Pharmacy & Part D

A coverage decision is when Verda Health Plan of Texas decides what they will help pay for with your medical services or medication. When we make an initial decision about Part D drugs, it’s called a “coverage determination.”

For more information or to request a Coverage Determination, click here.

Know when the plan can offer you a temporary supply of medication:

Temporary Supply of your Medication: There are some circumstances under which the plan can offer a temporary supply of a drug if the drug is not on the Drug List (Formulary) or if it is subject to certain clinical or utilization management criteria. This gives you time to talk to your doctor about your drug therapy.

If the drug that you have been taking is no longer on your plan’s Drug List or if it now has some prior authorization or step therapy criteria, you can be eligible to obtain a temporary supply.

To be eligible for a transitional or temporary supply of medication, you should be in one of the following situations described below:

For members new to the plan within their first 90 days of enrollment in the plan and your medication is not on the formulary or requires certain utilization management.

• We will cover a temporary supply of your drug during the first 90 days under your plan in the coverage year. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, in which case the plan will allow multiple fills to provide up to a total of 30 days of medication. The prescription must be filled at a network pharmacy.

For those members who were part of the plan last year and aren’t in a long-term care facility.

• We will cover a temporary supply of your drug during the first 90 days under your plan in the coverage year. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days, in which case the plan will allow multiple fills to provide up to a total of 30 days of medication. The prescription must be filled at a network pharmacy.

For those who are new members and are residents in a long-term care facility

• If the member is a resident in a long-term care facility, the plan will provide a supply up to 98 days during this period, in accordance with the dispatch increase, with necessary refills (unless the prescription indicates less refills).

Start by talking to your doctor. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Member Experience to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor identify a covered drug that might work for you. You can file an exception. You and your doctor or other 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 doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule. For example, you can ask the plan to cover a drug even if it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.

You can file an exception:
You and your doctor or other 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 doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule. For example, you can ask the plan to cover a drug even if it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.

For more detailed information, see Chapter 9, under section “What is an exception?” of your plan’s Evidence of Coverage or call Member Services.

For more information, click here.

Verda Health Plan applies several Quality Assurance and Utilization Management Initiatives that are designed to improve quality, prevent over- and underutilization and reduce costs. These programs include but are not limited to Medication Therapy Management, Concurrent Drug Utilization Review, and Retrospective Drug Utilization.  These programs are available to promote safe utilization of medications and at no extra cost to Part D Members.

Concurrent Drug Review

Verda Health Plan has policies and procedures designed to ensure that a review of the prescribed drugs is performed at the point of sale or distribution before a prescription is dispensed to a member. Verda Health Plan, through its Pharmacy Benefits Manager (PBM), promotes appropriate dispensing and use of drugs to ensure high quality of care and cost-effective therapy.  The program also periodically reviews claims data retrospectively.

On-line reviews or edits include but are not limited to:

• Drug-Drug Interactions
• Duplicate Therapy
• Duplicate Drug Class
• Drug Age/Gender Edit
• Over/Under utilization
• Incorrect Drug Dosage/Duration of Therapy
• Drug-to-Disease Contraindication
• Drug/Allergy Edits
• Abuse or Misuse

This program is not considered a benefit.

Retrospective Drug Utilization

Verda Health Plan utilizes a retrospective Drug Utilization Review (DUR). The DUR is designed to provide ongoing periodic examination of claims data and other records through a computerized drug claims and information retrieval system. The system being used to identify patterns of inappropriate or medically unnecessary drug use associated with specific drugs or groups of drugs.

These DUR reviews include but are not limited to the following:

Alerts to prescribers on drug related therapy problems.

Brand and Generic drug utilization with provision of alternative ways to improve costs.

Physician utilization reports that identify over/under utilization, patterns of prescribing, poly-pharmacy patients.

This program is not considered a benefit.

These programs also work in conjunction with other clinical management tools to encourage the safe, appropriate, and cost-effective use of Medicare Part D Prescription Drugs.  More information about these three programs is available within the Formulary Booklet. 

Prior authorization (PA)
A PA requirement means the member, or their doctor must get approval before your medication is covered at your pharmacy.

Step therapy (ST)
A ST requirement means you must first try one drug to treat a medical condition before another drug will be covered for that same condition.

Quantity limits (QL)
A Quantity Limit requirement limits the amount of a drug that will be covered with prior approval.

Together, these programs help us identify and work to resolve any health and safety risks that your medications could pose, and to help you get the most benefit from your Verda Health Medicare Part D plan.

Quality Assurance

Verda Health Plan ensures the safety and health of its members through the establishment of effective Quality Assurance measures and systems. We do this to reduce medication errors, adverse drug reactions, and improve medication utilization. These measures include making sure that providers comply with pharmacy practice standards, drug utilization review, internal medication error identification systems, medical therapy management programs, and pharmacy and therapeutics committees. Included in the Quality Assurance process, selected cases are discussed with the objective of improving care.

A major goal of Verda Health Plan is to ensure that our beneficiaries receive safe, high-quality, cost-effective medication therapy. To achieve this goal, Verda Health Plan works with a claims processor to put certain edits in place to promote appropriate medication therapy. These edits help prevent patients from taking drugs that may have harmful interactions, prevent patients from receiving higher than recommended doses of a medication, notify patients of lower cost alternative medications, and provide other safety and efficacy safeguards.

Verda Health Plan will also provide appropriate education and may coordinate with prescribers and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross overuse and inappropriate or medically unnecessary care.

