The information below describes some of the prescription drug benefits and requirements for your Medicare Advantage HMO patients who have AmeriHealth 65 Preferred Rx HMO and AmeriHealth Rx PDP plans during plan year 2014.

Temporary 30-day medication supply

If a newly enrolled member takes a medication that is either not on our formulary or is on the formulary but with certain restrictions (e.g., requires prior authorization or step therapy), AmeriHealth covers a temporary 30-day supply unless the prescription is written for fewer than 30 days. This policy ensures that your new patient receives an initial supply of a prescribed drug within the first 90 days of coverage.

AmeriHealth also covers a temporary 30-day medication supply for existing members whose medications have been removed from the formulary or have had certain restrictions applied to them. These members received the Annual Notice of Change (ANOC) and Evidence of Coverage by October 1, 2013, which notified them of changes to the formulary.

You can request a formulary exception for your patients by following the instructions below if no formulary alternative is appropriate.

Submitting prior authorization, step therapy, or tier/formulary exception requests

You can submit prior authorization, step therapy, and tier/formulary exception requests on behalf of your patients by completing the proper form. Medication-specific prior authorization forms are available on the FutureScripts^® Secure website at www.futurescripts.com. Select Prior Authorization from the For Health Care Professionals tab, and then select Medicare Part D.

A Coverage Determination Request form can be used for any drug, including those that do not have a specific form, or for a tier or formulary exception.

Completed forms must be faxed to FutureScripts Secure at 1-888-671-5285. When completing any form, all requested information must be supplied. Please include your office telephone and fax numbers on the form. Incomplete requests will require your office to be contacted to obtain additional information.

You will be notified by fax if the request is approved or denied. You and your patient will also receive a denial letter if the request is denied. If you have not received a response within 72 hours after submitting complete information, contact FutureScripts Secure at 1-888-678-7015, prompt 3.

Appealing a pharmacy coverage determination denial

If you do not agree with the outcome of the initial coverage determination, you can request a redetermination. In addition to being listed below, contact information will be listed on the denial letter you will receive.

For AmeriHealth 65 Preferred Rx HMO members:

Call: 1-866-569-5190 (TTY/TTD: 1-888-857-4816)
Fax: 1-888-289-3008
Write: AmeriHealth 65 Preferred HMO
Medicare Member Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652

For AmeriHealth Rx PDP members:

Call: 1-888-678-7007 (TTY/TTD: 1-888-289-3008)
Fax: 1-888-289-3008
Write: Medicare Member Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652

Medication Therapy Management program

In collaboration with Catamaran, a Pharmacy Benefits Manager, AmeriHealth New Jersey provides a Medication Therapy Management (MTM) program to ensure that your patients are receiving the most effective medications, while also helping to reduce the risk of side effects and interactions, as well as the patient?s out-of-pocket costs. The program is offered to your eligible patients at no cost. Specially trained pharmacists will work closely with you and your patients to solve any medication-related problems.

The Centers for Medicare & Medicaid Services requires us to enroll your eligible patients into the MTM program, but your patients can opt out at any time by calling the FutureScripts Secure MTM Department at 1-866-352-5305 (TTY: 1-888-206-8041), Monday through Friday, 9 a.m. to 9 p.m., ET.

Eligible MTM program members include:

• patients who have three or more chronic diseases, including:
  ? bone/joint disease (e.g., osteoporosis, rheumatoid arthritis)
  ? chronic heart failure
  ? diabetes
  ? high cholesterol
  ? HIV/AIDS
  ? high blood pressure
  ? mental health issues (e.g., depression)
  ? respiratory disease (e.g., asthma, COPD)
  
• patients taking six or more maintenance medications for chronic conditions;
• patients who will spend $3,017 or more per year on Medicare Part D covered medications.

For additional information about prescription drug benefits for Medicare Advantage HMO members, contact FutureScripts Secure at 1-888-678-7015. This information will also be available in the Pharmacy section of the Provider Manual for Participating Professional Providers, which you can find on AmeriHealth NaviNet^® Plan Central.

FutureScripts^® and FutureScripts^® Secure provide pharmacy benefits management services.

NaviNet^® is a registered trademark of NaviNet, Inc.