Ohio Medicare AssuredSM Pharmacy
Look up a Drug in the Medicare AssuredSM Formulary
Prior Authorizations Requirements
Frequenlty Asked Questions
What is the Gateway Health Plan Medicare AssuredSM Formulary?
Can the Formulary change?
How do I use the Formulary?
How much will I pay for Gateway Health Plan Medicare AssuredSM Covered Drugs?
Are there any drugs that are excluded from coverage?
Are there any other restrictions on coverage?
What if my drug is not on the Formulary?
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
How do I request an exception to the Gateway Health Plan Medicare AssuredSM Formulary?
What if my request for exception is denied?
Are my Part D drugs covered if I go to an out-of-network pharmacy?
What are generic drugs?
How many Pharmacies are in the Network?
For more information...
What is the Gateway Health Plan Medicare AssuredSM Formulary? TOP A formulary is a list of FDA-approved drugs selected by Gateway Health Plan Medicare AssuredSM in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Gateway Health Plan® Medicare AssuredSM will generally cover the drugs listed iin our formulary as long as the drug is medically necessary, the prescription is filled at a Gateway Health Plan Medicare AssuredSM network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage
Can the Formulary change? TOP
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. To get updated information about the drugs covered by Gateway Health Plan Medicare AssuredSM, please visit our Website at www.gatewayhealthplan.com or call Member Services at 1-800-685-5209 for Pennsylvania, 1-888-447-4505 for Ohio, 8:00 am - 8:00 pm, 7 days a week. TTY/TDD users should call 800-654-5988.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we notify members who take the drug that it will be removed at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug.
If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
How do I use the Formulary? TOP
There are two ways to find your drug within the online formulary:
- Medical Condition
The drugs in the formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, "Cardiovascular Agents." If you know what your drug is used for, click on the dropdown list labeled "Filter by Therapeutic Category" and select the appropriate category.
- Drug Name
Type the name of the drug in the "Search" box and click the "Search" button. If you are unsure of the spelling, you can try entering the first few characters of the drug name and the formulary will search for drugs (either brand name or generic name depending upon filter selected) that contain those letters. For example, if you are seaching for Amoxil, you can enter just "amo" and click "Search". The formulary will return all drug names containing the letters amo.
How much will I pay for Gateway Health Plan Medicare AssuredSM Covered Drugs? TOP
Before your total yearly drug costs reach $2,510:
- There is no co-payment for generic prescription drugs.
- You pay $3.10 or $5.60 (depending on your level of extra help) for each brand name prescription drug.
During the Coverage Gap (after your total yearly drug costs reach $2,510, but before they reach $5,726.25):
- You will pay $1.05 or $2.25 (depending on your income level) for each covered generic drug.
- You will pay $3.10 or $5.60 (depending on your income level) for each covered brand drug.
After you total yearly drug costs reach $5,726.25 you pay nothing for your prescription drug.
To learn more about what your costs will be, contact the Plan for more information.
Please Note: Gateway Health Plan Medicare AssuredSM places limits on the amount of medication you can receive from the pharmacy at any one time. If you fill your prescription at an in-network retail pharmacy, you can receive up to a 30-day supply of the drug at a time.
Are there any drugs that are excluded from coverage? TOP
Non-covered drugs include the following categories:
- Drugs when used for treatment of anorexia, weight loss, or weight gain
- Drugs when used to promote fertility
- Drugs when used for cosmetic purposes or to promote hair growth
- Non-prescription drugs (or over-the counter drugs)
- Drugs when used for the symptomatic relief of cough or colds
- Medications that are lost, stolen, or destroyed
- Benzodiazepines
- Barbiturates
- Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
Are there any other restrictions on coverage? TOP
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: Gateway Health Plan Medicare AssuredSM requires you or your physician to get prior authorization for certain drugs This means that you will need to get approval from Gateway Health Plan Medicare AssuredSM before you fill your prescriptions. If you don't get approval, Gateway Health Plan Medicare AssuredSM may not cover the drug.
