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
- The amount of money that CCA 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 covers
Search for Covered Drugs
CCA 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 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.
Coverage Determination Form (OptumRx) MI
Coverage Determination Forms 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 network.
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 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 (MTMP) is focused on improving therapeutic outcomes for Medicare Part D members.
To qualify for MTMP, a member must meet all of 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
- High blood pressure
- High cholesterol
- Congestive heart failure (CHF)
- Diabetes
- Depression
- Osteoporosis
- Rheumatoid arthritis
- Asthma
- COPD
- HIV
- Members must be likely to incur annual costs of $4,935 or more for all covered chronic Part D medications.
OR
- Members must be in a drug management program to help better manage and safely use medications such as opioids and benzodiazepines
Do you meet all of the criteria above? Learn more1 about how to manage the various medications you need to stay healthy.
The success of our MTMP is built upon our proven experience using a wide range of services designed 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
Our programs are evidence-based and can integrate both pharmacy and medical data, when available. They are built upon multiple measures that demonstrate positive clinical outcomes for members like you. Pharmacists, physicians, and PhDs develop, manage, and evaluate the programs for effectiveness.
One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their healthcare provider.
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 an MTMP. If you meet the criteria outlined above, you will receive an MTMP Enrollment Mailer or phone call offering our CMR services.
A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies, and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members’ prescribers may receive a member-specific report.
The CMR includes three components:
- 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
- An interactive, person-to-person consultation performed by a qualified provider at least annually to all MTM-eligible members
- An individualized, written summary of the consultation for the member, including but not limited to a medication list, reconciled medication list, and recommended to-do list for monitoring, education, or self-management
View or download a sample copy of our MTMP Enrollment Mailer
View or download a copy of the Recommended To-Do List
View or download a copy of the Medication List
Do you have unused expired medications that you are looking for a safe way to dispose of? Before you throw them away, here are some things you should know.
How to safely dispose of unused or expired medications before they do harm: For safety reasons, dispose of unused medications as soon as possible. Here are a few tips for safe disposal:
Find a nearby pharmacy or other local resource with a medication take-back service.
- The U.S. Drug Enforcement Administration (DEA) allows unused prescription medications to be returned to pharmacies or other authorized sites. You can locate participating locations at: https://apps2.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e2s1.1
- Community take-back sites are the preferred method of disposing of unused controlled substances.
- Additional drug disposal information can be found on the DEA website at: deatakeback.com.1
If you cannot get to a drug take-back location promptly, or there is none near you:
- Mix the unused supply with an undesirable substance such as dirt or coffee grounds.
- Put the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag, then place the sealed container in your trash.
- Make sure to conceal or remove any personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off to protect your privacy.
- Place both the sealed container with the mixture and the empty drug containers in the trash.
- Only flush approved unused or expired medications down the toilet if indicated on the label or patient information, or no other disposal options are available.
More information on the safe disposal of medications can be found on the United States Department of Health and Human Services website: https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html1
Contact OptumRx1 or your health plan at the number listed on the back of your ID card for more information about our MTM program. If you have any questions about the MTM program, please call the MTM department at 1-866-352-5305 (TTY users dial 711), Monday–Friday, 8 am to 8 pm CST.
These programs are provided at no additional cost as part of your coverage and are not considered a benefit.
1 When you click this link, you will leave the CCA Health website.