Prescription Drug Benefit
Prescription Drug Benefit
West Virginia Senior Advantage (HMO I-SNP) provides Medicare Part D prescription drug coverage through its partner, ElixirOptions.
ElixirOptions is a healthcare and pharmacy benefit management (PBM) company headquartered in Twinsburg, Ohio.
We have over 1500 employees supporting a rapidly growing membership base of over 21 million members, creating savings for them as well as thousands of plan sponsors. Rite Aid’s acquisition of Elixir in 2015 brings together two national healthcare companies that give consumers more pharmacy options, and plan sponsors improved manufacturer relationships and analytic capabilities.
For your convenience, there is a complete list of all covered drugs in the plan (a comprehensive formulary). Our Online Formulary lists the Part D drugs covered by West Virginia Senior Advantage. Our formulary is designed to cover the drugs most needed to treat the special needs of our members.
If the drug you are taking is not on the list of covered drugs, read your Prescription Drug Transition Policy and Evidence of Coverage to find out what you can do. This includes instructions for both new and current members.
If you would like help managing your prescription drugs, read about our Medication Therapy Management program and its eligibility requirements.
Need to find a participating pharmacy near you? Click here to search our Pharmacy Directory.
West Virginia Senior Advantage Plan Rating (Part D only). The Star Ratings Program is based off of CMS’ Quality Strategy of optimizing health outcomes by improving quality and transforming the health care system. View our Star Rating.
Member Part D Prescription Drug Benefits
Below is a brief summary of benefits. For a complete list of benefits and other resources, please review your Evidence of Coverage.
How much do I pay?
For Part B drugs such as chemotherapy drugs: 20% of the cost Other Part B drugs: 20% of the cost
After you pay your yearly deductible, you pay 25% of the cost for all drugs covered by this plan until your total yearly drug costs reach $4,130. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies.
If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130.
After you enter the coverage gap, you will pay no more than 25% coinsurance for generic drugs or 25% coinsurance for brand name drugs, for any drug tier during the coverage gap.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the greater of:
- 5% of the co insurance, or
- $3.70 copay for generic (including brand drugs treated as generic) and a $9.20 copayment for all other drugs.
If you have questions or want to request additional information , please call Member Services at 1-833-665-5423. TTY users should call 711. Live representatives are available 24 hours a day, 7 days a week.
How to Request a Coverage Determination
A coverage determination is decision made by our plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it.
If a drug is not covered on our plan, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.
A coverage determination may be requested by any of the following:
- You or your representative may request a coverage determination.
- Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.
A coverage determination may be requested for any of the following:
- Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary).
- You may ask our plan for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your drug plan’s list of covered drugs.
- You may ask for an exception if your network pharmacy can’t fill a prescription as written.
- Removing a restriction on the plan’s coverage for a covered drug.
- You may ask for an exception if you or your prescriber believe that a coverage rule (such as a prior authorization) should be waived.
- Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception)
- You may ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believe you can’t take any of the lower tier drugs for the same condition.
- Request for payment.
- You may ask us to pay for a prescription that you already paid for.
Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescriber when you ask for the exception.
Our plan can accept or deny your request.
If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. If your health requires a quick response, you must ask us to make a “fast decision”.
Prescription Utilization Management Step Therapy and Prior Authorization Criteria
West Virginia Senior Advantage Health Plan members can find Part D prescription Step Therapy and Prior Authorization Criteria by clicking on the Online Drug List under the Prescription Drug Benefit topics or at the Online Drug List Link below: