Direct Complete Plan (H5989)
Part D Member Information
Direct Complete Plan (H5989)
How to Contact Social Security or Medicaid for Extra Help
People with limited income and resources may qualify for “Extra Help”. If you qualify, you get help paying for any Medicare drug plan’s monthly premium, yearly deductible, and prescription co-payments.
This “Extra Help” also counts toward your out-of-pocket costs.
You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify for getting “Extra Help”, call:·
Prescription Drug Benefits
A formulary (drug list) is a list of covered drugs selected by Health Pointe Direct Complete Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Health Pointe Direct Complete Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Health Pointe Direct Complete Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage (PDF).
Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug:
A downloadable copy of our formulary is updated monthly to reflect the removal and addition of drugs noting when it was last updated. To get updated information about the drugs covered by Health Pointe Direct Complete Plan, please see the most recently posted formulary on this website or call Member Services.
Health Pointe Direct Complete Plan covers both brand name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Restrictions on Coverage:
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Health Pointe Direct Complete Plan (HMO I-SNP) limits coverage of blood glucose meters and test strips to the following Abbott Diabetes Care products:
Please refer to the Summary of Benefits for copay and coinsurance information or the Evidence of Coverage (EOC) for general benefit and coverage information.
You can find out if your drug is covered or has any additional requirements or limits by looking in the comprehensive formulary that you can download from this website. We have also posted documents that explain our prior authorization and step therapy restrictions. If you have questions about the formulary, any restrictions, or if your medication is not listed, please call Member Services.
Downloadable Comprehensive Formulary:
Downloadable Prior Authorization Criteria:
Downloadable Step Therapy Criteria:
You can also see an archive of Past Formularies and Prior Authorization and Step Therapy Criteria. Click Here
Drug Utilization Review
Health Pointe Direct Complete Plan requires participating pharmacies to perform drug utilization review (DUR) each time you fill a prescription. This is designed to analyze drug safety and usage for members based on their profile. The DUR is an important tool that screens for potential drug complications, such as:
Compliance Monitoring (Pharmacy)
The drug utilization review serves as a measure to ensure that drug usage criteria are met and satisfy FDA guidelines. Clinical protocols are adopted by the Pharmacy and Therapeutic (P&T) Committee. Based on this review, the attending pharmacist and/or physician can make the most beneficial decision regarding the pharmaceutical care for the patient.
Health Pointe Direct Complete Plan ensures the safety and health of its members through the establishment of effective Quality Assurance measures and systems. We do this to reduce medication errors and adverse drug reactions, and to improve medication utilization. These measures include making sure that providers comply with pharmacy practice standards, drug utilization review, internal medication error identification systems, and medical therapy management programs.
Medication Therapy Management
If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program. MTM is a service offered by Heath Pointe Direct Complete Plan at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit. This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.
To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program. Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.
To qualify for Health Pointe Direct Complete Plan’s MTM program, you must meet ALL of the following criteria:
-Have at least 3 of the following conditions or diseases:
-Take at least 8 covered Part D medications,
-Are likely to have medication costs of covered Part D medications greater than $4,255 per year.
To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:
Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, your caregiver, your pharmacist, and/or your doctor if we detect a potential problem.
Comprehensive medication review: at least once per year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This review, or CMR, is provided to you confidentially via telephone by pharmacies operated by SinfoníaRx. The CMR may also be provided in person or via telehealth at your provider’s office, pharmacy, or long-term care facility. If you or your caregiver are not able to participate in the CMR, this review may be completed directly with your provider. These services are provided on behalf of Health Pointe Direct Complete Plan . This review requires about 30 minutes of your time. Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors.
This summary includes:
To obtain a blank copy of the Personal Medication List (PML) that can help you and your health care providers keep track of the medications you are taking, click here (PDF).
If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please contact Member Services at (888)-201-4342 or, 711 for TTY users.
If a drug is not covered in the way you would like it to be covered, you can ask us to make an exception to our coverage rules. 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.
There are several types of exceptions that you can ask us to make.
Generally, Health Pointe Direct Complete Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tier, or utilization restriction exception. When you request a formulary, tier, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
You can use one of the following methods to request a formulary exception:
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision.
When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision. Under certain circumstances, you can request an expedited or “fast coverage decision” or fast appeal of a coverage decision. If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.
