What is Part D?

Prescription Drugs approved by Medicare are also known as Part D Drugs. In order to enroll in Part D drug coverage, you must have Medicare Part A and/or Part B. Part D drugs are offered by Medicare Advantage Prescription Drug Plans (MA-PD) or Stand Alone Prescription Drug Plans (PDP).

In this section you can learn a little more about Part D.

Basic rules for the First+Plus Part D Coverage

The plan will generally cover your drugs as long as you follow these basic rules:

• You must use a network pharmacy (Pharmacy Directory) to fill your prescription.
• Your drug must be on the plan’s List of Covered Drugs (Formulary).
• Your drug must be considered “medically necessary”, meaning reasonable and necessary for treatment of your illness or injury. It also needs to be an accepted treatment for your medical condition.

Part D Prescription Drug Restrictions

First+Plus uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs.

Prior Authorization: For certain drugs, our plan requires you to get prior authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don’t get the necessary information to satisfy the prior authorization, we may not cover the drug.

Click here for Prior Authorization Drug List
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Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to a number of units per defined prescription period (i.e., per 30-day period) for a formulary drug.

Click here for Quantity Limits Drug List
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Step Therapy: In some cases, we require you to first try one drug 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, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Click here for Step Therapy Drug List
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If a drug is not covered in the way you would like it to be covered, you can ask us to make an exception.

Click here for Exceptions Process Information

For more information on the types of restrictions we use for certain drugs, please refer to your Evidence of Coverage (Using the plan’s coverage for your Part D Prescription Drugs) or contact our Customer Service Department at 1-888-767-7717 Monday through Friday from 8:00 am to 8:00 pm. TTY users should call 1-877-672-4242.

There are a few special circumstances where First+Plus will cover prescriptions from providers who are not in the plan’s network.

These include:

• Prescriptions you get in connection with emergency care.
• Prescriptions you get in connection with urgently needed care when network providers are not available.

CMS’ Best Available Evidence Policy

For the CMS’ Best Available Evidence Policy, please click the following link:

http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Best_Available_Evidence_Policy.html