Medicare Medicare

Medicare Prescription Drug Information

Our Medicare Advantage plans are offered with or without a prescription drug benefit.  Click on the Medicare Formulary to see which drugs are covered by the plan. 

 

Click on the Notice of Formulary Change box to see a summary of the month to month formulary changes including additions and deletions.

 

Click on the Extra Help From Medicare box to find our if you may qualify for extra help to pay for your prescription drug costs.

 

The New York State EPIC Program box has a link directly to the NYS Website where you can learn if you qualify for additional help lowering your prescription drug costs.

2016 Medicare Formulary
View the 2016 Medicare Formulary (list of covered drugs)
View 2016 Medicare Formulary
Lista de medicamentos cubiertos (Formulario)


Notice of Medicare Formulary Change

View 2016 Medicare Advantage Formulary Update


Find a Pharmacy
With over 63,000 pharmacies serving our members locally and nationally, our pharmacy network meets the pharmacy access requirements as mandated by the Centers for Medicare and Medicaid Services (CMS).
Find a Pharmacy

Out-of-Network Prescription Drug Coverage
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 two instances when we would cover prescriptions filled at an out-of-network pharmacy.

  • There are no network pharmacies within a reasonable driving distance that provide 24 hour service.
  • You need to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

In situations like these, please check first with Member Services to see if there is a network pharmacy nearby. You can contact us at 1-8000-329-2972, TTY/TDD: 711

Drug Prior Authorization Requirements
2016 Drug Prior Authorization Requirements
View Prior Authorization Requirements


Medicare Pharmacy Quantity Limits
Quantity Limit amounts and days for prescriptions for Medicare Members.
See Medicare Formulary

Step Therapy Guidelines
Instructions for when we require you try certain drugs to treat a medical condition before we will cover another drug for that condition.
2016 Step Therapy Guidelines

 

Medication Therapy Management
Services or programs that optimize therapeutic outcomes for individuals through improved medication use. These programs are not considered a benefit. Please contact customer service for additional information. 
Medication Therapy Management


Extra Help from Medicare

You might qualify to get help in paying for your drugs. "Extra Help" from Medicare, also called the "low-income subsidy" or LIS.
Extra Help from Medicare

 

New York State's EPIC Program
EPIC (Elderly Pharmaceutical Insurance Coverage) is a program offered by New York State that helps seniors pay for prescription drugs. EPIC can help lower Part D drug costs by helping pay for drugs in the coverage gap, as well as providing assistance with Part D premiums, if eligible.
New York State's EPIC Program

Transition Policy

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 at least a 91 day transition supply, consistent with 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 a member submits a prescription for a transition eligible drug and it is rejected at Point of Sale, a message will be relayed to the pharmacist to call for additional instructions if the member underwent a recent level of care change. After confirming the member had a level of care change, the pharmacist will be instructed to enter a series of override codes to allow the member to receive a one-time transition supply of his or her prescription. At that time, all transition supply procedures will apply including member notifications for transition supply fills.


Best Available Evidence
Review this information if you believe you may qualify for 'extra help' with your Medicare Prescription Drug Plan costs, but your plan's system and CMS's systems do not reflect your eligibility for this help. Find out how you may be able to obtain your prescriptions at the correct Low Income Subsidy (LIS) cost sharing level if you can show evidence of your LIS eligibility.
Best Available Evidence

Request for Redetermination of Medicare Part D Prescription Drug Denial

If HealthNow New York Inc. denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
Request for Redetermination Form
Download Paper Form


Coverage Determination Form

A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage Plan.                                                               

Coverage Determination Form
Submit a Request Online

 

 

 

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year.  The Formulary, pharmacy network, and/or provider network may change at any time.  You will receive notice when necessary. You must continue to pay your Medicare Part B Premium.

 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

 

HealthNow New York Inc.  is a Medicare Advantage and stand-alone PDP plan with a Medicare contract. Enrollment in HealthNow New York Inc. depends on contract renewal. 

 

Y0086_MRK1600 Approved 

Content Last Updated January 19, 2016