2022 Prescription Drug Coverage
Doctors HealthCare Plans offers prescription drug coverage in ALL of its plans. Our formulary provides coverage for a list of medications divided into tiers. These medications fall into one of five tiers and, depending on your plan, determines the price you pay. Generic drugs usually cost less than the brand and are placed in a lower tier.
Our Member Portal Secure Access allows members to view and access their pharmacy-related data. Some of these features include: Access to view and download pharmacy claims, real-time benefit information, a drug pricing tool that will allow you to compare costs and multiple pharmacies, a participating pharmacy locator tool and drug information. Pharmacy and claims data are updated within 15 minutes. As a member of the plan, you can access this information by entering your credentials (member ID and password).
Please use the links below for additional information about the drugs covered by your plan. You may also refer to the search tool below to search for your medications by name.
Part D Coverage Determinations
A coverage determination means any decision made by Doctors HealthCare Plans as a Medicare Part D sponsor regarding payment or benefit to which you believe you are entitled to. Some drugs on the formulary may have additional requirements or limits where a request for a coverage determination is necessary. Some of these requirements and limits may include:
Expedited Coverage Determinations will be made within 24 hours. Standard Coverage Determinations will be made within 72 hours.
You can ask Doctors HealthCare Plans to make an Exception to its coverage rules or to cover a drug even if it is not available on your plan formulary.
Prior Authorization (PA)
Some prescription drugs require prior authorization (PA) to be covered. If your prescription drug requires prior authorization, you, your appointed representative, or your prescribing physician or other prescriber will need to request and receive approval in advance from Doctors HealthCare Plans before you fill your prescription. If you don’t get approval, Doctors HealthCare Plans may not cover the drug.
Step Therapy (ST)
With step therapy drugs, Doctors HealthCare Plans requests that you first try certain drugs to treat your medical condition before we cover another drug for that condition. If your drug has a step therapy requirement, your prescribing physician or other prescriber will need to provide a supporting statement to Doctors HealthCare Plans. Approval must be received before you fill your prescription. If you don’t get approval, Doctors HealthCare Plans may not cover the drug.
Quantity Limit (QL)
For certain drugs, Doctors Health Care Plans limits the amount of the drug that will be covered per prescription or for a defined period of time. If you require additional quantities over the limit, your physician will need to provide a supporting statement to Doctors HealthCare Plans. An approval must be received before you fill your prescription for the additional quantity, otherwise the additional quantity may not be covered.
Exceptions also require coverage determination. There are several types of exceptions you can ask us to make:
- You can ask us to cover a drug even if it is not on our formulary.
- You can ask us to cover a formulary drug at a lower cost-sharing level.
- You can ask us to waive coverage restrictions or limits on your drug.
All exception requests must be supported by a statement by the prescribing physician or other prescriber to demonstrate medical necessity.
Ways to Request a Coverage Determination
- CALL: Contact Member Services toll-free at 833-342-7463 (TTY: 711), 7 days a week 8 a.m. to 8 p.m.
- ONLINE SUBMISSION: Submit your Coverage Determination request online
- FAX: Download and complete a Coverage Determination form and fax the completed form to 858-357-2614. (English / Español)
- MAIL: Mail the completed request form to the plan’s Pharmacy Department address:
Doctors HealthCare Plans, Inc.
Attn: Pharmacy Department
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134
If you take maintenance medications for long-term conditions like arthritis, asthma, diabetes, high blood pressure or high cholesterol you may have your medications mailed to your home by using a participating mail-order service pharmacy. See information below:
Direct Member Reimbursement
- In-Network Pharmacies
Doctors HealthCare Plans offers national in-network prescription drug coverage. This means that you will pay the same cost sharing amount for your prescriptions in all 50 states and the District of Columbia at any of our in-network pharmacies. You should always present your Member ID card at the pharmacy so the pharmacy can gather the information needed to process your claim electronically. The plan’s in network pharmacies are required to submit your prescription claims. If you do not present your ID card, or if the pharmacy does not submit your claim electronically, you can pay cash and request reimbursement from Doctors HealthCare Plans. You are responsible for your cost-share plus the difference between the cash price and the negotiated rate, if the cash price is higher. Doctors HealthCare Plans will reimburse you the negotiated rate we agreed to pay the pharmacy. Please note, the plan will not pay for any prescriptions that are filled by pharmacies outside the United States.
- Out-of-Network Pharmacies
You may need to use pharmacies outside of the plan network under special circumstances. The plan will reimburse medications filled at an out-of-network pharmacy if: there are no open in-network pharmacies for a covered drug urgently needed; the medication is a specialty drug that is not usually kept in stock by in network pharmacies; prescription is for a medical emergency; you get a covered prescription drug from an institutional based pharmacy while a patient in an emergency room, provider based clinic, outpatient surgery clinic, or other outpatient setting; you are evacuated from your home due to state, federal, or public health emergency and don’t have access to an in-network pharmacy; or if you were eligible for Medicaid, without having been enrolled, at the time the prescription was filled.
For a reimbursement request, you will need to pay full cost for the covered drug and submit a Direct Member Reimbursement Claim Form. Please note, reimbursement may not cover your full cost for the covered drug. We will notify you of our decision (and make payment when appropriate) no later than 14 calendar days after receiving your request.