You can use one of the following methods to request an appeal:
How to Appoint a Representative
You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative,” to ask for a coverage decision or make an appeal. There may be someone who is already legally authorized to act as your representative under state law.
If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form or click here (PDF) to download the form. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.The form is also available on Medicare’s website. Click Here
Direct Member Reimbursement
Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for medical services or drugs that are covered by our plan.
For instance, if you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.
Request for Direct Member Reimbursement (DMR) (PDF)
The formal name for “making a complaint” is “filing a grievance”. The complaint process is used for certain types of problems only. This includes complaints you make about us or pharmacies related to quality of care, waiting times, and the customer service you receive. This type of complaint does not involve coverage or payment disputes.
If you have any of these kinds of problems, you can “make a complaint”:
Are you unhappy with the quality of the care you have received (including care in the hospital)?
Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?
-Has someone been rude or disrespectful to you?
-Are you unhappy with how our Member Services has treated you?
-Do you feel you are being encouraged to leave the plan?
-Are you having trouble getting an appointment, or waiting too long to get it?
-Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by our Member Services or other staff at the plan? Examples include waiting too long on the phone, in the waiting room, when getting a prescription, or in the exam room.
-Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office?
-Do you believe we have not given you a notice that we are required to give?
-Do you think written information we have given you is hard to understand?
The process of asking for a coverage decision and making appeals is explained in the Formulary Exceptions section and in your Evidence of Coverage (EOC)(PDF). If you are asking for a decision or making an appeal, you use that process, not the complaint process.
However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a complaint about our slowness.
Here are examples:
Contact us promptly – either by phone or in writing. Usually calling our Member Services is the first step. If you do not wish to call (or you called and were not satisfied) you can put your complaint in writing and send it to us. The complaint must be made within 60 days after you had the problem you want to complain about.
You can use one of the following methods to submit a grievance:
We will look into your complaint and give you our answer. If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days. If we decide to take an extra 14 days, we will tell you in writing. If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not. If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint.” If you have a “fast complaint,” it means we will give you an answer within 24 hours.
You can submit a complaint about us directly to Medicare. To submit a complaint to Medicare, Click here or go to https://www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.Information on the aggregate number of Health Pointe Direct Complete Plan grievances, appeals and exceptions is available by contacting Member Services.
Please contact us for any process or status questions you have regarding your grievance, appeal, or exceptions request at (888)-201-4342. From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST. (TTY users should call 711).
Tier Cost Sharing
Cost sharing is the amount that a member has to pay when services or drugs are received. Tier cost sharing is a term that means there is cost sharing for drugs that are classified under specified tier levels. Each level has co-payment amounts that the member is responsible to pay. The Health Pointe Direct Complete Plan formulary has two tiers:
Under certain circumstances, Health Pointe Direct Complete Plan can offer a temporary supply of a drug to you when your drug is not on the formulary or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
Part D Transition Guidelines:
Members and situations affected by this transitional fills policy in which Health Pointe Direct Complete Plan will apply a transition process are described below:
The transition process is applicable to:
Our transition process ensures that a new member is able to leave a network pharmacy with a temporary supply of non-formulary Part D drugs without unnecessary delays. While some step therapy, prior authorization or quantity limits edits may be implemented during transition, these edits can be resolved at the point of sale.
In certain instances, drug utilization management edits are applied during the beneficiary’s transition period. These edits are limited to:
Our transition processes will apply to all new prescriptions for a non-formulary drug. If we are unable to make a distinction between a new prescription and an ongoing prescription for a non-formulary drug at the point-of-sale, we will provide the enrollee with a transition fill. Pharmacies will receive messaging notification of a transition fill for the beneficiary in their claims adjudication system.
The Pharmacy & Therapeutics (P&T) Committee is an advisory committee responsible for reviewing clinical information regarding medications and making formulary recommendations. The P&T Committee is comprised of primary-care and specialty physicians, as well as pharmacists. We have procedures for medical review of non- formulary drug requests and, when appropriate, a process for switching new members to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination. The P&T Committee’s involvement ensures that transition decisions appropriately address situations involving members stabilized on drugs that are not the formulary (or that are on the formulary but require prior authorization, exceed quantity limits, or require step therapy) and which are known to have risks associated with any changes in the prescribed regimen.
