Drugs

If your drug is not 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 monthly. 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.

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

A coverage determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs.

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways.

As part of the Triple-S Advantage Utilization Management have different restrictions to encourage you to get a drug that works for your medical condition and is safe and effective. These requirements and limits may include:

• Preauthorization: For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.
• Quantity Limits: For certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
• Step Therapy: This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called “step therapy.”

There are different Types of Exceptions you can request:

• Non-Formulary: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.
• Tier Exception: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.
• You may ask us to waive a step therapy requirement (to try less costly but just as effective drugs before the plan covers another drug).

You or your doctor can also contact us and ask for a coverage determination. You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage determination. If your health requires a quick response, you must ask us to make a “fast coverage determination.”

Request the type of coverage determination you want. Start by calling, writing, or faxing us to make your request. You, your representative, or your doctor can do this. You can also access the coverage determination process through our website.

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/or would cause you to have adverse medical effects.

If we approve your request, usually the approval is valid for the remainder of the Plan year, as 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 determination.

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.

You may request 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 (Puerto Rico) and visit 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.

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

Your 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, address
• Prescription number
• Drug name
• Daily dose
• Dispensed quantity
• Amount paid
• Reason to request reimbursement
• For services that require a preauthorization, include a copy of the preauthorization.
• National Drug Code (NDC)
• National Provider Identifier (NPI) of the prescribing physician and pharmacy

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:

1. 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.

2. You must be in one of the situations described below:

• For those members who are new or who were in the plan last year:
  • 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-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 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.
• Level of Care Changes – include the following changes from one treatment setting to another:
  • a) Beneficiaries discharged from a hospital to a home
  • b) Beneficiaries who end a skilled nursing facility stay covered under Medicare Part A (including pharmacy charges), and revert to coverage under Part D
  • c) Beneficiaries who give up hospice status to revert standard Medicare Part A and B benefits
  • d) Beneficiaries who end an LTC facility and return to the community
  • e) Beneficiaries who are discharged from a psychiatric hospital with drugs regimens that are highly individualized.

We will cover a one month 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.

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.

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 Alliance RX Walgreens Home Delivery.

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 Alliance RX Walgreens Home Delivery).
2. For valid Fax prescription the doctor need to use the Mail Service Prescriber Fax Form (may be acceded thru www.alliancerxwp.com/home-delivery) and need to 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 AllianceRX Walgreens Prime Home Delivery store 3397,8350 South Riverview Parkway,Tempe AZ 85284-2615 (NPI 1164437406)
5. If is the first time you request the service you can register:
   • online -at www.alliancerxwp.com/home-delivery
   • By Mail – select the form at www.alliancerxwp.com/home-delivery, print and complete the Mail Service Registration & Prescription Order Form and mail the form with your original prescription to Alliance RX Walgreens Primes PO Box 29061 Phoenix AZ 85038-9061
   • Refills:
     • 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.
     • Or contact Alliance RX Walgreens Home Delivery at 1-800-778-5427 Spanish or 1-800-345-1985 English with 15 days before you think the drug you have on hand will run out.
6. The Mail Service Registration & Prescription Order Form online at www.alliancerxwp.com/home-delivery 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
7. AllianceRX Walgreens Prime Home Delivery 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.alliancerxwp.com/home-delivery.

How Can I order the Service?

1. Online at: www.alliancerxwp.com/home-delivery
2. via toll free at 1-800-778-5427 Spanish or 1-800-345-1985 for English.
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: Alliance RX Walgreens Primes PO Box 29061 Phoenix AZ 85038-9061 (remember to include the Formulary and the original prescription)