Prescription Plan FAQs

Questions about PriorityMedicare Rx

Click on any question to read the answer below.

How can I compare my Medicare prescription drug coverage options?
Where is PriorityMedicare Rx^SM available?
Who is eligible to join?
Where can I get my prescriptions filled?
What happens if I go to a pharmacy that's not in the PriorityMedicare network?
Does PriorityMedicare Rx cover the same drugs as Medicare Part B or Part D?
Does this plan have an approved drug list or formulary?
What do I do if I'm taking a drug that's not on the approved drug list?
What is a Medication Therapy Management (MTM) Program?
What should I do if I have other insurance in addition to Medicare?
How can I get help with drug plan costs?
What are my protections in this plan?
Can I quit or leave PriorityMedicare Rx any time?


Q: How can I compare my Medicare prescription drug coverage options?

The PriorityMedicare Rx plan for 2008 is a Medicare prescription drug plan. The charts in the Summary of Benefits brochure for PriorityMedicare Rx list some important drug benefits. You can use the information to compare the benefits offered by PriorityMedicare Rx to those offered by other Medicare prescription drug plans, or to Medicare Advantage plans with prescription drug coverage (like PriorityMedicare Value, PriorityMedicare and PriorityMedicare Plus). Go to the PriorityMedicare Rx Summary of Benefits (300KB PDF) for complete details.

Q: Where is PriorityMedicare Rx available?

PriorityMedicare Rx is available throughout all of Michigan. You must live in Michigan to join this plan.


Q: Who is eligible to join?

You can join PriorityMedicare Rx if you're entitled to Medicare Part A and/or enrolled in Medicare Part B and live in the service area (the state of Michigan). Eligible individuals may only enroll in one Medicare prescription drug plan at a time and may not be enrolled in a Medicare Advantage Plan (HMO, PPO), unless they are a member of a Medicare Private-Fee-For-Services plan or are enrolled in an 1876 Cost Plan. You may join a Medicare Prescription Drug Plan only during certain times of the year. Call PriorityMedicare Sales for more information on enrollment. For information on disenrollment periods, call PriorityMedicare Customer Service.


Q: Where can I get my prescriptions filled?

PriorityMedicare Rx has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. PriorityMedicare Rx may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases; see Section 1 of the PriorityMedicare Approved Drug List for details. The pharmacies in our network can change at any time. You can check our pharmacy directory or call Customer Service for a list.

Section 1 of our pharmacy directory includes information about how to get prescriptions filled at any type of pharmacy in our network: retail, mail order, long-term care, Indian Health Service/Tribal/Urban Indian Health Program, or home infusion. You can also contact Customer Service for help with our mail order procedures or other pharmacy questions.


Q: What happens if I go to a pharmacy that's not in the PriorityMedicare network?

If you go to a pharmacy that's not in our network, you may have to pay more for your prescriptions. You will have to pay the full price of your prescription up front at the pharmacy, then submit a claim to us. We will reimburse you up to the amount we would normally pay if you used a network pharmacy, less your copay and/or any coinsurance amount. Download a claim (member reimbursement) form (99K PDF*)

< br /> Q: Does PriorityMedicare Rx cover the same drugs as Medicare Part B or Part D?

PriorityMedicare Rx doesn't cover drugs that are covered under Medicare Part B as prescribed and dispensed. Generally, we only cover drugs, vaccines, biological products and medical supplies that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our Approved Drug List. Copays and limitations may apply.


Q: Does this plan have an approved drug list?

PriorityMedicare Rx uses an approved drug list (also known as a formulary). This is a list of drugs covered by your plan. We may periodically add or remove drugs, make changes to coverage limitations on certain drugs, or change how much you pay for a drug. If we make any change that limits your ability to fill your prescriptions, we will notify you before the change is made. View the PriorityMedicare approved drug list.


Q: What do I do if I'm taking a drug that's not on the approved drug list?

If you're currently taking a drug that is not on our approved drug list or that's subject to additional requirements or limits, you may be able to get a temporary supply. You can contact us to request an exception or switch to an alternative drug listed on our approved drug list with your physician's help. Call us to see if you can get a temporary supply of the drug or for details about our drug transition policy.


Q: What is a Medication Therapy Management (MTM) Program?

A Medication Therapy Management (MTM) Program helps us ensure that our members with multiple chronic conditions, such as asthma and heart disease, and who are taking multiple covered drugs, use them in ways that get the best results. You may be asked to participate in an MTM program designed for your specific health and pharmacy needs. We recommend that you take full advantage of this program if you are selected. Read more about the MTM program.


Q: What should I do if I have other insurance in addition to Medicare?

If you have a supplemental Medicare plan that includes prescription drug coverage, you must notify the plan sponsor that you have joined a Medicare prescription drug plan. If you decide to keep your current supplemental plan, your plan's sponsor will remove the prescription drug coverage portion of your policy. This will occur as of the effective date of your coverage in our Medicare prescription drug plan. Your supplemental plan sponsor will adjust your premium. Call your supplemental plan sponsor for more details.

If you or your spouse has, or is able to get, employer group coverage, talk to the employer to find out how your benefits will be affected if you join PriorityMedicare Rx. Get this information before you decide to enroll in this plan.


Q: How can I get help with my drug plan costs?

If you qualify for extra help with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join PriorityMedicare Rx, Medicare will tell us how much extra help you're getting. Then we will let you know the amount you will pay. If you're not getting this extra help you can see if you qualify by calling 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048.


Q: What are my protections if I enroll in a PriorityMedicare plan?

1. One-Year Coverage Guarantee.

All medical plans in the Medicare program (including PriorityMedicare Rx) agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare health plan leaves the program, you will not lose Medicare prescription drug coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage ends. The letter will explain your options for Medicare coverage in your area.

2. Requests for Exceptions, Appealing Our Decisions, and Filing Grievances (complaints).

As a member of a PriorityMedicare plan, you have the right to request a coverage determination, which includes the right to request an exception, file an appeal if we deny coverage for a prescription drug, and file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost.

You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or with one of our network pharmacies that does not involve coverage for a prescription drug.
Read more about the exceptions, appeals and complaints process.


Q: Can I quit or leave PriorityMedicare Rx any time?

There are limits to when you may leave, how often you can make changes and what type of plan you can join after you leave. You may only enroll in or disenroll from a plan during specific times of the year unless you're newly eligible for Medicare. For 2008 coverage, you must sign up between November 15 and December 31, 2007. Your next opportunity to change plans won't be until November 15, 2008 (for 2009 coverage).

There are also a few situations where you would be required to leave. For example, we will disenroll you from your PriorityMedicare plan if you move permanently out of our geographic service area. We're not allowed to ask you to leave the plan because of your health.

If you disenroll from your PriorityMedicare plan, it may take some time for your membership to end and your new Medicare plan to take effect. Until your membership ends, you must keep getting your Medicare services through PriorityMedicare or you will have to pay for them yourself.

For more information about your rights and responsibilities or the disenrollment process, see your plan's Evidence of Coverage document.





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