2025 PrimeTime Health Plan Pharmacy Program

If one of your drugs is not covered in the way you would like it to be covered, you have the right to ask for a “coverage determination.” A coverage determination is when we make a decision about whether a drug is covered by the plan and the amount, if any, you are required to pay for the prescription. When you ask for an exception, your doctor or another prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.

You cannot ask for coverage of any “excluded drugs” or other non-Part D drugs which Medicare does not cover. (For more information about excluded drugs, see Chapter 5 of the Evidence of Coverage.)‍

Here are examples of exceptions that you or your doctor or another prescriber can ask us to make:

1. Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary). Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a “formulary exception.”

2. Removing a restriction on the plan’s coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on the plan’s List of Covered Drugs such as quantity limits. Asking for the removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.”

• If our plan agrees to make an exception and waive a restriction for you, you can ask for an exception to the co-payment or coinsurance amount we require you to pay for the drug.

3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on the plan’s Drug List is in one of 5 cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug. Asking to pay a lower preferred price for a covered non-preferred drug is sometimes called asking for a “tiering exception.”

• For drugs in Tiers 2 and 4, as well as generic drugs included in Tier 3, you may ask us for a tiering exception. If approved, this would lower your share of the cost of the drug.

• You cannot ask us to change the cost-sharing tier for any drug in Tier 5 which is our Specialty Drug tier.

4. Asking the plan to pay our share of the cost of your covered prescription. In certain situations, you may be required to pay the full cost of your medication or may have paid more than you expected to under the coverage rules of your plan. In either case, you may ask our plan to pay you back. Asking for payment is called a coverage determination about payment or “request for reimbursement.”

How to ask for a coverage decision, including an exception

You may ask our plan to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast decision.” You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought.

What to do

• Request the type of coverage decision you want. You, your representative, or your doctor (or another prescriber) can request a coverage determination by calling, emailing, writing, or faxing our plan at the numbers below. This form may be used for formulary and/or tiering exceptions (as described above).

‍Telephone: 330-363-7407 or toll-free 1-800-577-5084 or, for TTY users 711, Monday through Friday, 8:00 a.m. to 8:00 p.m. (October 1st – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.)

Email: PTHPPharmacy@aultcare.com

Fax: 330-580-6764

Mail: P.O. Box 6905, Canton, Ohio 44706

• When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we will answer within 24 hours.

To get a fast decision, you must meet two requirements:

- You can get a fast decision only if you are asking for a drug you have not yet received. (You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought.)

- You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

• If your doctor or other prescriber tells us that your health requires a “fast decision,” we will automatically agree to give you a fast decision.

• If you ask for a fast decision on your own (without your doctor’s or other prescriber’s support), our plan will decide whether your health requires that we give you a fast decision.

- If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter that says so (and we will use the standard deadlines instead).

-This letter will tell you that if your doctor or other prescriber asks for the fast decision, we will automatically give a fast decision. The letter will also tell how you can file a complaint about our decision to give you a standard decision instead of the fast decision you requested. It tells how to file a “fast” complaint, which means you would get our answer to your complaint within 24 hours. (The process for making a complaint is different from the process for coverage decisions and appeals).

Our plan can say yes or no to your request

‍If we approve your request we will provide the coverage we have agreed to within the appropriate time frame. We will also notify you in writing of our decision.

If we deny your request, we will send you a written notice that explains why we said no. If we say no to your coverage request, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

Appointment of Representative Form

If you choose a friend, relative, provider, or other person to be your representative, please complete and return this form. It must be signed by you and the representative acting on your behalf. You must give us a copy of the signed form.

Grievance/Coverage Determination

PrimeTime cares about our member satisfaction. Please contact us (link to contact info above) so we can help. You can also submit a complaint directly to Medicare if you’d like by completing the Medicare Complaint Form.   You can also call 1-800-MEDICARE. The office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. Visit their site here.

