Prescription Drug Benefits

 

Drug Coverage Information

Below you will find information on the drug benefits for all plans of HealthSun.  Medicare Part D covered drugs are listed on the plan’s prescription drug formulary and are available only by prescription.  You must generally use network pharmacies to use your prescription drug benefit.  The drug formulary may change at any time and you will receive notice when necessary. Click here to find additional information on how to file grievances, coverage determinations, and appeals

2017 Prescription Drug Formularies

A formulary is a list of covered drugs selected by HealthSun in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.  HealthSun will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a HealthSun network pharmacy, and other plan rules are followed. To find out more information on covered drugs by HealthSun Health Plans, click on the links below

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Medicare Part B vs. D (BD), and High Risk Medication (HRM).

2017 Prior Authorization Criteria

HealthSun requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug.

2017 Step Therapy Criteria

In some cases, HealthSun requires you to first try certain drugs 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, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

What are over-the-counter (OTC) drugs?

 OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. HealthSun pays for certain OTC drugs. The plan will provide these OTC drugs at no cost to you. The cost to the plan of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count towards the coverage gap.) 

Over the Counter (OTC) Order Forms

How do I request an exception to the HealthSun Drug Formulary?

You can ask HealthSun to make the following exceptions to our Prescription Drug coverage rules:

  • Cover a drug that is not on our Formulary. If approved, it will be covered at a pre-determined cost-sharing level and will not be allowed to a lower cost-sharing level.
  • Cover a Formulary drug at a lower cost-sharing level if it is not on the specialty tier. If approved, this would lower the cost of your drug.
  • Waive coverage restrictions or limits on your drug. For example, for certain drugs, HealthSun limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, HealthSun will only approve your request for an exception if the alternative drug is included on our Formulary.  The lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact our Member Services Department to ask us for an initial coverage decision for an exception on the Formulary, tiers or a utilization restriction. You should also submit a statement from your prescriber or physician supporting your request.  Generally, we must make our decision within 72 hours of getting your prescriber's supporting statement. You 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.

Low Income Subsidy (LIS)

Extra Help from Medicare to Help Pay for your Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help form Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This does not include any Medicare Part B Premium you may have to pay. You must continue to pay your Medicare Part B premium.

HealthSun Health Plans provides coverage for both medical services and Part D prescription drug.  Click here for additional information on our available plans or contact our Member Services Department at 877-336-2069. 

2017 LIS Premium Summary- Monthly Plan Premium if you are getting Extra Help

Your level of extra help Monthly Premium for
SunPlus Advantage 001 (HMO)
(Miami-Dade)

Monthly Premium for
MediMax 006 (HMO)
(Miami- Dade and Broward) 

Monthly Premium for
HealthAdvantage 012 (HMO)
(Broward) 
 100%  $0  $0  $0
 75%  $0  $7.30  $0
 50%  $0  $14.50  $0
 25%  $0  $21.80  $0

If you have any questions, please call Member Service at 877-207-4900 or 305-234-9292 from 8:00 a.m. to 8:00 p.m. Monday through Friday.  TTY 877-206-0500. 

If aren't getting extra help, you can see if you qualify by calling:

  • 1-800-Medicare, 24 hours a day, 7 days a week.  TTY 1-877-486-2048 
  • Your State Medical Office or the Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday.  TTY 1-800-325-0778. 

Limitations, copayments, and restrictions may apply.  The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.  Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.