You can mail a written reimbursement request along with any bills, receipts and/or medical record documentation; Or mail a completed Direct Member Reimbursement Claim Form request to:
Doctors HealthCare Plans, Inc.
Attn: Pharmacy Department
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134
The purpose of providing a transition is to promote continuity of care and avoid interruptions in drug therapy. If your prescription drugs are not on the formulary or are limited on the formulary because it has utilization management requirements, such as prior authorization, step therapy or quantity limits, Doctors HealthCare Plans may cover your drug in certain cases during the first 90 days you are a member of our plan.
For more information, please review below:
Medication Therapy Management Program
Doctors HealthCare Plans, Inc. offers a Medication Therapy Management (MTM) program to assist our members in unique situations, including individuals who have several complex medical conditions, those who take multiple drugs, or those who have high drug costs.
If you are a member of Doctors HealthCare Plans, Inc., you may be eligible for this program if:
- You have 3 or more chronic diseases, such as Chronic Heart Failure, COPD, End Stage Renal Disease, Alzheimer’s Disease, Asthma, and/or Osteoporosis; AND
- You take 8 or more Part D prescription drugs; AND
- You are likely to incur at least $4,696 annually in Part D medication costs.
The MTM program, which is completely voluntary and at no cost to members, helps ensure that our members are receiving optimal care. If you qualify for the MTM program, you will receive notification of eligibility within 60 days. This notification will provide detailed information about the MTM program as well as our contact information should you have any questions.
One of the key components of the MTM program is our attention to your chronic diseases and the medications you take.
- A pharmacist or other health professional will contact you by phone to provide you with a Comprehensive Medication Review (CMR) of all your medications. The MTM provider will work to schedule a time that is convenient for you and your schedule. The CMR typically lasts about 30 minutes, depending on your specific needs and questions. The MTM provider is available to discuss how to best take your medications, your costs, or any problems you’re currently experiencing.
- Following the CMR, you will receive a written summary of the discussion via mail. This summary will contain a Medication Action Plan (MAP) with recommendations on how to make the best use of your medications; it also includes adequate space for you to take notes or jot down any follow-up questions.
- You will also receive a Personal Medication List (PML), which will include all the medications you’re currently taking and why you take them.
- In addition to the CMR, Targeted Medication Reviews (TMR) are conducted throughout the year. During a TMR, all MTM program members qualifying for the TMR will have a TMR performed through member (mail) and/or prescriber outreach (fax).
If eligible, it’s a good idea to schedule your medication review prior to your annual “Wellness” visit so that you can discuss your Medication Action Plan (MAP) and Personal Medication List (PML) with your physician. Bring your MAP and PML to your next Wellness visit or any discussions with your doctors, pharmacists, or healthcare providers.
If you qualify for the MTM program, we will automatically enroll you and send you information about the program. However, should you decide not to participate, please notify us, and we will withdraw you from the program.
The Doctors HealthCare Plans, Inc., Medication Therapy Management Program is not considered a benefit.
If you received written notification about MTM qualification, and would like additional information regarding the MTM Program, MedImpact, on behalf of Doctors HealthCare Plans, will transfer you to the Medication Management Center at 1-844-866-3735. Hours of operation are Monday-Friday 10:00am – 8:00pm Eastern Standard Time (EST). TTY/TDD users should call 800-367-8939.
Drug Management Program
Prescription opioid pain medications—like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine—can help treat pain after surgery or after an injury, but they carry serious risks, like addiction, overdose, and death. These risks increase the higher the dose you take, or the longer you use these pain medications, even if you take them as prescribed. Your risks also increase if you take certain other medications, like benzodiazepines (commonly used for anxiety and sleep), or get opioids from multiple doctors and pharmacies. Doctors HealthCare Plans is dedicated to helping you use prescription opioid pain medications more safely.
Doctors HealthCare Plans, Inc. offers a drug management program (DMP) to help members who are at risk for prescription drug abuse to safely manage these pain medications. If you get opioids from multiple doctors or pharmacies, we may talk with your doctors to verify the safe utilization of these medications. After consulting with your doctors if it is concluded that your use of prescription opioids and/or benzodiazepines is not appropriate, we (with the consent of your doctors) may limit your coverage of these medications under the DMP by limiting the amount of medication dispensed, by limiting prescribing to a specific prescriber(s), and/or by limiting dispensing of these medication to a specific pharmacy(ies) to better coordinate your health care.
Before Doctors HealthCare Plans places you in our DMP, we will notify you by letter. You will be able to tell the plan which doctor(s) or pharmacy(ies) you prefer to use to get your prescription opioids and/or benzodiazepines, and about any other information you think is important for the plan to know. After you’ve had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you anther letter confirming our conclusion. You and your prescriber can appeal if you disagree with our decision or think we made a mistake.
Note: The safety reviews and Drug Management Programs generally won’t apply to you if you have cancer, get hospice, palliative, or end-of-life care, if you live in a long-term care facility or if you have sickle cell disease.
For more information regarding the DMP Program, please call 833-342-7463 (TTY: 711) 7 days a week 8 a.m. to 8 p.m.
Last Updated: 11/04/2022