Prescription Coverage

Cost Sharing, Premiums & Deductibles

Commonwealth Care Alliance is a Medicare contractor offering a prescription drug benefit. As an enrolled member, you have no out-of-pocket expense for your prescription drug coverage. Our comprehensive drug formulary lists drugs we cover. We will cover the drugs listed in the formulary as long as they are medically necessary. The drugs on the formulary are selected with the help of a team of healthcare providers. Your enrollment entitles you to coverage of those drugs that you would normally receive under Medicare Parts A and B. Our Senior Care Options HMO program also covers some additional vaccines and drugs that are not normally covered by Medicare Part B.

You will receive an Explanation of Benefits every month. The Explanation of Benefits will contain information about the prescription drugs that you get from our programs; the amount of money that our programs pay for your drugs; information about how to request an exception and how to appeal our coverage decisions; and a description of changes that will occur to the drug formulary at least 60 days in the future.

If you are admitted to a hospital, we will provide your prescription drugs under your medical benefit. When you are released from hospital, we will provide your prescription drugs under your outpatient drug benefit. Drugs on our formulary are organized into different drug “tiers”, or groups of different drug types. A generic drug has the same active ingredient formula as the brand name drug. Generic drugs usually cost less than brand name drugs, and are rated by the Food and Drug Administration (FDA) to be safe and as effective as brand name drugs.

Plan Transition

New Commonwealth Care Alliance members may take drugs that are not on our Drug List, or fall under step therapy or prior authorization restrictions. Under certain circumstances, we 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 doctor about the change in coverage and figure out what to do.

For those members who are new to the plan and aren't in a long-term care facility:

We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days.

For those who are new members and are residents in a long-term care facility:

We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.

During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask us to make an exception for you and cover the drug in the way you would like it to be covered. The sections below tell you more about these options.

How do I change my prescription?

You can ask us if we cover another drug used to treat your medical condition. If we cover another drug for your condition, you can ask your doctor if any of these drugs is an option for you. If your doctor tells you that none of the drugs we cover for treating your condition is medically appropriate for treating your condition, you have the right to request a formulary exception from us. You also have a right to request exception if your doctor tells you that a prior authorization, quantity limit, or other limit we have placed on a drug you are taking is not medically appropriate for treating your condition.

How do I request an exception?

The first step in requesting an exception is for you or your prescribing doctor to contact us. Please call, fax, or write to us at:

Commonwealth Care Alliance
30 Winter Street
Boston, MA 02108

Toll free: 1-866-610-2273
TTY: 1-866-322-7357
Fax: 617-426-1311

Your doctor must submit a statement supporting your request. The doctor's statement must indicate that the requested drug is medically necessary for treating your condition because none of the drugs we cover for your condition would be as effective as the requested drug or would have adverse effects for you. If the exception involved a prior authorization, quantity limit, or other limit we have placed on a drug you are taking, the doctor's statement must indicate that the prior authorization or limit would not be as effective for treating your condition or would have adverse effects for you.

See your current Evidence of Coverage for more information.

Best Available Evidence Policy

Commonwealth Care Alliance works with the Centers for Medicare and Medicaid Services to ensure that your Low-Income Subsidy status is accurate. We achieve this with the Best Available Evidence policy. However, because all Senior Care Options HMO members pay $0 copayments for medications, this Low-Income Subsidy status, and Best Available Evidence policy, do not have an effect on how much you pay for medications. All Senior Care Options HMO members pay $0 for medications regardless of your Low-Income Subsidy status.

For more information, click here to visit the CMS website.*

*When you click this link, you will leave Commonwealth Care Alliance's web site.

Last Updated 1/1/12