Drugs

Drug Formulary

A formulary is a list of covered drugs selected by a team of health care providers, representing the prescription therapies considered to be essential for 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 which of your drugs are covered in our Drug List or Formulary for our Medicare Advantage plans.

Drugs Formulary

Óptimo Plus (PPO)

Download PDF Document

Royal / Vital Plus / Royal Plus

Download PDF Document

Platino Plus / Platino Ultra / Platino Advance

Download PDF Document


Notice of Changes to Formulary

Our plan notifies removals or changes to the preferred levels or tiered cost-sharing status of any Part D drugs included in the formulary.

Notice of changes

  • There are no changes at this moment

Can the Drug List or Formulary change?

We may make certain changes to our Drug List or Formulary throughout the year. Changes to the Drug List or Formulary may affect which drugs are covered and how much you will pay when filling your prescription. The changes to the Drug List or Formulary may include:

  1. Adding or removing drugs
  2. Adding drug restrictions, such as preauthorizations, quantity limits, or step-therapy restrictions on a drug
  3. Moving a drug to a higher or lower co-payment tier

If we remove drugs from the Drug List or Formulary, we will notify you of the change at least 60 days before the change becomes effective. If a drug is removed from our Drug List or Formulary because the drug has been recalled, we will not give a 60-day 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 you have at home, check the updated Drug List or Formulary by visiting your plan’s webpage (see column on right). This document is updated on a monthly basis. You may also contact our Customer Service Center to check if a drug is covered. If Customer Service confirms that we don’t cover your drug, you have two options:

  1. Ask your doctor if you can switch to another drug covered by us.
  2. You or your doctor may request an exception (a type of coverage determination) to cover your drug.

How do 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.

There are different types of exceptions you can request:

  1. 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.
  2. You may ask us to waive the quantity limits on your Part D drug (restrictions on the amount of the drug you can have).
  3. You may ask us to change a coverage of a drug to a lower cost-sharing tier. This would lower the coinsurance/copayment amount you must pay for your Part D drug.
  4. You may ask us to waive a step therapy requirement (try a different drug first before we agree to cover the drug you asking for).

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 to Request a Coverage Determination?

A coverage determination is a decision made by Triple-S Advantage to not cover all or part of a drug, vaccine or other drug benefits covered under Medicare Part D. When we make a coverage determination, we are interpreting how the prescription drug benefits in Part D are covered for our plan members and how they apply to your specific situation.

You, your prescribing physician, or someone appointed to act on your behalf may request a coverage determination. The person you appoint would be your “Appointed Representative”. You may appoint a relative, friend, advocate, doctor, or anyone else to act on your behalf.

Some people may already be authorized under State law to act on your behalf. If you want someone to act on your behalf, then you and that person must sign and date the Representative Appointment Form, which will legally authorize that person to act as 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 in their coverage. These requirements and limits may include:

  • Preauthorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means you will need to get our plan’s approval 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 we will cover. For example, our plan provides 9 tablets for 30 days per prescription for Sumatriptan 100mg tabs. This may be added 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 covering 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 and generic drugs. A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs.

The Medication Therapy Management (MTM) Program is designed to improve your health and quality of life through the safe and effective use of your medications.

Drugs that Require Preauthorization

Triple-S Advantage will require you or your physician to 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 approval, Triple-S Advantage will not cover the medication.

List of Drugs that require preauthorization

Óptimo Plus (PPO)

Download PDF Document

Royal / Vital Plus / Royal Plus

Download PDF Document

Platino Plus / Platino Ultra / Platino Advance

Download PDF Document

Which drugs require preauthorization?

Our Drug List or Formulary identifies the drugs that require preauthorization with the letters PA. If you need the information from this document in Spanish, you may contact our Customer Service Department at 1-888-620-1919; Monday through Sunday, from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

Step Therapy (ST)

In some cases, our plan requires you to first try certain drugs to treat your medical condition before covering 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, Triple-S Advantage will then cover Drug B. If you need the information from this document in Spanish, you may contact our Customer Service Department at 1-888-620-1919; Monday through Sunday, from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

Step Therapy Drug List

Óptimo Plus (PPO)

Download PDF Document

Royal / Vital Plus / Royal Plus

Download PDF Document

Platino Plus / Platino Ultra / Platino Advance

Download PDF Document

When can you request a reimbursement for your medications?

