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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.

Find additional information on how to file grievances, coverage determinations, and appeals.


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:

2021 Prescription Drug Formulary - Updated 09/16/2021

2022 D-SNP Prescription Drug Formulary – Updated 09/24/2021

For the following DSNP plans:

  • MediSun Plus (HMO DSNP) 015
  • MediSun Plus (HMO DSNP) 016
  • MediSun Extra (HMO DSNP) 019

2022 Non-SNP Prescription Drug Formulary – Updated 09/24/2021

For the following non-SNP plans:

  • HealthAdvantage (HMO) 001
  • HealthAdvantage (HMO) 012
  • HealthAdvantage (HMO) 013
  • HealthAdvantage Plus (HMO) 017
  • HealthAdvantage Plus (HMO) 018
  • MediMax (HMO) 006

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.

2021 Prior Authorization Criteria - Updated 09/16/2021

2022 Prior Authorization Criteria – Updated 09/24/2021


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.

2021 Step Therapy Criteria - Updated 09/16/2021

2022 Step Therapy Criteria – Updated 09/24/2021

2022 Step Therapy Criteria Part B Drugs only – effective 01/01/2022


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.)

Health Plan Accredited by AAAHC

HealthSun Health Plans is an HMO plan with a Medicare Contract and a Medicaid contract with the State of Florida Agency for Health Care Administration. Enrollment in HealthSun Health Plans depends on contract renewal. Every year, Medicare evaluates plans based on a 5-star rating system. Star rating is for contract years 2018, 2019, 2020, 2021, and 2022. HealthSun complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-336-2069. (TTY: 1-877-206-0500). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-336-2069. (TTY: 1-877-206-0500).

Do you need to file a complaint? File your complaint online via CMS by submitting the Medicare Complaint Form. Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare.

Report suspected instances of FWA or any other non-compliance activity. For your convenience, you can call our Compliance Hotline at 1-844-420-0080 (USA and Canada only) available 24 hours a day and 7 days a week provided by LightHouse Services. Para español llama al 1-800-216-1288 (Si usted esta llamando desde México marque el 1-800-681-5340). You can also email issues to [email protected] or fax to 215-689-3885 (must include the company name on the email and fax).