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Prescription Help

Prescription Help

Vibra Health Plan has provided a wealth of information below to assist with your prescription related questions.

Find a Medication

Our plan will generally cover the drugs listed in our Formulary (list of covered drugs) as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed.

You may request a copy of the formulary by calling us at 844.388.8268 (TTY 711), 8:00 AM - 8:00 PM, 7 days a week.

Mail Order

Our plan's mail order service allows you to order at least a 30-day supply of the drug and no more than a 90-day supply.

To get order forms and information about filling your prescriptions by mail, contact AllianceRx Walgreens Prime at 855.457.1345, (TTY/TTD users should call 711), 24 hours a day, 7 days week.

For more information on how to fill your prescriptions or sign-up for mail order, please review Chapter 6 of the Vibra Health Plan Evidence of Coverage.

What to do if

Your prescription’s not covered

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 (Enhanced Complete PPO or Essential Advocate PPO).

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).

You need to file an appeal

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).

You need extra help covering your prescriptions

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 Complete Coverage PPO will be if you receive Extra Help.

Your level of Extra Help	2020 Monthly premium for Enhanced Complete Coverage PPO
100%	$15.20
75%	$17.60
50%	$20.10
25%	$22.50

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:

800.633.4227 or TTY users call 877.486.2048 (24 hours a day/7 days a week),
Pennsylvania’s Department of Human Services at 800.692.7462; TTY users call 800.692.7462, or
The Social Security Administration at 800.772.1213. TTY users should call 800.325.0778 between 7:00 AM - 7:00 PM, Monday through Friday.

If you have any questions, please call Member Services at 844.388.8268 (TTY users call 711), from 8:00 AM - 8:00 PM, 7 days a week.

You'd like information about a prescription transition

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.

You'd like to know how Vibra manages your prescriptions

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:

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.

You want to know about Medication Therapy Management

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:
- Asthma
- Cardiovascular Disease
- Chronic Heart Failure
- Diabetes
- Mental Health Disorders, including depression
- Osteoporosis
- Chronic Obstructive Pulmonary Disease (COPD)
Take eight or more prescription medicines covered by Medicare Part D AND
Expect to spend more than $4,376 annually or at least $1,094 quarterly 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.

How can I get more information about the MTM Program?

Call Member Services at 844.866.3735 (TTY:711), 24 hours a day, 7 days a week.

Updated October 1, 2020
H9408_WBST21_M

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Out-of-network/non-contracted providers are under no obligation to treat Vibra Health Plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Every effort has been made to ensure that this site is accessible to all people and groups. If you have any questions or comments on the site's accessibility or usability, please contact us at 844.388.8268 (TTY 711).

Vibra Health Plan is a PPO with a Medicare contract. Enrollment in Vibra Health Plan depends on contract renewal.

Medicare beneficiaries may also enroll in the Essential Advocate PPO or Enhanced Complete PPO plan the CMS Medicare Online Enrollment Center.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, copayments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

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