Pharmacy Benefits
Jump to: Drug Recalls | Pharmacy Programs | Find a Pharmacy | Reimbursement
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 (EOB) statement in the mail. This is for your Medicare prescription drug coverage (Part D). Your EOB shows:
- The prescriptions you filled
- What we paid
- What you and others have paid
- What counts towards your Out-of-Pocket Costs and your Total Drug Costs
Your EOB is not a bill.
If you paid a co-pay or coinsurance for your drug, the EOB should show the amount you paid.
You may not get an EOB every month
When we get a claim (bill) from your pharmacy, you’ll get an EOB the next month. For example, if we get a claim in March, you’ll get an EOB in April.
Take a minute to look over your EOB
Check your EOB to make sure everything is correct. If you have questions, find mistakes, or suspect fraud, we’re happy to help. Call us at the number below.
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 Maximum Coverage
Real-time Benefit Tool
What’s my out-of-pocket expense? Click below to check up-to-date medication costs at your pharmacy of choice.
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.
Coverage Determination Request Form Vaccines (Medicare B vs D)
CCA Rhode Island – Prescription Drug Coverage Determination Request Form
CCA Health Redetermination Form
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.
Drug Coverage Redetermination Form
If you’ve been prescribed a drug that’s not on the formulary (or “drug list”) you may still be able to get a temporary supply of the drug; request a similar drug that’s on the formulary; or ask the plan to grant an exception or otherwise remove restrictions. Refer to the transition process document based on the plan you’re enrolled in below.
Transition Process for CCA Medicare Preferred (PPO) and Medicare Value (PPO), RI
Transition Process for CCA Medicare Maximum (HMO D-SNP), RI
Prescription Fills
Show your CCA Health member ID card to get your prescription filled at your pharmacy. Make sure your pharmacy is in our network first. There are some cases when we will cover prescriptions filled at an out-of-network pharmacy: when you travel, if you need urgent or emergency care, or if a network pharmacy or drug is not available. Prior to filling your prescription at an out-of-network pharmacy, get in touch with our Member Services team at 833-346-9222 (TTY: 711) to find out if there is an in-network pharmacy where you are.
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.
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. You can also check the CCA Health directory by selecting “Pharmacy” from the “Specialty” drop-down.
Reimbursement
CCA works in partnership with its Pharmacy Benefit Manager (PBM), Navitus Health Solutions, 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 OR faxed to Navitus Health Solutions, using the contact information provided on the form.
You must submit your claim to Navitus Health Solutions within 12 months of the date you got the service, item, or drug.
CCA Medicare Advantage Plans (RI) – Prescription Reimbursement Form
CCA Medicare Dual Special Needs Plan RI – Prescription Reimbursement Form
Pharmacy Programs
CCA Health offers support with your medications through a range of free services and programs.
You can have your prescriptions mailed to your home for free. The medications available for mail-order service are generally medications that you take on a regular basis for a chronic or long-term medical condition, such as those for high blood pressure, high cholesterol, or diabetes.
CCA Health partners with Costco Mail Order Pharmacy to provide this service. There are four ways to order your prescriptions:
- Online: pharmacy.costco.com1
- Phone: 800-607-6861, 8 am to 10 pm Monday to Friday, and 12:30 pm to 5 pm Saturday
- Mail: You will be sent a pre-addressed, postage-paid envelope with each order, and it can be used to refill or order a new prescription.
- Fax: Your doctor can fax in orders to 800-633-0334.
Costco Mail Order Pharmacy Form
Visit pharmacy.costco.com1 or mail this form to register for a Costco Pharmacy account.
CCA Health covers the cost of the mail order service. A credit card is required for processing by Costco, but it will not be charged for this service. Your prescription drug copays remain the same. If you have a copay, you will be charged; if you do not have copays, you will not be charged. For detailed information about your plan’s coverage of prescription drugs, read your Evidence of Coverage/Member Handbook.
Your prescriptions will be delivered within 10 to 14 days of when Costco Pharmacy receives your prescription or refill request.
CCA Health partners with Lumicera Health Services1 to provide speciality medications. They offer CCA Health members personalized support and refill reminders too. Contact Lumicera 24/7 at 855-847-3553 with any questions about filling your speciality medications.
You can get a 90-day supply for medications you take regularly for chronic conditions. A 90-day supply can help you reduce trips to the pharmacy. Some pharmacies will only provide a 30-day supply of medications, so ask your pharmacy about their policy.
CCA Health allows members to have all their medications filled on the same day. This is called medication synchronization, or “med sync.” This will help reduce trips to the pharmacy.
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
Best Available Evidence Policy
This is a policy from the Centers for Medicare & Medicaid Services (CMS). It requires CCA Health to inform CMS when presented with evidence that a CCA Health member’s low-income subsidy (LIS) status is incorrect in CMS systems. For more information, visit the CMS website.1
1 When you click this link, you will leave the CCA Health 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.