Potassium Chloride – AHP - 7/1/2024

Potassium Chloride – Glenmark - 7/10/2024

Clonazepam - Endo - 7/24/24
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MEDICARE PRESCRIPTION PAYMENT PLAN

In 2025, the Medicare Prescription Payment Plan is a new payment option offered by all Medicare Part D plans that may help you manage your out-of-pocket drug costs by spreading them across the calendar year (January – December). This plan is free to join, is voluntary and if you opt in, it allows you to make a monthly payment to PrimeTime Health plan for your prescription drug costs instead of paying at the pharmacy. Each month you’ll pay your plan premium (if you have one) and you’ll get a separate bill for your prescription drugs. You may opt out at any time.

How it works:

If you opt into the Prescription Payment Plan, when you fill a prescription for a Part D covered drug, you won’t pay the pharmacy when you pick up your medication. Instead, you will receive a bill for the amount you would have owed. Even though you won’t pay for your drugs at the pharmacy, you’re still responsible for the costs. The program may help manage your monthly expenses, but it does not save you money or lower your drug costs.

Monthly Billing:

Your monthly bill is based on what you would have paid for any prescriptions you get, plus your previous month’s balance, divided by the number of months left in the year. All plans use the same formula to calculate your monthly payments. (Click on the Fact Sheet to see examples that start on page 6)

In a single calendar year (January – December), you’ll never pay more than:

•  The total amount you would have paid out of pocket to the pharmacy if you weren’t participating in this payment option.
•  The Medicare drug coverage annual out-of-pocket maximum ($2,000 in 2025).

The prescription drug law caps your out-of-pocket drug costs at $2,000 in 2025. This is true for everyone with Medicare drug coverage, even if you don’t participate in the Medicare Prescription Payment Plan.

If you miss a payment, you will receive a reminder to pay your bill. If you don’t pay your bill by the date listed on the reminder, you will be removed from the Medicare Prescription Payment Plan. You are still required to pay the amount you owe, but you won’t pay any interest or fees even if your payment is late.

Will this help me:

Not everyone will benefit from the Prescription Payment Plan.

Here are some reasons why the payment option may not be beneficial for you:

•  You get or are eligible for Extra Help from Medicare (see Fact Sheet page 5).
•  You qualify for a Medicare Savings Program (see Fact Sheet page 5).
•  Your yearly drug costs are low.
•  You don’t want to change how you pay for your drugs.

You’re most likely to benefit from participating in the Medicare Prescription Payment Plan if you have high drug costs earlier in the calendar year. Although you can start participating in this payment option at any time in the year, starting earlier in the year (like before September), gives you more months to spread out your drug costs. To find out if you’re likely to benefit from this payment option, click on the “a decision-support tool” below to be directed to Medicare.gov to answer a few questions.

Low-Income Subsidy (LIS) and the Medicare Prescription Payment Plan:

Recently, the Low-Income Subsidy (LIS) program (also known as Extra Help) expanded the eligibility requirements so that if your income and resources meet the updated threshold, you will be eligible for the full LIS benefit. This subsidy provides fixed copayments for covered prescription drugs. Many people qualify and don’t realize it. You can visit https://www.ssa.gov/medicare/part-d-extra-help to apply and find out if you’re eligible.

If you are eligible for LIS, the payment plan will most likely not be advantageous for you. The fixed copayments are typically lower than the monthly payments. To learn more, visit https://www.medicare.gov/basics/costs/help, or contact your local Social Security office.

How to enroll:

You can sign up for the Prescription Payment Plan by phone, online or mail.

• Call: 1-844-368-8729, TTY 711
• Online:
  •  Prior to 1/1/2025: https://m3p-form.optumrx.com/?cid=pthpm3p
  •  After 1/1/2025: www.optumrx.com (you will either create an account or sign into your existing account)
• Mail: print and complete the below Participation Form and submit to:
  •  Optum Rx, Attn: M3P Election Processes, PO BOX 650287, Dallas, TX 75265-0287

Medicare Prescription Payment Plan Participation Request Form

After your enrollment request is received, you will be notified within 10 days of the status of your participation if you have requested participation prior to the plan year or your new effective date.

If your request is received during the plan year, you will be notified of the status of enrollment within 24 hours after your request is received.

