
For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility:
- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days the calendar year if you were in the plan last year. The total supply will be for a maximum of 91-day supply and may be up to a 98-day supply depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 91-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
- We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
For those members who are new or who were in the plan last year with:
Level of Care Changes – include the following changes from one treatment setting to another:
1. Beneficiaries discharged from a hospital to a home
2. Beneficiaries who end a skilled nursing facility stay covered under Medicare Part A (including pharmacy charges), and revert to coverage under Part D
3. Beneficiaries who give up hospice status to revert standard Medicare Part A and B benefits
4. Beneficiaries who end an LTC facility and return to the community
5. Beneficiaries who are discharged from a psychiatric hospital with drugs regimens that are highly individualized.
We will cover one 30-day transition supply to be provided to current enrollees with Level of Care Changes.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you more about these options.
You can change to another drug
Start by talking to your doctor. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call customer Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor to find a covered drug that might work for you.
What is Mail-Order Pharmacy?
A service that allows you to order prescription drugs by mail so that they are delivered to your home. Triple-S Advantage offers mail-order pharmacy services through Walgreens Mail Service
Why is it convenient?
Ordering prescription drugs by mail is convenient because it enables you to receive drugs directly at your home within a 14 day period from the date in which your order is processed.
Process to request the service
1. Requires two prescriptions from your prescriber. One for an initial short term supply (up to 30 days) that your local pharmacy can fill immediately and one for 90 days’ supply with a maximum of three refills. (Send to Walgreens Mail Service Pharmacy).
2. For valid Fax prescription the doctor need to use the Mail Service Prescriber Fax Form and must be faxed from a prescriber s Office to be valid to fax 1-800-332-9581.
3. If the doctor sent the prescription by fax without the Mail Service Prescriber Fax Form then need to Mail the original prescription
4. If physician has ePrescribing (electronic prescriptions) can be sent via internet to Walgreens Mail Service, Inc. 03397
5. The first time you request the service you can register:
- a. You can choose to have your refills processed automatically. All you need to do is check the Automatic Refill ‡ option on your Mail Service Registration & Prescription Order Form under Order Preference.
- b. Or contact Walgreen Mail Service Pharmacy at 1-800-345-1985 with 15 days before you think the drug you have on hand will run out.
7. The Mail Service Registration & Prescription Order Form found online at www.Walgreens.com/MailService may be completed by the member or his authorized representative.
- a. Select the Payment Options required at time of order.
- b. Once the formulary is completed mail along with the original prescription
8. Walgreens can only accept prescription by eprescribing ( electronic prescription), Mail Service (original prescription) or thru fax using the Mail Service Prescriber Fax Form found in www.Walgreens.com/MailService.
How Can I order the Service?
- 1. Online at: www.Walgreens.com/MailService
- 2. via toll free at 1-800-345-1985.
- 3. For valid Fax prescription the doctor need to use the Mail Service Prescriber Fax form and must be faxed from a prescribers Office to fax 1-800-332-9581
- 4. Mail: Walgreens PO Box 29061 Phoenix AZ 85038-9061(remember include the Formulary and the original prescription)
Note: Low Income Subsidy (LIS) does not apply in Puerto Rico.
Authorized by Comisión Estatal de Elecciones CEE SA -16-12054
Last update: 08/08/2017