About Alterwood Advantage's Medicare Part D Prescription Coverage
What does Alterwood Advantage offer?
Alterwood Advantage has five (5) plans that offer prescription drug benefits. These plans are:
- Alterwood Advantage Select (HMO)
- Alterwood Advantage Choice (HMO)
- Alterwood Advantage Choice Plus (HMO)
- Alterwood Advantage Dual Secure (HMO D-SNP)
- Alterwood Advantage Dual Value (HMO D-SNP)
These plans are Medicare Advantage plus Prescription Drug plans that include medical coverage for medical services such as hospital expenses, doctor visits, and prescription drug coverage.
What drugs are covered?
Each plan has a formulary, which is a CMS approved list of medications covered by Alterwood Advantage. The formulary drugs covered are similar from plan to plan, but your out-of-pocket copay or coinsurance for a prescription will vary.
All formularies offer you and your doctor a variety of choices to treat your condition. You may view or download a copy of the formularies we offer by selecting the links below. In addition, you may search for your drug(s).
Some drugs on our formularies are subject to a coverage determination (also known as prior authorization), step-therapy, and or quantity limits. These are utilization management tools we use to ensure appropriate and medically necessary use of these drugs. More information about these utilization management tools can be found here.
When transitioning into our plan, you may be on drug(s) that are not on the Alterwood Advantage formulary. We have made arrangements with the network pharmacies to provide you a transition supply that will allow you to contact your prescriber(s) to transitioning you to similar drug(s) on our formulary that treats your condition(s). More information regarding our Transition Policy can be found here.
Member Pharmacy Benefit Tool
A portal where Alterwood Advantage members can register to look-up complete, accurate, timely, clinically appropriate, formulary and benefit information. This includes cost sharing amounts, alternative formulary medications that may be used for the same health condition as a given drug, and coverage restrictions (Prior Authorization, Step Therapy, Quantity Limits) that apply to alternative medications. You will need to register an account with Elixir.
What is Extra Help?
If you have limited income and resources, you may qualify for Extra Help to pay for your prescription drugs. You may apply or get more information by calling your local Social Security Administration (SSA) office or call 1-800-772-1213 (TTY 1-800-325-0778 using specialty TTY equipment) between 8:00 AM and 7:00 PM Monday through Friday or visiting the Social Security Administration website. You may find the phone number to your local SSA office by using their Social Security Office Locator. SSA also has a variety of online services.
Does my plan cover other items such as OTC?
Over-the-counter (OTC) drugs and products are not covered under the Part D benefit. However, you may be enrolled in a plan that covers OTC drugs and products through a supplemental benefit. More information about the OTC supplemental benefit can be found here.
Does my plan cover other items such as insulin, diabetic supplies, vaccines, and other Part B drugs?
Your copay/coinsurance for insulin, vaccines, and other Part B drugs will improve in 2023 as a result of the Inflation Reduction Act of 2022. The goal of this Act is to lower the amount you pay for your healthcare over the next few years and included in the information below.
Insulin is covered under your Part D (prescription drug) and Part C (medical) benefits depending on how it is administered.
Diabetic supplies and certain vaccines are covered under your Part C benefit and are not covered under your Part D benefit. For your convenience and greater access, Alterwood Advantage allows certain diabetic supplies and Part B vaccines to be available at network pharmacies. Note: Please contact your network pharmacy to determine if they have these diabetic supplies in-stock and/or they have qualified pharmacist(s) to administer vaccinations. More information is provided in your EOC.
Insulin
Starting January 1, 2023, insulins on our formulary that you administer to yourself are covered under Part D at no more than $35 for up to a month supply no matter what cost-sharing tier it’s on, even when you have not met your deductible.
Starting July 1, 2023, insulin administered through a durable medical equipment (DME) such as an insulin pump will also be no more than $35 for up to a month supply. Refer to your Evidence of Coverage (EOC) for more information about your current 2023 coinsurance for insulin administered through a DME.
Diabetic Supplies
Alterwood Advantage covers certain Abbott and LifeScan diabetic supplies such as blood glucose monitors, blood glucose test strips, and lancets at network pharmacies with a valid prescription at a lower cost to you. Quantity limits are defined by CMS and more details can be found in your EOC.
Alterwood Advantage covers other manufacturers of diabetic supplies at network pharmacies at a higher copay/coinsurance. Various brands of diabetic supplies may also be available at network DME providers with a valid provider order.
Vaccines
Coverage of vaccines vary depending on the vaccine, what it is being used for, and where you get the vaccine.
The following Part D vaccines are available at certain network pharmacies and covered by Alterwood Advantage at $0 effective January 1, 2023:
- Shingles
- Human papillomavirus (HPV)
- Measles, mumps, rubella (MMR)
- Diphtheria
- Pertussis
Part D vaccinations do not have a cost-share when recommended by the U.S. Advisory Committee on Immunization Practices (ACIP). If you get a Part D vaccine at your doctor’s office, your cost-share can vary, and you will need to submit for a receipt for reimbursement to Elixir. More information can be found in your EOC.
The following Part B (medical) vaccines are also available at certain network pharmacies and covered by Alterwood Advantage:
- Influenza (flu shot)
- Pneumococcal pneumonia
- Hepatitis B*
*Subject to a coverage review to determine Part B or Part D coverage.
These Part B preventive vaccinations do not have a cost-share. These vaccinations are available at network providers and certain network pharmacies
Other Part B Drugs
Starting April 1, 2023, your coinsurance on certain Part B drugs (usually given by a doctor in an office or at a facility) will range from $0 to 20% of the drug price as defined by CMS. These Part B drugs will also be selected by CMS, because their prices are rising faster than inflation. If you receive a Part B drug over a period of time, you may see your coinsurance adjusted up or down (within $0 to 20% of the drug price) every three months.
Where can I get my prescription(s)?
Alterwood Advantage has a national network of pharmacies. For your convenience, the network pharmacies in Maryland are listed in our Provider & Pharmacy Directory that you can access below. In addition, you may search our pharmacy network in Maryland and out-of-state by selecting Search Pharmacies.
View or Download Provider & Pharmacy Directory
If you wish to obtain your prescription(s) that you take regularly through the mail, we have partnered with Elixir Pharmacy for this service. You would simply place a completed mail order form with your prescription(s) into an envelope and mail it to Elixir Pharmacy, LLC, 7835 Freedom Ave. NW, North Canton, OH 44720.
If you have any questions regarding your mail order prescription(s), call us at 1-866-909-5170 (TTY: 711). Your provider can fax prescriptions to 1-866-909-5171.
What happens if you go to an out-of-network pharmacy?
Alterwood Advantage offers over 60,000 network pharmacies across the country. If you need to get your prescription(s) from a pharmacy not in our network, you may send us a copy of your prescription receipt(s) with a completed Direct Member Reimbursement form.
We will only reimburse you for up to a ten (10) days supply of your out-of-network prescriptions under certain circumstances. These circumstances can be found in your EOC.
What is Medication Therapy Management?
Alterwood Advantage’s Medication Therapy Management Program (MTMP) is available to members who meet certain qualifying parameters. You may find out more about our program by selecting MTMP.
Who do I call if I have any questions regarding my Part D benefit, prescription drugs, and/or pharmacy, including mail order?
You may contact us at 667-261-8050 or 866-267-3144 (TTY: 711). We are available 24 hours a day, 7 days a week.
Various prescription related Part D forms can be found here.