Prescription Drug Information (Part D)
Abrazo Advantage (HMO)
Abrazo Advantage Health Plan pharmacy network equals or exceeds CMS' requirements for pharmacy access in your area.
- Online Formulary
- Abridged Formulary English Spanish
- Comprehensive Formulary
- Prior Authorization Criteria
- Drug Quantity Limits
- Step Therapy
Click Here to Find a Doctor/Pharmacy
Click Here to learn more about a Prescription Drug Coverage Request
Click Here for our Pharmacy Transition Plan
What is BAE?
BAE stands for Best Available Evidence and is used to determine the Medicaid eligibility status for members when it is not readily available in other applications. Medicare has outlined what is considered BAE and acceptable by Part D plan sponsors.
Click here for additional information about the Centers for Medicare and Medicaid Services (CMS) BAE policy.
Please note: by clicking on this you will be leaving the Abrazo Advantage Health Plan website and be redirected to the CMS website.
Out of Network Coverage
We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. We recommend that you fill all prescriptions prior to traveling out of the area so that you have an adequate supply as you could pay more for any drugs you get from
an out-of-network pharmacy.
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy and quantity limitations and restrictions may apply. There are two common circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- Emergency situations
- When you are out of the service area for up to but no more than 6 months
Please call Member Services at (888) 864-1114 or TTY (800) 489-1472 from 8 am to 8 pm, seven days a week, for details about other circumstances for out-of-network access.
How do you ask for reimbursement from the plan?
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. We will reimburse you at our contracted rate which is our share of the cost. The difference will be your responsibility.
In these situations, please call Member Services first at (888) 864-1114 or TTY (800) 489-1472 from 8 am to 8 pm, seven days a week, to see if there is a network pharmacy nearby.
Medication Therapy Management (MTM)
Abrazo Advantage Health Plan (AAHP) has programs that help our members manage their Part D medications in special situations. For example, some members have several medical conditions and may need to take many drugs at the same time, or they could have very high drug costs. A team of pharmacists and doctors developed the Medication Therapy Management (MTM) program to help these members with their care.
Abrazo Advantage Health Plan, through its relationship with Express Scripts, Inc. has partnered with the University of Arizona College of Pharmacy Medication Management Center (MMC) to offer this free service for eligible Medicare Part D members.
The MTM program can:
- Help make sure that our members are using the drugs that work best to treat their medical conditions;
- Help identify possible medication errors
- Help identify any drug-drug or drug-disease interactions.
The program is voluntary and provided at no cost to members. If you meet the criteria for MTM, we will automatically enroll you in the program and send you information.
The MTM program is required by the Centers for Medicare and Medicaid Services (CMS). The purpose of the program is to:
- Address safety concerns regarding your medications, such as allergies, side effects and drug-drug interactions (complications)
- Provide you with options for potentially more cost effective medications (to be discussed with your prescriber)
- Identify any barriers you may have to taking your medication, and help create solutions to such barriers.
To take part in this program, you must meet certain criteria set in part by CMS. These criteria identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet the program criteria, the Medication Management Center at the University of Arizona, College of Pharmacy will contact you about the program. Your participation in the MTM program is voluntary and does not affect Medicare coverage for drugs covered under Medicare Part D.
HOW CAN I PARTICIPATE IN THE MTM PROGRAM?
To qualify for the AAHP MTM program, you must meet the following three criteria:
1. You have at least three of the following conditions or diseases:
o Hypertension (High Blood Pressure)
o Dyslipidemia (High Cholesterol)
o Chronic Heart Failure (CHF)
o Asthma/Chronic Obstructive Pulmonary Disease (COPD)
o End-Stage Renal Disease (ESRD)
2. You take at least seven chronic Medicare Part D medications
3. You are likely to have medication costs of covered Part D medications greater than or equal to $3,144 per year.
SERVICES OFFERED THROUGH THE MTM PROGRAM
If you qualify for the MTM Program, you will have the opportunity for a one-on-one telephone call with a pharmacist or licensed pharmacy intern (under the supervision of a pharmacist) to discuss and review your medication(s) at no charge to you. During this review, the pharmacist will:
- Assess your patient health history to include conditions, prescription medications, over-the-counter drugs and herbal supplements;
- Talk about side effects that may make it hard to take your medicine;
- Suggest the best ways to take your medicine;
- Suggest other medications that may work for you;
- Answer any questions you may have regarding your medications.
You will receive in the mail a written summary of this conversation. This is what CMS calls a Comprehensive Medication Review (CMR). The written summary will include:
- Medication Action Plan with tips on how to take your medicine(s)
- Personal Medication Record that lists your medicine(s) you are now taking
You can take this written summary with you when you talk with your doctor(s). You may obtain a blank Personal Medication List (PML) to assist you in organizing your medications by clicking, here.
HOW OUR PROGRAM WORKS
- If you meet the three eligibility criteria listed above, you will automatically be enrolled in the MTM program.
- When you receive a letter informing you of your inclusion in the MTM program, you will have the option to schedule a one-on-one telephone consultation or OPT OUT; your participation is up to you.
- The Medication Management Center at the University of Arizona College of Pharmacy may also call you directly to discuss your medications.
The University of Arizona College of Pharmacy Medication Management Center pharmacists have extensive experience in delivering clinical services to patients with asthma, chronic obstructive pulmonary disease, hypertension, congestive heart failure, hyperlipidemia and diabetes through their work with Medicare Part D patients. Since the center opened in 2006, it has delivered medication therapy management services to more than 1 million Medicare beneficiaries across the country.
AAHP has systems in place for all of our members to make sure that they are getting safe and appropriate care. Our programs include real-time and historic review of prescription claims to reduce medications errors and adverse drug interactions. Our reviews are especially important for members who have more than one doctor who prescribe their medications, use more than one drug, or have more than one pharmacy.
Utilization Management (Prior Authorization Requirement)
AAHP had a team of doctors and pharmacists create tools to help us provide quality coverage to our members. The tools include but are not limited to: prior authorization criteria, clinical edits, quantity limits and step therapy. Some examples include:
Age Limits: Some drugs require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.
Quantity Limits: For certain drugs, AAHP limits the amount of the drug we will cover per prescription or for a defined period of time.
Prior Authorization: We require you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval before you fill your prescriptions. If you don't get approval, AAHP may not cover the drug.
Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher co-pay and/or the difference in cost between the brand and generic medications.
H5985_246-2013 Pending CMS Approval