If you believe that waiting 24 hours may seriously jeopardize your life, health, or ability to regain maximum function, you may be eligible to request a retroactive election. You must request this within 72 hours of the date and time your urgent prescription was filled.

Opting out of the program:

You can opt of the Medicare Prescription Payment Plan at any time by contacting us at the phone number listed above or online. This means that you’ll pay the pharmacy directly for new out-of-pocket drug costs. As a reminder, if you still owe a balance, you are required to pay that amount even though you no longer participate in the payment option.

Fact Sheet - PDF

Medicare Information:

The Centers for Medicare & Medicaid Services (CMS) has posted materials and tools to its website to help educate Part D enrollees about the Medicare Prescription Payment Plan (MPPP), and whether they would be likely to benefit from participating in the program. On the beneficiary-focused website, materials are available that Part D enrollees can review that include:

· key questions to consider before deciding to participate in the MPPP

· a decision-support tool to help you determine if participating in the MPPP will help you

· examples of how the MPPP would work in three different situations

· what Part D enrollees can expect after electing to participate in the MPPP

· and an educational video about the MPPP 

If you would like more information on the Medicare Prescription Payment Plan, please contact us at the phone number listed at the top of the website or by clicking on the Contact Us option also at the top of the website page.

PrimeTime cares about our member satisfaction. If you think we made a mistake regarding your Medicare Prescription Payment Plan, please contact us at the phone number listed at the top of this page or by clicking on the Contact Us option so we can help you. You can also submit a complaint directly to Medicare if you’d like by completing the Medicare Complaint Form or by calling 1-800-MEDICARE. The office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. Visit their site here.

PrimeTime Health Plan covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

The Formulary is subject to change during the year. Most of the changes in drug coverage happen at the beginning of each year (January 1); however, the plan may make changes during the year, with CMS approval. In cases of any changes to our formulary including addition of a prior authorization, adding quantity limits, step therapy, making a drug non-formulary and changing cost share due to a tier level change of formulary drugs, PrimeTime Health Plan will send a letter to the members that have been affected by the change.

If one of your drugs is not covered in the way you would like it to be covered, you have the right to ask for a “coverage determination”. A coverage determination is when we make a decision about whether a drug is covered by the plan and the amount, if any, you are required to pay for the prescription.

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. (You cannot ask for coverage of any “excluded drugs” or other non-Part D drugs which Medicare does not cover).

You, your representative, or your doctor (or other prescriber) can request a coverage determination by calling, emailing, writing, or faxing our plan at the numbers below. In addition, you may contact us for the most recent list of covered drugs here.

Telephone: 330-363-7407 or toll-free 1-800-577-5084 (TTY Line: 711) Monday through Friday, 8:00 a.m. to 8:00 p.m. (October 1st – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.)

Email: PTHPPharmacy@aultcare.com

Fax: 330-580-6764

Mail: P.O. Box 6905, Canton, Ohio 44706

For more detailed information, please refer to the “Coverage Determination” link above or the Evidence of Coverage.

2025 Formulary

‍2025 Abridged Formulary- 8/26/2024

• An abridged version of our 2025 Formulary

2025 Comprehensive Formulary - Effective 1/1/2025

• 2025 Complete list of covered drugs Prescription Drug Information (Part D)

2025 Prior Authorization Criteria - Effective 1/1/2025

2025 Step Therapy Criteria - Effective 1/1/2025

Pfizer Patient Assistance Program for COVID-19

If you have been prescribed Paxlovid for COVID-19 treatment you may enroll in
the Patient Assistance Program operated by the drug manufacturer Pfizer. This
will allow you to pay $0 for the medication. For more information please visit:
https://www.paxlovid.com/enroll-in-co-pay-program

To get started with Patient Assistance Program enrollment call 1-877-219-7225 or
visit the PAXCESS Patient Portal to see if you are eligible for enrollment in the
PAXCESS Patient Support Program.

Medication Therapy Management (MTM)

Explore your pharmacy costs with the Optum Cost tool 

Pharmacy Directory - 12/05/2024

If you would like a printed version of the Provider and Pharmacy Directory, please email us at Directory@PrimeTimeHealthPlan.com or Contact Us.