You may submit a reimbursement for your drug expenses in the situations described below:

  1. Drugs purchased out-of-network –You have to pay the total cost of the drug when you go to an out network pharmacy, then you can summit a reimbursement.
  2. Drugs completely paid when you don’t have your member’s id card– if you pay the total cost of the prescription rather than paying just your coinsurance or copayment, you may ask us to reimburse you for our share of the cost by submitting a reimbursement.
  3. Drugs completely paid for in other situations – if you pay the total cost of the prescription rather than paying just your coinsurance or copayment because it is not covered (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 reimbursement. In these situations, your doctor may need to submit additional documentation supporting your request.
  4. While traveling outside the Plan’s service area (United States), if you run out of your covered Part D drug or you become ill and need a covered Part D drug and cannot access a network pharmacy.

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.

Triple-S Advantage, Inc.

Pharmacy Department

PO Box 11320
San Juan, PR 00922
Fax: (787) 993-3262
DRUG REIMBURSEMENT REQUEST

How do you submit a reimbursement?

Please include your receipt for reimbursement and send it the following address:

Triple-S Advantage, Inc.

Reimbursement Department

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. Daily dose
  • National Drug Code (NDC)
  • National Provider Identifier (NPI) of the physician and pharmacy

How do you submit a Reimbursement?

Please send your reimbursement request to the following address or fax number:

Triple-S Advantage, Inc.

Reimbursement Department

PO Box 11320
San Juan, PR 00922
Fax: (787) 993-3262

Please attach your corresponding receipts to the request.

Your reimbursement request must include the following:

  • Name and contract number of the beneficiary who received the service
  • Date of service
  • Stamp or letterhead with pharmacy’s name and address
  • Prescription number
  • Drug name
  • Daily dose
  • Dispensed quantity
  • Amount paid
  • Reason to request reimbursement
  • For services requiring precertification, include a copy of the precertification
  • National Drug Code (NDC)
  • National Provider Identifier (NPI) of the prescribing 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.

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. This temporary supply will be for a maximum of 30-days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-days 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. 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 be as effective 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 be as effective for you.

If Your Drug Is Not Included in the Drug List

Start by talking to your doctor. There may be a different drug covered by the plan that could work just as well for you. You may call the Customer Service Center to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you.

Mail-Order Pharmacy

This is a service that allows you to order prescription drugs by mail to have them delivered to your home. Triple-S Advantage offers mail-order pharmacy services through Walgreens Mail Service

 

Why is it convenient?

This service is convenient because it enables you to receive your drugs at home within a 14-day period (from the date your order is processed).

Process to request the service

1. Two prescriptions from your prescribing doctor are required: one 30-day supply (to purchase immediately), and one 90-day supply, with a maximum of three refills (to send to Walgreens Mail Service Pharmacy).

2. For faxed prescriptions, the doctor needs to use the Mail Service Prescriber Fax Form, which may be obtained at www.walgreens.com/MailService. Have your prescribing doctor fill out this form and fax it from his/her office to 1-800-332-9581.

3. If the doctor faxes the prescription without the Mail Service Prescriber Fax Form, then he/she needs to mail in the original prescription.

4. If the doctor has ePrescribing (electronic prescriptions), he/she may send the prescription online to Walgreens Mail Service, Inc. 03397.

5. If this is the first time you request mail service, you may register:

  • Online at www.Walgreens.com/MailService
  • By Mail, through the Walgreens portal (www.Walgreens.com/MailService). You may print and complete the Mail Service Registration & Prescription Order Form, and mail it along with your original prescription.

6. For refills:

  • You may request to have your refills processed automatically. All you need to do is circle the Automatic Refill option in your Mail Service Registration & Prescription Order Form, under Order Preference.
  • Contact Walgreens Mail Service Pharmacy at 1-800-345-1985, 15 days before the drugs you have on hand run out.

7. The Mail Service Registration & Prescription Order Form found online at www.Walgreens.com/MailService may be completed by the beneficiary or his/her authorized representative.

  • a. Select a payment option when submitting the Form.
  • b. Once the form is completed, mail along with the original prescription

8. Walgreens can only accept prescriptions by ePrescribing (electronic prescriptions), mail service (original prescription), or by fax, using the Mail Service Prescriber Fax Form found in www.Walgreens.com/MailService.

 

How to Request the Service

  1. Online, at www.Walgreens.com/MailService
  2. By phone, toll-free at 1-800-345-1985.
  3. By fax, send the Prescriber Fax form through the doctor’s office, to 1-800-332-9581
  4. By mail, send the Registration Form and original prescription to:Walgreens Mail Service
    Walgreens P.O. Box 29061
    Phoenix AZ 85038-9061

Note: Low Income Subsidy (LIS) does not apply in Puerto Rico.

Last update: 10/16/2017

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