A comprehensive formulary (sometimes called a “Drug List) is a list of all covered drugs selected by Gateway Health 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. Our Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Plan network pharmacy, and other Plan rules are followed. Gateway Health 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. For more information on how to fill your prescriptions, please review your Evidence of Coverage or contact Member Services by using the phone number on your ID card.
Generally, if you are taking a drug on the Drug List 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.
By Medical Condition The drugs on 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 Drugs”. If you know what your drug is used for, click on the link under the “Therapeutic Class Search" menu and select the appropriate category.
OR
By 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 searching for Amoxil, you can enter just "amo" and click "Search". The formulary will return all drug names containing the letters "amo".
To see if you qualify for getting extra help, call:
1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days 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.
Here are the 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.
- 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 (AHFS-DI), the Micromedex DrugDex, and (for anti-cancer chemotherapy drugs only) Clinical Pharmacology and the National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium. 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.
- Non-prescription drugs (also called over-the-counter drugs)
- Drugs when used to promote fertility
- Drugs when used for the relief of cough or cold symptoms
- 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
These requirements and limits may include:
Prior Authorization: Gateway Health 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 before you fill your prescriptions. If you don’t get approval, Gateway Health Medicare AssuredSM may not cover the drug.
Quantity Limits: For certain drugs, Gateway Health Medicare Assured limits the amount of the drug that you can have. For example, Gateway might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
Step Therapy: In some cases, Gateway Health 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 may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Gateway Health Medicare Assured will then cover Drug B.
You can ask Gateway Health Medicare Assured to make an exception to these restrictions or limits. "How do I request an exception to the Gateway Health Medicare Assured formulary?"
If your drug is not included on this formulary, you should first contact Customer Services and ask if your drug is covered. If you learn that Gateway Health Medicare Assured does not cover your drug, you have two options:
You can ask Customer Services for a list of similar drugs that are covered by Gateway Health 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.
You can ask Gateway Health Medicare Assured to make an exception and cover your drug. "How do I request an exception to the Gateway Health Medicare Assured formulary?"
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 supply of the drug during the following situations described below:
• For those members who were in the Plan last year and aren’t in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year if your claims history shows you were previously on the drug and Gateway made formulary changes from the previous year that negatively impacted you. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days.
• For those members who were in the Plan last year and are in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year if your claims history shows you were previously on the drug and Gateway made formulary changes from the previous year that negatively impacted you. We will cover a 91-98 days’ supply, or less if your prescription is written for fewer days.
• For those members who are new to the Plan and aren’t in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the Plan. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days.
• For those members who are new to the Plan and reside in a long-term care facility: We will cover a 91 to 98 day supply consistent with the dispensing increment (unless the prescription is written for less), with refills provided if needed during the first 90 days of a beneficiary’s enrollment in the plan, beginning on the enrollee’s effective date of coverage,
• For those members who have been in the Plan for more than 90 days and reside in a long-term care facility and need a supply right away: We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
You can ask us to make an exception and cover your drug. You, your doctor or someone who is your representative can request that we make an exception to our usual formulary rules. For more information or questions on how to use the formulary exception process or to request a formulary exception, please contact Member Services by using the phone number on your ID card or
click here
You have the right to request Reconsideration (redetermination) of this denial. To file your request by phone 8:00 AM - 8:00 PM Eastern Time 7 Days a week from October 1 through March 31.
* From April 1 through September 30 our business hours are 8 a.m. - 8 p.m., Monday through Friday.
Pennsylvania Residents: Call 1-800-685-5209
Ohio Residents: Call 1-888-447-4505
North Carolina Residents: Call 1-855-847-6430
TTY users should call 711
Or you can use the Part D Standard Redetermination Form.
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 Medicare AssuredSM Appointment of Representative Form (pdf) 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 can mail your request to this address:
Gateway Health
Attention: Appeals &Grievance
P.O. Box 22278
Pittsburgh, PA 15222-1222
You may also wish to refer to your Evidence of Coverage for further details about the reconsideration process and further appeal options.
