A formulary is a list of covered drugs. Sentara Medicare has a single formulary, although coverage may vary by your chosen plan.
The Sentara Medicare formulary is available for use by Sentara Medicare members.
Sentara Medicare plans offer the convenience of all-in-one plans including medical and Part D prescription drug coverage. Part D coverage may help lower prescription drug expenses and protect against higher costs in the future. Search the formulary to see if your prescription is included.
Quantity limits, step therapy criteria, and prior authorization forms can be found under Prescription drugs on the member website.
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Below are some frequently asked questions and other information about our prescription drug formulary listings. Information on requesting exceptions and determinations can be found under Prescription Drugs in our member portal.
Expand All Expand all accordion items What if my prescriptions are not listed?If you do not see your drug listed on the formulary or your drug is listed on the formulary with restrictions, you have two options:
You can ask us to make an exception to our coverage rules. Some covered drugs may have additional requirements or limits on coverage. See the Utilization and quality assurance program section below for more information.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You or your prescriber should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You or your prescriber can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
You or your prescribing physician can request to initiate a coverage determination. You can request it several ways:
Our medication therapy management program is focused on improving therapeutic outcomes for Medicare Part D members. This program is administered by Express Scripts, our pharmacy benefits manager. Sentara Medicare members can participate in this program at no cost. There is no change to insurance benefits, copays/coinsurance, prescription coverage, or available doctors or pharmacies while in this program.
To qualify for MTMP, a member must meet all of the following criteria:
The success of our MTMP is built upon our proven experience using a wide range of services designed to help members with multiple conditions by:
Our programs are evidence-based and can integrate both pharmacy and medical data, when available. They are built upon multiple measures that demonstrate positive clinical outcomes for members. Pharmacists, physicians, and PhDs develop, manage, and evaluate the programs for effectiveness.
One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their healthcare provider.
The Centers for Medicare & Medicaid Services (CMS) require all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of MTMP. If you meet the criteria outlined above, you will receive an MTMP enrollment mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies, and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members may receive a member-specific report.
Sentara Medicare has contracted with Express Scripts to deliver MTM services to eligible members. If you would like more information or do not want to take part in the program, please call the Express Scripts MTM Department at 1-844-866-3730 (TTY: 711), Monday through Friday from 9:00 a.m. to 7:00 p.m. CST.
Sentara Medicare works with physicians to make sure members get the most appropriate, safe, and cost-effective drugs. The Plan's utilization management and quality assurance program is designed to ensure adverse drug events and drug interactions are avoided and ensure optimum medication use. The utilization management and quality assurance program is provided at no additional cost to members or providers.
Utilization management and quality assurance programs incorporate tools to encourage appropriate and cost-effective use of Part D drugs. These tools include prior authorization, quantity limits, additional charges, and clinical interventions. Other tools may be used if necessary.
See Sentara Medicare's formulary for drugs that have prior authorization requirements, step therapy, quantity limits, or where additional charges may apply.
As part of the utilization management and quality assurance program, all prescriptions are screened by systems to detect and address the following:
A review of prescriptions is performed before the drug is dispensed. These are concurrent drug reviews and are clinical edits at the point-of-sale (at the pharmacy counter).
Retrospective drug utilization reviews identify inappropriate or medically unnecessary care. Sentara Medicare performs periodic reviews of claims data to evaluate prescribing patterns and drug use that may indicate inappropriate use.
Physicians treating patients who are receiving potentially inappropriate drug therapy will receive provider-specific reports detailing the patient's drug utilization. The providers receive educational materials explaining the report and the intervention it addresses. The reports identify individual patients who may require evaluation, the reason for the report, and options for the provider to consider.
How does the transition of care process work?When you join a Sentara Medicare plan as a new member, you may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. You should talk with your doctor to determine what is best for your care. During the first 90 days of your new membership, Sentara Medicare may provide a temporary supply of a drug which is not on our formulary or which has restrictions. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary refill supply for the drug during the first 90 days of the new plan year.
We will provide a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy for a Part D drug that is not on our formulary or that is subject to restrictions, such as prior authorization or step therapy. You can only receive one temporary 30-day supply as part of our transition process. After you receive the temporary 30-day supply, we will provide you with a written notice explaining the steps you can take to request an exception and how to work with your doctors if you should switch to a drug we cover.
Can members in a long-term care facility receive a transition drug supply?If a new member is a resident of a long-term-care facility, like a nursing home, we will cover a temporary transition supply (unless you have a prescription written for fewer days). The first supply will be for a maximum of 98 days, or less if your prescription is written for fewer days. If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our plan when that member is a resident of a long-term care facility. If a new member, who is a resident of a long-term care facility and has been enrolled in our plan for more than 90 days, needs a drug that isn’t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 34-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. This is in addition to the initial transition supply provided.
If a current member transitions to a different level of care, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days) and cover more than one refill during the first 90 days if the member transitions into a long-term care facility. If the transition is out of a long-term care facility, we will cover a temporary 31-day supply (unless the prescription is written for fewer days) when the member goes to a network pharmacy (and the drug is otherwise a Part D drug). After we cover the temporary 31-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
Do you qualify for best available evidence?For more information on if you qualify for a low-income subsidy (LIS), please visit CMS.gov