A formulary is a list of covered drugs (both generic and brand name) selected by Nascentia Health Plus in consultation with a team of healthcare providers to offer prescription therapies believed to be an important part of a quality prescription program. Nascentia Health Plus will generally only cover the drugs listed in the formulary, unless your health care provider contacts Nascentia Health Plus and gets prior approval.
Envision Rx is the company Nascentia Health Plus works with to manage members’ prescription drug coverage for Medicare. You will see Envision Rx listed on your member ID card and on letters sent to you about your medications.
As a member, you can call our pharmacy benefit manager, Envision Rx, at 1.833.459.4424 TTY 711, 24 hours a day, 7 days a week, if you have any questions or concerns regarding pharmacy benefits, picking up or paying for your prescription medicines at the pharmacy, getting an emergency exception to our approved medicines list (formulary), obtaining information on the aggregate number of grievances, appeals, and exceptions filed with us, or any other questions about prescription medicines or medication supplies you may need.
Prior Authorizations (pdf)
Quantity Limits (pdf)
Step Therapy (pdf)
Pharmacy Transition Process
When taking a medication that is no longer covered by the plan, Nascentia Health Plus wants to ensure your prescription drug transitions are safe and as easy to navigate. Please review the information below for guidance on any prescription drug transition.
Pharmacy Exceptions and Coverage Determinations
If you require a medication that is not on Nascentia Health Plus’ formulary and you cannot use a formulary alternative, or if you require an exception to one of our utilization management rules, you have the right to request a coverage determination. Review the information below to learn more.
Coverage Determination Form (pdf)
You may also initiate a coverage determination by contacting Envision Rx:
- by phone, at 1.833.459.4424 (TTY 711), 24 hours a day, 7 days a week
- on website at https://envision.promptpa.com
Pharmacy Appeals and Grievances
Is Your Drug Covered By Our Plan?
If a drug you take isn’t covered by our plan and you can’t switch to another drug, you and your prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your prescriber says that you have medical reasons that justify asking us for an exception, your prescriber can help you request an exception to the rule. This is called a “coverage determination.”
You and your prescriber can complete the Coverage Determination Request Form (pdf) and submit it to the pharmacy department for consideration.
If we approve your request for a Formulary exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If we deny your request for a Formulary exception, you can ask for a review of our decision by making an appeal. This is called a “redetermination.”
You and your prescriber can complete the Redetermination Request Form (pdf) and submit it to the Nascentia Health Plus appeals department for consideration.
If your request is denied, you have the right to ask for an independent review of the plan’s decision. You have 60 days from the date of the plan’s Redetermination Notice to ask for an independent review. You can complete the Request for Reconsideration Form (pdf) and submit it to the plan for action.
Part D Quality Assurance
Nascentia Health Plus has implemented special programs to help you access your prescriptions safely.
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: Nascentia Health Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Nascentia Health Plus before you fill your prescriptions. If you don’t get approval, Nascentia Health Plus may not cover the drug.
- Quantity Limits: For certain drugs, Nascentia Health Plus limits the amount of the drug that Nascentia Health Plus will cover. For example, Nascentia Health Plus provides 60 or 90 pills per prescription (depending on the strength of the drug), for oxycodone hcl. This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, Nascentia Health Plus 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, Nascentia Health Plus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Nascentia Health Plus will then cover Drug B.
- Generic Drugs: Nascentia Health Plus covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Drug Utilization Review
Through our Drug Utilization Review (DUR) program, Nascentia Health Plus reviews the drugs that you are taking to ensure quality care through a disease management approach. We are committed to continuous quality improvement and as part of our review, we assess for issues such as:
- Duplication of drugs
- Drug dosage error or therapy duration
- Inappropriate medication
- Clinical use and misuse
- Over and under-utilization
Medication Therapy Management (MTM)
Medication Therapy Management (MTM) is a free program designed to help members with specific medical needs take medications safely and effectively. MTM is not a benefit and is only available to members who meet the criteria outlined below.
Eligible participants are those members with Medicare Part D prescription coverage who take at least 8 (eight) Part D drugs and are likely to incur or exceed annual costs of the CMS dictated threshold for all covered Part D drugs.
Participants of the program also have at least 3 (three) of the below mentioned chronic diseases/conditions:
- Alzheimer’s Disease
- Bone Disease Arthritis Osteoporosis
For more information about the MTM program, call member services at 1.888.477.HOME (TTY 711).
Hours of Operation 8am – 8pm, 7 days* a week
*October 1st – March 31st / Mon- Fri rest of the year
Once you are selected for the MTM Program, you will receive an eligibility notification letter and will be contacted to schedule a telephone consultation with a pharmacist. They will review your current prescriptions and over-the-counter medications and conduct an ongoing comprehensive medication review (CMR) to identify any potential medication related issues. If any medication issue is identified during the telephone consultation with a pharmacist, we will discuss it with your provider. Through this review, the pharmacist is able to identify and reduce the chance for medication errors; they will have more information about your current medication therapy, can help reduce duplicative therapy and offer affordable formulary alternative if applicable and it’s a great opportunity to identify and educate you on the side effects of the drugs you are taking and discuss ways to reduce those effects.
Upon completion of the CMR, an individualized written summary in the CMS standard format will be provided to you within 14 days of the CMR. The summary has a medication action plan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any follow-up questions. You will also get a personal medication list that will include all the medications you are taking and why you take them. A blank copy of the Personal Medication List is available here (pdf).
All MTM participants will receive follow-up mailings on a quarterly basis to remind them of their opportunity for the CMR and to provide general member education materials.
Participation in this program is voluntary. You are not required to participate in this program if you do not wish to do so. You can contact Envision Rx at 1.833.459.4424 (TTY 711), 24 hours a day, 7 days a week to opt-out.