If you are newly eligible for Medicare, there are a few things you should know about selecting a Medicare prescription drug plan. In general, if you want to receive the Medicare prescription drug coverage, you have two choices:
- You may enroll in a Medicare Advantage plan, like QHP, or join another Medicare health plan that covers your doctor and hospital care and provides Medicare Part D prescription drug coverage as a plan benefit.
- You may choose to purchase a Medicare Part D prescription drug plan that adds coverage to the Original Medicare plan.
Quality Health Plans of New York members already have Medicare Part D prescription drug benefits. If a member signs up for Medicare prescription drug coverage from any other Medicare prescription drug plan, they will be automatically dis-enrolled from their current QHPNY Medicare Advantage plan. Dis-enrolling from the QHPNY plan could affect physician choices, as well as the costs of hospital and other covered care, including prescription drug benefits and any other supplemental benefits. If you have any questions please Contact Us or visit www.medicare.gov.
QHPNY Medicare Advantage Plans Part D Benefits
Please click HERE for MA Plan Documents and Medicare Part D benefits. Cost sharing, such as co-payments and co-insurance, vary from plan to plan, please see your particular plan’s Summary of Benefits and Evidence of Coverage for important information on co-pay amounts, restrictions on coverage, how to request an exception to coverage rules and other information. Covered drugs are those included in the plan formulary which may be viewed HERE.
- Quality Health Plans of New York gives 60-day notice regarding removal or change in the preferred or tiered cost-sharing status of a Part D drug.
Prior Authorization: For certain drugs, QHPNY requires you or your physician to get prior authorization. This means that you will need to get approval from Quality Health Plans of New York before you fill your prescriptions. If you don’t get approval, Quality Health Plans of New York may not cover the drug. Click HERE to access member forms.
Quantity Limits: For certain drugs, Quality Health Plans of New York limit the amount of the drug that Quality Health Plans of New York will cover. Click HERE to access member forms.
Step Therapy: In some cases, Quality Health Plans of New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. Click HERE to access member forms.
Requesting a Coverage Determination or Formulary Exception
To request a Coverage Determination or to file a Formulary Exception, you may:
Call to make an oral request – see contact information below
- Fax or mail a written request – see the contact and mailing information below.
- Click HERE to access the Request For Medicare Prescription Drug Coverage Determination Form
- Click HERE to send a request via a SECURE electronic web message
Pharmacy Access Information
QHP has contracts with over 61,000 pharmacies which meets or exceeds the CMS requirement for pharmacy access in your area. To locate a pharmacy in your area please refer to our online the Pharmacy Directory. You may also contact our Customer Service department.
Mail Services Pharmacy
CastiaRX provides convenient service and savings on maintenance medications. Maintenance medications are typically those drugs you take on a regular basis for a chronic or long-term condition, such as high blood pressure, arthritis, diabetes, high blood pressure and others.
How to Get Started
Phone: Call CastiaRX at 866.516.1121 or visit CastiaRx.com/members to complete the registration form. Please have your medication name, payment information and physician’s name and telephone number ready when you call. They can get you set up with home delivery right over the phone.
Fax: (314) 652-1126
For More Information
You are not required to use the plan’s Preferred Mail Service Pharmacy to obtain a 90-day supply of your maintenance medications, but you may pay more out-of-pocket compared to using the Preferred Mail Service Pharmacy.
Your prescriptions should arrive in about seven days from the date the completed order is received by EnvisionMail Mail Order Service. If there is an issue or concern the Mail Service Pharmacy will contact you prior to delivery of your medications.
Medication Adherence Program
MedlyCare is a Medication Adherence Program that Quality Health Plans of New York contracts with to help members comply with their doctor’s medication plan. The program is entirely voluntary and is provided without cost to the member.
To participate, members must use MedlyCare network pharmacies which offer a variety of popular packaging systems, in combination with a reliable notification system, that tells you when to take your medication.
The system uses calendarized packaging and text reminders to assure that you need never again wonder “did I take my morning meds?” LEARN MORE
Over-The-Counter Medications (OTC) Program
Some members of QHPNY have access to mail order delivery of many over-the-counter medications and medical supplies through a quarterly allowance. Please refer to your member documents to see if this is available to you or call the QHPNY Customer Service number and they will gladly assist you. Quality OTC Pharmacy is the provider. To view the Quality OTC Pharmacy order form click the appropriate link below.
QHPNY has contracted network pharmacies outside of our service area where members can get prescriptions filled. It is recommended to please check first with Customer Service to see if there is a network pharmacy nearby.
Generally, we cover drugs filled at an out-of-network pharmacy only when members are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- Coverage at out-of-network pharmacies is generally available in all cases covered by network pharmacies; however, there may be a difference between what the out-of-network pharmacy charges and the covered amount. Members are responsible for paying any such difference.
- Members are limited to a 30-day medication supply when using an out-of-network pharmacy.
Prescription Reimbursement Forms
There may be times when you have to pay for your prescription out of pocket. Here, you’ll find the forms needed to get a refund from Quality Health Plans. If you have to purchase your prescription at a non-contracted pharmacy or at a pharmacy that will not accept your Quality Health Plans of New York (QHPNY) ID card, please fill out the Prescription Reimbursement Form. Be sure to include the receipt of proof of purchase and mail to Quality Health Plans at the address listed on the form.
- The documents on our website are presented in PDF format. Click Here to install Adobe Acrobat.
CMS Best Available Evidence
Beneficiaries with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for seventy five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048. Exactly how much you save is dependent upon your LIS level. To find out your LIS status and level, contact your local Social Security Office. In New York, call by county: Suffolk County DDS, 631-854-9700; Nassau County, 516-227-7474; Richmond and Queens County, 718-557-1399. To learn more Click Here.
Part D Coverage Determinations and Exceptions
For information on Part D Drug Coverage Determinations and how to file an Exception, please visit our Coverage Determinations and Exceptions page.
If you do not have prescription drug coverage, you may be eligible to get the medicine you need at little or no cost. Visit The Partnership for Prescription Assistance at www.pparx.org for more information. To see if you qualify for money-saving programs from the drug manufacturers, please visit www.NeedyMeds.org. Click below to download their brochure.
Quality Assurance and Medication Therapy Management
QHP offers a special service to members with multiple chronic illnesses, high drug costs or multiple medications. This program is described in our Medication Therapy Management document which can be viewed below. Additionally, our Utilization Management Polices may be viewed below or contact our Customer Service department.
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|Drug Utilization Management|