- Quantity Limits: For certain drugs, Gateway Health Plan Medicare AssuredSM limits the amount of the drug that Gateway Health Plan Medicare AssuredSM will cover. For example, Gateway Health Plan Medicare AssuredSM provides coverage for 60 tablets every 30 days for oxycodone extended release tablets. This may be in addition to a standard one-month supply.
- Step Therapy: In some cases, Gateway Health Plan Medicare AssuredSM requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Gateway Health Plan Medicare AssuredSM may not cover drug B unless you try Drug A first. If Drug A does not work for you, Gateway Health Plan Medicare AssuredSM will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the online formulary.
You can ask Gateway Health Plan Medicare AssuredSM to make an exception to these restrictions or limits. See "How do I request an exception to the Gateway Health Plan Medicare AssuredSM formulary?," for information about how to request an exception.
What if my drug is not on the formulary? TOP
If your drug is not included in this formulary, you should first contact Member Services and ask if your drug is covered. If you learn that Gateway Health Plan Medicare AssuredSM does not cover your drug, you have two options:
- You can ask Member Services for a list of similar drugs that are covered by Gateway Health Plan Medicare AssuredSM. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Gateway Health Plan Medicare AssuredSM.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception? TOP
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. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
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.
If you experience a level of care change (i.e. are admitted to a long-term care facility or discharged from a long-term care facility to home) you will also be able to obtain a 31-day emergency supply of your medication (unless you have a prescription for fewer days) until you can switch to another drug that is covered by us or you pursue a formulary exception.
How do I request an exception to the Gateway Health Plan Medicare AssuredSM formulary? TOP
You can ask Gateway Health Plan Medicare AssuredSM to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Gateway Health Plan Medicare AssuredSM limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
Generally, Gateway Health Plan Medicare AssuredSM will only approve your request for an exception if the alternative drugs included on the plan's formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception a statement from your physician supporting your request must be submitted. Generally, we must make our decision within 72 hours of your request. Your physician must complete the Nonformulary Drug Exception Form.
What if my request for exception is denied? TOP
You have the right to request a Reconsideration (redetermination) of this denial. To do this, you may call Gateway Health Plan® at 1-888-447-4505 to file your request by phone or use the Request for Medicare Prescription Drug Coverage Determination Form to file your request. If you wish to have someone else make this request for you, you must include a completed Gateway Health Plan Medicare AssuredSM Appointment of Representative Form to give this person permission.
If you wish to send us your request in writing, you may fax it to us at 412-255-4503. You may hand deliver or mail your request to this address:
Gateway Health Plan®
Attention: Medicare Complaints Administrator
U. S. Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704
You may also wish to refer to the Gateway Health Plan Medicare AssuredSM Evidence of Coverage Section 9 and Section 10 for further details about the reconsideration process and further appeal options.
Are my Part D drugs covered if I go to an out-of-network pharmacy? TOP
Covered Part D drugs are available at out-of-network pharmacies in special circumstances, including beneficiary's illness while traveling outside of the Plan's service area where there is no network pharmacy.
Please refer to the Gateway Health PlanMedicare AssuredSM Evidence of Coverage or Provider Directory for details on Out-of-Network coverage.
What are generic drugs? TOP
Gateway Health Plan Medicare AssuredSM covers both brand-name drugs and generic drugs. A generic drug has the same active-ingredient formula as the brand name drug. Generic drugs usually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).
How many Pharmacies are in the Network? TOP
Gateway has over 2300 pharmacies in its Medicare AssuredSM network. Gateway has contracts with pharmacies that equal or exceed Centers for Medicare and Medicaid Services (CMS) requirements for pharmacies in your area. Get a listing of pharmacies in your area.
For more information TOP
For more detailed information about your Gateway Health Plan Medicare AssuredSM prescription drug coverage, please review your Evidence of Coverage document and other plan materials.
If you have questions about Gateway Health Plan Medicare AssuredSM, please call Member Services at 1-800-685-5209 for Pennsylvania, 1-888-447-4505 for Ohio, 8:00 am - 8:00pm, 7 days a week, TTY/TDD users should call 800-654-5988, or consult our Medicare AssuredSM Online Formulary.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048 or visit http://www.medicare.gov.
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