Medicare Resources

• Formulary
  • A formulary is a list of prescription drugs (both generic and brand name) that are preferred by your health plan. Your health plan may only pay for medications that are on this "preferred" list, unless your healthcare provider talks with your health plan and gets prior approval.

  • The symbol (QLL, units/days supply) in the Notes column indicates that quantities dispensed may be limited.  The quantity allowed is  listed following the QLL, symbol and may be read as “units per days supply”.

    For example, on page 8 the drug ZMAX is listed with the symbol (QLL, 1pkg/1).  This means that this drugs availability is limited to a quantity of 1 package per 1 day supply of the drug.  

    If your prescription for any of these medications exceeds the maximum quantity listed,  you and your doctor will need to request a formulary exception.
     

• Some of the prescription drugs on the Healthfirst NJ Medicare Plan formulary have restrictions on when or how they may be accessed. You can look up individual drugs on our formulary and see if any of these restrictions apply. If you prefer, you can look on the lists available below that show all of the drugs on our formulary that require Prior Authorization, Quantity Limits, or Step Therapy.
  
• Our formulary may change during the year.  Look on the formulary’s first page to see the date it was last updated.  If we make a negative change, we will also list it in the section below, Changes to the Healthfirst NJ Medicare Plan Formulary.

• Healthfirst NJ may add or remove drugs from Healthfirst NJ’s Medicare Part D formulary during the year. Before removing drugs from the formulary or adding prior authorization, quantity limits and/or step therapy restrictions on a drug, Healthfirst NJ will notify members of the change via this website at least 60 days before the date that change becomes effective. Exceptions to this would be when the US Food and Drug Administration deems a drug on the formulary to be unsafe or when the drug’s manufacturer removes the drug from the market, in which case Medicare will promptly remove the drug from the Part D formulary.
  
• When changes are made, the notices can be viewed using the link below.

• Healthfirst NJ has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. We have a national network of more than 56,000 pharmacies that work with ESI. There are 1,870 network pharmacies in our service area. To find a pharmacy near you, please visit our Find a Pharmacy Lookup Tool.

We encourage you to use our in-network pharmacies at all times to fill your prescriptions. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. We will cover your prescription at an out-of-network pharmacy only for certain reasons.  For Example:

• If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
  
• If you are trying to fill a covered prescription drug that is not regularly stocked at an in-network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited.

You should talk to your doctor to decide if you should: 

• switch to a drug that we cover, or
• request a formulary exception so that we will cover the drug you currently take.

We may cover your drug in certain cases during the first 90 days you are a member of our plan to give you and your doctor time to discuss other options.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Coverage Determination

When Express Scripts Inc. receives a request for payment or to provide a Part D drug to a member, ESI must determine whether or not the request is necessary and appropriate and what your part of the cost is for the drug. These actions by ESI are known as “coverage determinations”. 

Coverage determinations include exception requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower copay. 

Before you request a drug determination please call express ESI at 1-877-266-1484, 24 hours a day, 7 days a week, TTY/TDD members 1-800-899-2114 and ask if your drug is covered. If you request an exception, your doctor must provide a statement to support your request. Once we receive a statement from your doctor, we must make a coverage determination. We must make coverage determinations and notify the affected member within 72 hours of receiving the request or sooner if their health condition requires more immediate action. If immediate action is necessary, you or your physician can request that we review your situation in 24 hours. 

We accept request for a coverage determination in any format.

You can send your written requests to: 

Express Scripts, Inc.
Attn: Prior Authorization Part D - B7P
Mail Stop B401-03
8640 Evans Road
St. Louis, MO 63134
Fax: 1-877-837-5922

You can also contact Express Scripts by email:

medicarepartdparequests@express-scripts.com

Note: Often ESI will not have all of the information it needs to make a coverage determination. In those cases, an extra two weeks is allowed to gather all necessary supporting documentation.  In addition, if we approve your exception request for a non-formulary drug you cannot request an exception to the copay you must pay for the drug.

For further information, please refer to Chapter 9 of your Evidence of Coverage.

Who May Ask for a Coverage Determination?
You or someone you name to act for you (your appointed representative) may request a coverage determination (including exception). You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at: 1-877-266-1484, 24 hours a day, 7 days a week or TTY/TDD members call 1-800-899-2114 if you need help filling out the form or want to learn more about appointing a representative.

* Coverage Determination Request Form  (English / Spanish)

Appointment of Representative form (English / Spanish)

Grievances
A grievance is a complaint about any problem you had with Healthfirst NJ Medicare Plans or one of our network pharmacies that does not relate to coverage for a prescription drug. Grievances do not relate to payment for or approval of a prescription drug, which are known as coverage determinations. If you (your appointed representative) have a grievance, please call Express Scripts Member Services at 1-866-533-8512 or TTY/TDD members 1-800-889-2114 for the hearing or speech impaired. We will try to resolve any complaint over the phone. 

