Frequently Asked Questions

What is the Gateway Health Plan Medicare Assured^® HMO SNP Formulary?

Can the Formulary change?

How do I use the Formulary?

How much will I pay for Gateway Health Plan Medicare Assured^® 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 Assured^® Formulary?

What if my request for exception is denied?

How much will I pay towards a Part D drug deductible on Gateway Health Plan Medicare Assured^®

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...

A formulary is a list of covered drugs selected by Gateway Health Plan Medicare Assured® 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 Assured® will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Gateway Health Plan Medicare Assured® network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

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. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before 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 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. To get updated information about the drugs covered by Gateway Health Plan Medicare Assured®, please visit our Web site at www.GatewayHealthPlan.com/Medicare or call Member Services at 1-800-685-5209, 8:00am - 8:00pm, 7 days a week. TTY/TDD users should call 711.

How do I use the Formulary? TOP

There are two ways to find your drug within the online formulary:

1. 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.
2. 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 Assured^® HMO SNP Covered Drugs? TOP

Are there any drugs that are excluded from coverage?  TOP

Here are three general rules about drugs that Medicare drug Plans will not cover under Part D:

• Our Plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.
• Our Plan cannot cover a drug purchased outside the United States and its territories.
• Our Plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.

     o Generally, coverage for “off-label use” is allowed only when the use is supported by certain reference books. These reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor. If the use is not supported by any of these reference books, then our Plan cannot cover its “off-label use.”

Also, by law, the categories of drugs listed below are not covered by Medicare. However, some of these drugs may be covered for you under your Medicaid drug coverage To find out which drugs are covered under Medicaid please call 1-866-542-3015.

• Non-prescription drugs (also called over-the-counter drugs)
• Drugs when used to promote fertility
• Drugs when used for cosmetic purposes or to promote hair growth
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
• Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
• Drugs when used for treatment of anorexia, weight loss, or weight gain
• Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
• Barbiturates and Benzodiazepines

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 Assured^® 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 Assured® before you fill your prescriptions. If you don’t get approval, Gateway Health Plan Medicare Assured® may not cover the drug.

• Quantity Limits: For certain drugs, Gateway Health Plan Medicare Assured^® limits the amount of the drug that Gateway Health Plan Medicare Assured® will cover. For example, Gateway Health Plan Medicare Assured® provides 30 per prescription for Lisinopril 10mg tablets. This may be in addition to a standard one month or three month supply.

• Step Therapy: In some cases, Gateway Health Plan Medicare Assured^® 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 Assured® may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Gateway Health Plan Medicare Assured® will then cover Drug B.

You can ask Gateway Health Plan Medicare Assured^® HMO SNP to make an exception to these restrictions or limits. See "How do I request an exception to the Gateway Health Plan Medicare Assured^® HMO SNP 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 Assured^®  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 Assured^®. 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 Assured^® .

• You can ask Gateway Health Plan Medicare Assured^®  to make an exception and cover your drug. See "How do I request an exception to the Gateway Health Plan Medicare Assured^® HMO SNP formulary?"

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 allow you to refill your prescription until we have provided you with a 93 day transition supply, consistent with the dispensing increment, (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. eption.

How do I request an exception to the Gateway Health Plan Medicare Assured^® HMO SNP formulary? TOP

You can ask Gateway Health Plan Medicare Assured^® to make an exception to our coverage rules. To contact us please call 1-800-685-5209 (TTY: 711), 8:00am-8:00pm, 7 days per week.

You can also make a request by secure email.
Click here for instructions on how to login and set up an account to submit a request by email.You may want to print the instruction page.

Please submit the following information to ensure that your request is processed appropriately:

• Member Name
• Member ID Number
• Member DOB
• Prescriber Name
• Prescriber Phone Number
• Prescriber Fax Number
• Drug Name
• Drug Dose
• Drug Frequency

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 Assured^®  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 Assured^® 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 you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. 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 Medicare Assured^®  at 1-800-685-5209 to file your request by phone or use the Request for Medicare Prescription Drug Coverage Determination Form  to file your request. Your doctor may also make this request for you. If you wish to have someone else make this request for you, you must include a completed Gateway Health Plan Medicare Assured^® 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 Assured^®  Evidence of Coverage  for further details about the reconsideration process and further appeal options.

How much will I pay towards a Part D drug deductible on Gateway Health Plan Medicare Assured^® TOP

The Part D drug deductible is $320 in 2012. Members with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could help pay for drug costs including Part D drug deductible.

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
• Your State Medical Assistance Office.

Are my Part D drugs covered if I go to an out-of-network pharmacy? TOP

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our Plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, have the out-of-network pharmacy call the Gateway Health Plan Medicare Assured® Pharmacy Services Department at 1-800-685-5215 to obtain an out-of-network pharmacy override.
• 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. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time by having your physician call into the Gateway Health Plan Medicare Assured® Pharmacy Services Department at 1-800-685-5215 to request a vacation supply.
• If you are traveling within the United States, but outside of the Plan’s service area, and you become ill, or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. In this situation, have the out-of-network pharmacy call the Gateway Health Plan Medicare Assured® Pharmacy Services Department at 1-800-685-5215 to request an out-of-network pharmacy override.

In these situations, please check first with Member Services to see if there is a network pharmacy nearby.

There are other times you can get your prescription covered if you go to an out-of-network pharmacy. Have the out-of-network pharmacy call the Gateway Health Plan Medicare Assured® Pharmacy Services Department at 1-800-685-5215 to request an out-of-network pharmacy override. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

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

What are generic drugs? TOP

Gateway Health Plan Medicare Assured^® covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

How many Pharmacies are in the Network? TOP

Gateway has over 3000 pharmacies in its Medicare Assured^® HMO SNP 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 Assured^® HMO SNP prescription drug coverage, please review your Evidence of Coverage  document and other plan materials.

If you have questions about Gateway Health Plan Medicare Assured^®, please call Member Services at 1-800-685-5209, 8 am - 8 pm, 7 days a week, TTY/TDD users should call 711, or consult our Medicare Assured^® HMO SNP 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 www.medicare.gov

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