The pharmacy network and/or provider network may change at any time. You will receive notice when necessary.‍

Number of pharmacies and Out of Network plan coverage

PrimeTime Health Plan contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

PrimeTime Health Plan is contracted with over 300 network pharmacies. A network pharmacy is one who has the ability to process your prescription via an electronic submission. While we encourage the use of network pharmacies, you may have benefits at a non-network pharmacy. 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:

• If the prescriptions are related to care for a medical emergency or urgently needed care they will be covered. In this situation you will have to pay the full cost (rather than paying just the co-payment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary, and reasonable (UCR) or the contracted rate, whichever is less. Any amount you pay over the UCR will be applied to your TrOOP (True Out Of Pocket cost). Please refer to the paper claims process described below.

• If you are traveling within the United States, but outside 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 (rather than paying just the co-payment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary, and reasonable (UCR) or the contracted rate, whichever is less. Any amount you pay over the UCR will be applied to your TrOOP.

• If you are unable to get a covered drug in a timely manner within our service area because there is not a network pharmacy within a reasonable driving distance which provides 24 hour service.

• If you are trying to fill a covered prescription that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or specialty pharmaceuticals).

• Self-administered medications that you receive in an outpatient setting may be covered under Part D. For consideration, please submit a paper claim.

In these situations, please check first with Member Services to see if there is a network pharmacy nearby. The pharmacy directory does not include all contracted pharmacies. Please contact PrimeTime Health Plan member services at 330-363-7407 or 1-800-577-5084 (TTY users should call 711) with any questions regarding your pharmacy benefits. A customer service representative is available to assist you Monday through Friday from 8 a.m. to 8 p.m. (October 1 – March 31, we are available 7 days a week, 8 a.m. to 8 p.m.).

Last updated: 09/6/2024

PrimeTime Health Plan's Pharmacy Program provides you with a variety of prescription choices to meet your medication needs. Talk to your doctor about which prescriptions will work best for you. Generic medications, with the lowest co-payments, can be affordable alternatives that have met multiple quality and safety standards set by the FDA. You and your doctor can discuss which medication options are best for you. The PrimeTime Health Plan formulary can be accessed online at this site.  If you would like a copy of the formulary, you may call the PrimeTime Service Center (numbers and hours are listed below).

Quality Assurance Policies and Procedures

PrimeTime Health Plan’s Part D Quality Assurance Program has policies and procedures including medication therapy management and drug utilization programs to prevent over and under utilization of prescribed medications to ensure measurements for medication error, reduction of drug interactions and promote member safety.

Utilization Management maintains methods to ensure cost-effective drug utilization management. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of these utilization tools include:

• Prior Authorization: We require you to get prior authorization for certain drugs.

• Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.

• Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition.

• Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

TRANSITION PROCESS

If your drug is not on the Drug List or is restricted, here are things you can do:

• You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply).

• You can change to another drug.

• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug. Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage. Perhaps there is a different drug covered by the plan that might work just as well for you.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:

• The drug you have been taking is no longer on the plan’s Drug List

-- or --

• the drug you have been taking is now restricted in some way

2. You must be in one of the situations described below:

• For those members who were on 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. This temporary supply will be for a maximum of 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.

• 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 during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.

• For those who are new members, and are residents in a long-term care facility:

We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31 days, or less if your prescription is written for fewer days. If needed, we will cover additional refills, up to a 31 day supply during your first 90 days in the plan.

• For those who have been a member of the plan for more than 90 days, and are a resident of a long-term care facility and need a supply right away:

We will cover one 31 day emergency supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

New members on our Plan may be taking drugs that are not on our formulary or that are subject to certain restriction, such as prior authorization or step therapy. Current members may also be affected by changes to our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception. Please contact PrimeTime Health Plan at 1-800-577-5084 or, for TTY users, 711, Monday through Friday, 8:00 a.m. to 8:00 p.m. (October 1st – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.).

If you and your doctor or other prescriber want to ask for an exception, please refer to your Evidence of Coverage. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.

To view PrimeTime Health Plan’s Transition Policy and Procedure document, visit the document.