Pharmacist holding pill packet

Drug Benefit

Our goal is to help you get the best results from your medications at the lowest possible price.

Coverage Determination

If your doctor or pharmacist tells you that we will not cover a prescription drug, you should contact us by phone at 855.457.1352 (TTY 711) and ask for a coverage determination. You or your prescriber may ask for a coverage determination using the Medicare Prescription Drug Coverage Determination Form.

The following are examples of when you may want to ask us for a coverage determination:

  • If there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation
  • If there is a requirement that you try another drug before we will pay for the drug you are requesting
  • If you request a formulary or tiering exception

Secure Email Request

You may also ask for a coverage determination by making a  secure email request through MyPrime.com.

Be sure to select Vibra Health Plan and your plan (Essential Coverage OR Enhanced Coverage).

If your health requires a quick response, you should ask us to make a "fast coverage decision", also known as an "expedited determination". You, your doctor, or your representative can request a "fast coverage determination" by calling us at 855.457.1352 (TTY 711).

To request data on the total number of exceptions filed with Vibra Health Plan, you may contact us at 844.388.8268 (TTY 711).


Redetermination Request

To appeal an adverse coverage determination on Medicare Part D benefits, you can use our Redetermination Request Form. This form, along with any documentation to support your appeal, can be submitted by mail, fax or phone to:

Prime Therapeutics, LLC 
Attention: Medicare Appeals Department 
1305 Corporate Center Drive 
Building N10 
Eagan, MN 55121 
Fax: 800.693.6703 
Phone: 855.457.1352 (TTY 711)

If your health requires a quick response, you should ask us to make a "fast appeal", also known as an "expedited redetermination". You, your doctor, or your representative can request a "fast appeal" by contacting us at the address, fax, or phone number listed above.

Secure Email Request

You may also ask for a redetermination by making a secure email request through MyPrime.com.

Be sure to select Vibra Health Plan and your plan (Essential Coverage OR Enhanced Coverage).

You must file your appeal within 60 calendar days from the date of the initial coverage determination.

To request data on the total number of grievances, appeals, and exceptions filed with Vibra Health Plan, you may contact us at 844.388.8268 (TTY 711).


Receive extra help with Low-Income Subsidy (LIS)

If you receive Extra Help/Low-Income Subsidy (LIS) from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not receive Extra Help from Medicare. The amount of Extra Help you receive will determine your total monthly plan premium as a member of our plan.

This table shows you what your monthly plan premium for the Enhanced Coverage PPO will be if you receive Extra Help.

Your level of Extra Help 2019 Monthly premium for Enhanced Coverage PPO
100% $23.00
75% $32.20
50% $41.50
25% $50.70

The premiums listed above do not include a Part B premium amount, and if you qualify for Extra Help you are still required to pay the Part B premium.

Vibra Health Plan’s premium includes coverage for both medical services and prescription drug coverage.

If you are not receiving extra help, you can see if you qualify by reviewing the Centers for Medicare & Medicaid Services "best available evidence" policy for forms of evidence to establish the subsidy status, and by calling:

If you have any questions, please call Member Services at 844.388.8268 (TTY users call 711), from 8 AM -8 PM Eastern Time, 7 days a week.


Prescription Drug Transition Policy

Our Prescription Drug Transition Policy describes the transition requirements published by Medicare, which state that Vibra Health Plan must provide an appropriate prescription drug transition benefit for members.


Drug Utilization Management

Utilization Management (UM) is a process that is part of your health plan and is not considered a separate benefit. UM helps to make sure that you are getting the right drugs — all while helping to make medicine more affordable.

UM is made up of several different programs

Health plans call for UM on some medicines to keep you safe, by helping to make sure the medicines you take are prescribed by your doctor and used correctly. UM is made up of programs that include:

  • Step Therapy helps lower costs through safe, less expensive drugs. This program uses a "step" approach with drugs for certain conditions. This means that you may have to first try a safe, lower-cost drug, or one that may be more clinically effective, before "stepping up" to a different drug.
    As a member of Vibra Health Plan, if your drug requires Step Therapy, your doctor must submit a Step Therapy Exception Form for approval. If the request is not approved, you have the option to appeal the coverage decision or you can purchase the drug at your own expense.
  • Prior Authorization helps improve safety. Some drugs can be misused or overused, or may not be the best choice for your health condition. Prior authorization (sometimes called pre-approval) means that your medicine needs to be approved by your health plan before it will be covered.
    As a member of Vibra Health Plan, if your drug requires Prior Authorization, your doctor must submit a Prior Authorization Request Form for approval. If the request is not approved, you have the option to appeal the coverage decision or you can purchase the drug at your own expense.
  • Quantity Limits helps to lower waste. This program controls how often or the amount you can get filled at once. These limits promote safe, cost-effective drug use. They also help reduce waste and overuse.
    As a member of Vibra Health Plan, if your drug has specific Quantity Limits, your doctor must submit a Quantity Limit Exception Form for approval of any amount over that limit. If the request is not approved, you have the option to appeal the coverage decision.
  • Formulary Exceptions are required for some drugs. As a member, if your drug requires a Formulary Exception, your doctor must submit a Formulary Exception Form for approval. If the request is not approved, you have the option to appeal the coverage decision or you can purchase the drug at your own expense.

Medication Therapy Management Program

The Medication Therapy Management (MTM) program reviews the medicines you take to make sure that they are safe, work well and fit your lifestyle. This program is offered at no additional cost to eligible members and is not considered a separate benefit.

The goal of MTM is to help you get the best results from your medicines, at the lowest possible price. The MTM program can help you:

  • Learn how to get the most from your medicines
  • Lower your risk for potentially harmful drug reactions and side effects
  • Learn why it is important to take your medicines on time

The program can also help you and your doctor make sure that your medicines are the best choice for you.


Who is eligible for MTM?

If we have a MTM program that fits your needs, we will automatically enroll you and send you information.

You are automatically enrolled if you meet the following criteria:

  • Have three or more of the following conditions:
    • Chronic Heart Failure
    • Diabetes
    • High blood pressure
    • High blood cholesterol
    • Rheumatoid arthritis
  • Take eight or more prescription medicines covered by Medicare Part D AND
  • Expect to spend more than $3,967 in 2018 on prescription medicines covered by Medicare Part D.

Opting out

Medicare requires us to automatically enroll you if you are eligible. But, this service is voluntary — you are not required to participate. You may also choose to take part in only certain services you find valuable. You can cancel your enrollment at any time during the calendar year. Your prescription drug coverage will not change whether you take part in the MTM program or not.


For more information

If you would like to know more, call us at 855.457.1352 (TTY users should call 711), 24 hours a day, 7 days a week. Or learn more through MyPrime.com. Be sure to select Vibra Health Plan and your plan (Essential Coverage OR Enhanced Coverage). GO TO MYPRIME.COM

Specialty Medicines

  • Are injected or infused (however, some may be taken by mouth)
  • Have unique delivery, storage or shipment requirements
  • Require additional patient education, training and safety monitoring
  • May not be stocked at retail pharmacies

Specialty conditions:

  • Multiple sclerosis
  • Hemophilia
  • Hepatitis C
  • Rheumatoid arthritis
  • Other chronic and complex conditions

Prime Specialty Pharmacy

If you are a member and receive medicine through Prime Specialty Pharmacy, you may call 877.627.6337 with questions or for help. Pharmacy hours are 8AM to 8PM Eastern time, Monday through Friday.

Updated October 1, 2018
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