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Call CommunityCare Senior Health Plan at 1-800-642-8065, TTY/TDD call 1-800-722-0353 for more information and rate quotes.

Drug Management Programs

Utilization management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Please consult your copy of our formulary or the formulary on our website for more information about these requirements and limits.

The requirements for coverage or limits on certain drugs are listed as follows:

Prior Authorization: We require you to get prior authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don't get the necessary information to satisfy the prior authorization, we may not cover the drug.

Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 30 tablets per 30-day period for Singulair.

Step Therapy: In some cases, we require you to first try one drug 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, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary or on our website, or by calling Member Services. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren't able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination). See Chapter 9, Section 6 of the 2017 Evidence of Coverage for more information about how to request an exception.

Drug utilization review

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

  • Possible medication errors
  • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Drugs that are inappropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking
  • Drug allergies
  • Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Disclaimers

  • You may join or leave a plan only at certain times. Please call Senior Health Plan at the telephone number listed in the previous section of this web page or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this number 24 hours a day, seven days a week.
  • You can join Senior Health Plan if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Senior Health Plan unless they are members of our organization and have been since their dialysis began.
  • Senior Health Plan has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or search the Senior Health Plan provider directory on this website. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither Senior Health Plan nor Original Medicare will pay for these services.
  • You must continue to pay your Medicare Part B premium, even if the Senior Health Plan premium is $0.