Pharmacy Benefits
Jump to: Covered Drugs | Find a Pharmacy | Real-time Benefit | Drug Recalls | Medication Therapy Management Program
Your Pharmacy Benefits
Below you’ll find important information about your pharmacy and drug coverage.
Explanation of Benefits
When you use your prescription drug benefits, we will send you an Explanation of Benefits statement in the mail. The statement will include:
- A list of your prescription drugs covered by CCA Health Michigan, Inc.
- The amount of money that CCA Health Michigan pays to cover your prescriptions
- Instructions for how to request an exception and appeal our coverage decisions
- A list of upcoming changes to the list of drugs that CCA Health Michigan covers
Search for Covered Drugs
CCA Health Michigan covers a wide range of both over-the-counter, brand-name and generic prescription drugs at no cost to you. Find out if a medication is covered under your plan and what to do when it’s not.
CCA Medicare Advantage Plans Coverage
CCA Medicare Dual Special Needs Plan Coverage
Coverage Determinations and Redeterminations
For some drugs, you will need to get approval (“prior authorization”) from CCA Health Michigan before we can agree to cover a drug for you. The requirement for getting approval in advance may also help to guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. To learn more, view the documents below.
Prior Authorization Request Form (OptumRx) MI
Coverage Determination Form MI
If your request for coverage for a prescription drug was denied, you have the right to ask for an appeal of our decision within 60 days of the Notice of Denial.
Redetermination Request Forms MI
Filing a Grievance, Complaint, Coverage Decision, or Appeal MI
Find a Pharmacy
You can fill your prescriptions at any pharmacy in our large network. Ask your pharmacist if they’re in the CCA Health Michigan network.
Reimbursement
CCA Health Michigan works in partnership with its Pharmacy Benefit manager (PBM), OptumRx, to provide Medicare Part D prescription reimbursements.
To submit a claim for reimbursement of medications, please fill out a prescription reimbursement form. Forms can be mailed to Optum Rx using the contact information provided on the form.
The number of days after the fill date a manual claim can be submitted is 1,095 days.
OptumRx Medicare Part D Claim Form (MI) (2024)
Real-time Benefit Tool
What’s my out-of-pocket expense? Current members can verify their up-to-date medication costs at pharmacies of choice.
Click below to price your medications.
Drug Recalls
CCA Health Michigan is committed to protecting the health and safety of our members. We monitor alerts from the U.S. Food and Drug Administration (FDA) about drug recalls and withdrawals. We will notify you and your prescriber if we learn of potential problems with a medication.
A drug recall is when a medication or an over-the-counter product is removed from the market. A drug can be voluntarily recalled by the drug company and the FDA, or the FDA can require a recall. The FDA makes sure that recalls are handled correctly to safely stop the drug from being sold.
A drug may be recalled for many reasons, like safety concerns, mislabeling, or because it was poorly produced by the company.
Do not stop taking your medication until you speak to your doctor. In some cases, stopping a medication suddenly can cause a return of your symptoms that can be worse than before. In other cases, stopping a medication suddenly can be life-threatening. Follow these steps:
- Contact your doctor to discuss your options.
- Contact your pharmacy to discuss possible substitutes. For example, the pharmacist may be able to get the same medication from a different drug company. If not, they can contact your doctor to switch to another drug.
Visit the FDA website1 to learn more and to sign up to receive alerts on drug recalls.
Medication Therapy Management (MTM) Program
Our Medication Therapy Management Program is focused on improving therapeutic outcomes for Medicare Part D members.
Better therapeutic outcomes for members with multiple conditions.
Our Medication Therapy Management (MTM) program is focused on improving therapeutic outcomes for Medicare Part D members. To qualify for the MTM program, a member must meet all the following criteria:
Members must have filled eight or more chronic Part D medications; and Members must have at least three of the following ten chronic conditions:
- Asthma
- Chronic Obstructive Pulmonary Disease (COPD)
- Congestive Heart Failure (CHF)
- Depression
- Diabetes
- High Blood Pressure
- High Cholesterol
- Osteoporosis
- Rheumatoid Arthritis
- HIV
In addition, members must be likely to incur 2024 annual costs of $5,330 for all covered chronic Part D medications.
If you meet all the criteria above, our MTM program will help you learn about how to manage the various medications you need to stay healthy free of charge.2
Our MTM program offers a wide range of services to help members with multiple conditions by:
- Ensuring they take their medications correctly
- Improving medication adherence
- Detecting potentially harmful medication uses or combinations of medications
- Educating members and health care providers
Comprehensive medication review (CMR)
You’ll have a one-on-one consultation with a clinician to ensure you’re taking your medications as prescribed by your health care provider(s).
The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of the MTM program.
If you meet the criteria outlined above, you’ll receive an MTM program enrollment mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over the counter, herbal therapies, and dietary supplements) intended to assess your medication therapy and to optimize your outcomes.
Also, you’ll be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which your prescribers may receive a member-specific report.
The CMR includes three components:
1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or “behind the scenes” by a qualified provider and/or using computerized, clinical algorithms.
2. An interactive, person-to-person consultation performed by a qualified provider at least annually. This is typically conducted over the phone and will take about an hour to complete.
3. An individualized, written summary of the consultation for you which will include (but not be limited to) a medication list, reconciled medication list, and recommended to-do list for monitoring, education, or self-management. This will be delivered within two weeks of completing your CMR.
How to get started
You don’t need to do anything to access the program. A CCA representative will reach out to you if you meet the criteria to complete your CMR with you. To prepare for the CMR, you can download and complete the Personal Medication List below.
Medication List (MI)
You can also learn more about the program from a CCA representative. Call us at 855-959-5855 (TTY 711), April 1 to September 30, 8 am – 8 pm, Monday – Friday.
1 When you click this link, you will leave the CCA Health Michigan website.
2 This program is not a benefit; therefore, if you qualify for our program based on our criteria, we will automatically enroll you in the program and offer you program services over the phone or send you information by mail. The MTM program is free of charge to eligible members. Program participation is voluntary.