You may also send your grievance to the following address or by email:

Express Scripts, Inc.,
Attn: Director of Grievances
P.O. Box 66517
St. Louis, Missouri 63166-6517
Fax: 1-800-305-1686

utilizationmgtcoor@express-scripts.com

All grievances will be acknowledged promptly and in writing. The Appeals & Grievances Department will research your issues and respond to you in writing once it has completed its investigation.

Expedited Grievances
If you are complaining about the decision by ESI not to expedite an initial determination or an appeal, you can request an expedited grievance. ESI will respond to you within 24 hours.

Prescription Drug Coverage Appeals
Once ESI notifies you of a coverage determination decision, you may or may not agree with it. You (or your authorized representative) can ask us to reconsider our decision. This is known as filing an appeal. Much like coverage determinations, there is a fast track and routine process for handling appeals. 

The information below explains how these different time frames work.

You have a right to appeal if you think ESI:

• Decided not to cover a drug, vaccine, or other Part D benefit
• Decided not to reimburse you for a Part D drug that you paid for
• Reimburse you less than you feel you should have received
• Ask you to pay a different cost-sharing amount than you think you are required to pay for a prescription
• Denied your exception request
• Made a coverage determination you disagree with.

ESI will consider your appeal thoroughly and promptly. It is important to let ESI know as soon as possible that you wish to file an appeal. We accept request for a redetermination in any format. If you wish to file a regular appeal (also called a "standard appeal"), you may complete a Request for Redetermination of Medicare Prescription Drug Denial Form and send your request in writing within sixty (60) days from the date of the notice of coverage determination from ESI to:

Express Scripts, Inc.,
Pharmacy Appeals - Part D
Mail Route: BL0390
6625 West 78th Street
Bloomington, MN 55439
Fax: 1-877-852-4070

You can also contact Express Scripts by email:

utilizationmgtcoor@express-scripts.com

To request a fast appeal, you may call ESI at
1-800-344-3405, extension 373022 or TTY 1-800-899-2114, 24 hours a day, 7 days a week for the hearing or speech impaired.

If you are concerned about the quality of care you have received, for example, you believe our pharmacist provided you with the incorrect dose of a prescription; you may also file a complaint with Healthcare Quality Strategies, Inc (HQSI), through their hotline at 1-800-624-4557, the State of New Jersey's Quality Improvement Organizations, or QIO, which is a group of doctors and health professionals who monitor the quality of care given to Medicare beneficiaries. The QIO review process is designed to help stop any improper medical practices.

Who May Ask for a Grievance or an Appeal?
You or someone you name to act for you (your appointed representative) may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at: 1-877-266-1484, 24 hours a day, 7 days a week or TTY/TDD members call 1-800-899-2114 if you need help filling out the form or want to learn more about appointing a representative.

Redetermination Request Form (English / Spanish)

Appointment of Representative form (English / Spanish)

Healthfirst NJ Medicare Plan wants to make sure that you are getting the most out of the prescription drugs you use. This program was designed and is managed by licensed pharmacists at ESI to improve the way prescription drugs are used.

Participating in the Healthfirst NJ Medicare Plan MTMP program will help you to:

• Improve the way you use your prescription drugs
• Make sure you get the most out of the prescription drugs you are taking
• Reduce your risk for harmful drug events
• Avoid possible interactions between your prescription drugs

To be eligible you must:

• take many different prescription drugs,
• have certain medical condition(s) like Asthma, Chronic Obstructive Pulmonary Desease (COPD), diabetes, dyslipidemia, heart failure, hypertension, depression or osteoperosis
• have high out-of-pocket costs for your prescription drugs.

We will contact you by mail, if you are eligible to participate in this program. 

If you have any questions about Healthfirst NJ Medication Therapy Management program, you may call Express Scripts 24 hours per day, 7 days per week at 1-877-697-7244. TTY users should call
1-800-899-2114.

When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. When that happens, you may have to pay the full cost of your prescription and then ask us to pay you back using a paper claim.

To submit a paper claim, you must send Express Scripts a copy of the receipt for the prescription drugs from the pharmacy where you bought them and a completed paper claim form. 

Please send your paper claim to the following address: 

Express Scripts, Inc.
P.O. Box 66752
St. Louis, MO 63166-6752
Attn: MED-D Accounts

For more information, please call Express Scripts at 1-877-266-1484 (TTY 1-800-899-2114), 24 hours a day, 7 days a week.

Prescription Claim Form

Federal regulations specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. To address these situations, CMS created the best available evidence (BAE) policy. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.

By clicking the below link, you will leave the Healthfirst NJ web site and be redirected to the Centers for Medicare & Medicaid Services Best Available Evidence page for the Low Income Subsidy.

Best Available Evidence Information