Usually, we only cover drugs obtained from an out-of-network pharmacy in limited circumstances:

• When you travel out of the plan’s service area.
• If you lose your medication or get sick and need a covered drug immediately and you do not have access to a network pharmacy.
• If you cannot obtain a covered drug in your service area in a timely manner due to lack of availability of a network pharmacy.
• If your covered drug is provided in an out-of-network pharmacy while you are in an emergency room, in a provider’s clinic, outpatient surgery, or in another facility.
• If a covered prescription is not in inventory at an accessible in-network retail pharmacy.

For detailed information consult your plan’s Evidence of Coverage (Chapter 5, Using the plan’s coverage for your Part D prescription drugs, Section 2.4 “When can you use a pharmacy that is not in the plan’s network?”) or call our Member Experience Call Center:

1-888-256-5123 (TTY: 711)

Hours of Operation

October 1 – March 31: 7 days a week, 8:00 AM – 8:00 PM (except Thanksgiving and Christmas)

April 1 – September 30: Monday-Friday, 8:00 AM – 8:00 PM (except holidays).

Please note that if you do go to an out-of-network pharmacy, you may have to pay the full cost (rather than paying just your copay) when you fill your prescription. You can request a reimbursement for our share of the cost by submitting a claim form.

You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay will help you qualify for the catastrophic coverage phase of the prescription drug benefit.

How to request a reimbursement for a prescription which you paid out of pocket and did not use your Verda Health Plan Member Identification Card:

If you received a bill for prescriptions or if you paid for medications that should be covered by the plan, you can request that we pay for the invoice or request a reimbursement.

Send us your request for payment, along with your bill and/or documentation of any payment you have made. Even if it is not a requirement, we suggest you fill out our claim form to make your request for payment. This form, which you can find below, will help us process the information faster, with all the information we need to make a decision. It’s also a good idea to make a copy of your bill and receipts for your personal records

Send your request for pharmacy reimbursement along with any invoices or receipts by mail or fax

Download and complete the form according to your plan for services reimbursement and mail to the address noted in the form. 

Click here for a copy of the Pharmacy Direct Member Reimbursement Request Form

Important details

You must submit your claim within a period of 12 months from the date when you received the medication. When the request arrives to the plan, it must be processed within 14 calendar days. If the plan’s decision is favorable to you, the plan must make the payment within a period of 14 calendar days after receiving the request.

For more details on how to submit a claim in writing, you can refer to the Claims Process that is explained in Chapter 7 of the Evidence of Coverage of your plan. For more information or help in submitting your request, you can contact Member Experience.

If you think you are eligible for Medicare’s extra help and that you are not paying the correct monthly premium or costs for your drugs, you or your appointed representative may be able to correct your Medicare records by providing us with information, known as Best Available Evidence (BAE), about your eligibility for extra help.

When we receive and verify your BAE, we will share it with Medicare and update our records within 3 business days. You also will need to provide the information to a network pharmacy when you obtain prescriptions so that we can charge you the appropriate cost-sharing amount until Medicare updates its records to reflect your current status.

Acceptable examples of BAE documents include copies of the following.

• your state Medicaid card
• your extra help Social Security award letter
• Supplemental Security Income (SSI) Notice of Award with an effective date
• a state document that confirms your active Medicaid status
  other official state documentation showing your Medicaid status
• a Home and Community-Based Services (HCBS) Notice that includes your name and HCBS eligibility date

For members who are institutionalized or in a long-term care facility, an appointed representative can provide a copy of the following BAE examples:

• a remittance from the facility showing Medicaid payment for a full calendar month with that individual’s name on the statement
• a copy of a state document that confirms Medicaid payment to the facility for a full calendar month on behalf of the individual
• a screen printout from the state’s Medicaid information system showing that individual’s institutional status based on at least a full calendar month stay for Medicaid payment purposes

You or your appointed representative can mail a copy of your BAE document with your medical or health record number to:

Verda Health Plan
Attn: Best Available Evidence
7755 Center Ave., Suite 1200
Huntington Beach, CA 92647

Or you may fax it to 800-958-1129. For more information on Low Income Subsidy and Best Available Evidence (BAE) policy, visit cms.gov OR https://www.cms.gov/medicare/coverage/prescription-drug-coverage-contracting/best-available-evidence-bae

NOTE: You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, co-payments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

• People with limited incomes may qualify for extra help to pay for their prescription drug costs: the Low-Income Subsidy (LIS).
• Additionally, those who qualify will not be subject to the deductible stage (if applicable), coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it.
• We can help you find out if you are eligible. If you qualify, you may have lower monthly premiums for the prescription drug coverage under your Verda Health Plan. You also may have lower cost sharing for your prescriptions.
• For general information about Extra Help, please call toll-free 1-800-MEDICARE (1-800-633-4227), or toll-free 1-877-486-2048 (TTY for the hearing/speech impaired), 24 hours a day, seven days a week. Or visit medicare.gov.

You also may call:

• Our Member Services department at (888) 256-5123 (TTY 711) (Monday – Friday 8:00 am – 8:00 pm except major holidays. Between October 1^st – March 31^st, representatives are available Monday to Sunday 8:00 am – 8:00 pm).
• Social Security toll-free at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday, or toll-free at 1-800-325-0778 (TTY for the hearing/speech impaired).
• Or visit the Social Security website at ssa.gov 
• Your state Medicaid Office
• Apply for extra help online at ssa.gov
• Additional information is also available at: https://www.medicare.gov/basics/costs/help/drug-costs