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.
Find additional information on how to file grievances, coverage determinations, and appeals.
Prescription Information Tool
CarelonRx is HealthSun's prescription information tool. As our member, you can use the CarelonRx's tool below to view your medication history, locate participating pharmacies near you, read important information about prescription drugs, verify your prescription drug benefit information, and keep a journal of medications. Your prescription information is available real-time providing the most accurate information possible to assist you with your prescription benefit needs.
For more information on how to register, click on the link below.
Medicare Prescription Payment Plan (M3P)
Starting January 2025, all Medicare drug plans and Medicare health plans with drug coverage will offer a new payment option ‘Medicare Prescription Payment Plan’, to help you manage your out of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). This payment option might help you manage your expenses if you have high out-of-pocket prescription drug costs, but it doesn’t save you money or lower your drug costs. This payment option might not be the best choice for you if you get help paying for your prescription drug costs through programs like Extra Help from Medicare or a State Pharmaceutical Assistance Program (SPAP).
For more information about the plan, please refer to the Medicare Prescription Payment Plan fact sheet below:
Medicare Prescription Payment Plan Fact Sheet
There’s no cost to participate in the Medicare Prescription Payment Plan. Participation is voluntary.
How do I opt-in?
SimplicityRx is managing the Medicare Prescription Payment plan on behalf of HealthSun Health Plans. If you are interested in participating in this payment plan, please follow one of the options below.
1. Complete the SimplicityRx Participation Request form online at SimplicityRx Participation Portal.
2. Call SimplicityRx at 1-833-696-2087 (TTY: 711) to submit your Participation Request via telephone.
3. Download the SimplicityRx Participation Request form below, fill out and mail back as per the instructions in the form. Newly enrolled members will also receive a copy of this form in their new member packet.
Medicare Prescription Payment Plan Participation Request Form
If you need more information regarding the Medicare Prescription Payment Plan or need help completing the Participation Request form, please contact SimplicityRx at 1-833-696-2087 (TTY: 711) Monday through Friday 8am to 8pm EST.
Please visit Medicare.gov for interactive educational materials, tools and examples related to the Medicare Prescription Payment Plan.
We appreciate you trusting us as your health partner.
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. The formulary may change at any time. You will receive notice when necessary. Find out more information on covered drugs by HealthSun Health Plans here:
2025 Prescription Drug Formulary – updated 09/23/2024
2025 Creole Prescription Drug Formulary – updated 09/23/2024
2024 Prescription Drug Formulary – updated 11/06/2024
2024 Prescription Drugs Formulary Changes – updated 11/14/2024
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).
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.
2025 Prior Authorization Criteria – updated 11/22/2024
2024 Prior Authorization Criteria – updated 11/06/2024
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.
2024 Step Therapy Criteria Part B Drugs only – effective 10/01/2024
2025 Step Therapy Criteria – updated 10/03/2024
2024 Step Therapy Criteria – updated 11/06/2024
Exceptions 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.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year.
Prescription Forms and Documents
Over the Counter (OTC) Order Forms
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.)