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 Medicare Assured Pharmacy Services Department at the following numbers to obtain an out-of-network pharmacy override:
In Pennsylvania: Call 1-800-685-5209
In Ohio: Call 1-888-447-4505
In North Carolina: Call 1-855-847-6430
8:00 AM - 8:00 PM Eastern Time 7 Days a week from October 1 through March 31. * From April 1 through September 30 our business hours are 8 a.m. - 8 p.m., Monday through Friday.
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 Medicare Assured Pharmacy Services Department at the following numbers to request a vacation supply:
In Pennsylvania: Call 1-800-685-5209
In Ohio: Call 1-888-447-4505
In North Carolina: Call 1-855-847-6430
8:00 AM - 8:00 PM Eastern Time 7 Days a week from October 1 through March 31. * From April 1 through September 30 our business hours are 8 a.m. - 8 p.m., Monday through Friday.
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 Medicare AssuredSM Pharmacy Services Department at the following numbers to request an out-of-network pharmacy override:
In Pennsylvania: Call 1-800-685-5209
In Ohio: Call 1-888-447-4505
In North Carolina: Call 1-855-847-6430
8:00 AM - 8:00 PM Eastern Time 7 Days a week from October 1 through March 31. * From April 1 through September 30 our business hours are 8 a.m. - 8 p.m., Monday through Friday.
In these situations, please check first with Customer Services to see if there is a network pharmacy nearby by using the number on your ID card.
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 Medicare Assured Pharmacy Services Department at the following numbers to request an out-of-network pharmacy override**:
In Pennsylvania: Call 1-800-685-5209
In Ohio: Call 1-888-447-4505
In North Carolina: Call 1-855-847-6430
8:00 AM - 8:00 PM Eastern Time 7 Days a week from October 1 through March 31. * From April 1 through September 30 our business hours are 8 a.m. - 8 p.m., Monday through Friday.
**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).
Gateway Health 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.
Gateway Health Medicare AssuredSM has over 3,000 pharmacies in its network. Gateway has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid Services (CMS) requirements for pharmacies in your area. Get a listing of pharmacies in your area.
The rules for coverage of a vaccine are complicated. You may want to call us at the number listed on the back of your card before you get a vaccination. In general, here are the coverage rules:
Situation 1:
You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.)
• You will have to pay the pharmacy the amount of your co-payment for the vaccine itself.
• Our Plan will pay for the cost of giving you the vaccination shot.
Situation 2:
You get the Part D vaccination at your doctor’s office.
When you get the vaccination, you will pay for the entire cost of the vaccine and its administration.
You can then ask our Plan to pay you back for our share of the cost by using the procedures that are described in Chapter 7 of your Evidence of Coverage booklet.
You will be reimbursed the amount you paid less your normal co-payment for the vaccine (including administration).
Situation 3:
You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccination shot.
You will have to pay the pharmacy the amount of your co-payment for the vaccine itself.
When your doctor gives you the vaccination shot, you will pay the entire cost for this service. You can then ask our Plan to pay you back for our share of the cost by using the procedures described in Chapter 7 of your Evidence of Coverage booklet.
You will be reimbursed the amount charged by the doctor for administering the vaccine.
Your TrOOP (True-Out-Of-Pocket) status, including your total drug spend towards your coverage gap (donut hole) can be found on your most recent explanation of benefits (EOB). If you are unable to locate your most recent EOB or have additional questions about this amount, please call the number listed on the back of your card.
For more information
For more detailed information about your Gateway Health Medicare Assured prescription drug coverage, please review your Evidence of Coverage document and other plan materials.
If you have questions about Gateway Health Medicare Assured, please call Customer Services, 8:00 AM - 8:00 PM Eastern Time 7 Days a week from October 1 through March 31. * From April 1 through September 30 our business hours are 8 a.m. - 8 p.m., Monday through Friday.
In Pennsylvania: Call 1-800-685-5209
In Ohio: Call 1-888-447-4505
In North Carolina: Call 1-855-847-6430
TTY users should call 711
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.