Health Pointe Direct Complete Plan will charge cost-sharing for a temporary supply of drugs provided under our transition process. For non-LIS eligible enrollees, this cost-sharing is consistent with cost-sharing that we would charge for non-formulary drugs approved under a coverage exception and the same cost sharing for formulary drugs subject to utilization management edits provided during the transition that would apply once the utilization management criteria are met. Cost-sharing for transition supplies for low-income subsidy (LIS) eligible members can never exceed the statutory maximum co-payment amounts.
Within the first 90 days of coverage for a new member under a Part D plan, we will provide a temporary fill when our new member requests a refill of a non-formulary drug, including Part D drugs that are on Part D formulary but require prior authorization, exceed quantity limits, or require step therapy under this medication utilization management policy.
Emergency Supply for Current Members
Level of Care Changes
-Members who enter LTC facilities from hospitals with a discharge list of medications from the hospital formulary with very short term planning taken into account (i.e. under 8 hours)
-Members who are discharged from a hospital to a home with very short-term planning taken into account
-Members who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary
-Members who give up hospice status to revert to standard Medicare Part A and B benefits
-Members who end an LTC facility stay and return to the community
-Members who are discharged from psychiatric hospitals with drug regimens that are highly individualized
In certain circumstances, Health Pointe Complete Direct Plan will extend the transition period and provide the necessary drugs if the enrollee’s exception request or appeal has not been processed by the end of the minimum transition period. This extension is granted on a case-by-case basis taking into account whether the member’s exception request or appeal has not been processed by the end of the minimum transition period
Transition Across Contract Years
After members receive their Annual Notice of Change (ANOC) by September 30thof a given year, Health Pointe Direct Complete Plan will a transition process for current members at the start of the new contract year or prior to the start of the new contract year.
Objective information includes:
Health Pointe Direct Complete Plan sends written notice within three business days after providing a temporary supply of non-formulary Part D drugs (including Part D drugs that are on the formulary but require prior authorization, exceed quantity limits, or require step therapy. We also provide the prescriber of record with a copy of the transition notice that was sent to the member labeled “PRESCRIBER COPY”.If the enrollee completes the transition supply in several fills, we will send the notice with the first fill only. All transition notices include:
An explanation of the temporary nature of the transition supply the member or new enrollee has received
Formulary exception requests will be available to members, their prescribing physicians (or other providers), and/or their representatives via mail or phone.
Low-Income Subsidy/Extra Help
Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. Health Pointe Direct Complete Plan’s premium includes coverage for both medical services and prescription drug coverage.
This table shows you what your monthly plan premium will be if you get extra help.
If you aren’t getting extra help, you can see if you qualify by calling Medicare, your State Medicaid Office, or the Social Security Office. (See section titled “How to Contact Social Security or Medicaid for Extra Help”)
Best Available Evidence of Low-Income Subsidy Status
If you believe that you are paying too much for your prescription drugs because Health Pointe Direct Complete Plan does not have the correct low-income subsidy status, please call our Member Services Department. We can help you find out if you should be paying less for your prescription drugs because you are eligible for Medicaid and/or the low-income subsidy. Please visit the Centers for Medicare and Medicaid Services website to learn more.
Pharmacy Network and Out-of Network Pharmacy Coverage
Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members. You can use the Pharmacy Directory to find the network pharmacy you want to use. In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies.
You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you can ask either to have a new prescription written by a provider or to have your prescription transferred to your new network pharmacy.
Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility’s pharmacy as long as it is part of our network.
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Please check first with Member Services to see if there is a network pharmacy nearby. If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost.
Check your Pharmacy Directory to find out if pharmacy is part of our network. If it isn’t, or if you need more information, please contact Member Services at (888)-201-4342.
Pharmacy Directory (PDF) – Spanish
Please contact our Member Services number at 1-888-201-4342 for additional information. (TTY users should call 711.) From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST.
We do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, gender identity, age or disability in our health programs and activities.
ATENCION: Si habla español, tiene a su diposicion servicios gratuitos de assistencia linguistica. Llame a 1.888.201.4342 / TTY: 711
Health Pointe Direct Complete Plan (HMO I-SNP) is a Health Plan with a Medicare Contract. Enrollment in Health Pointe HMO I-SNP depends on contract renewal.
CMS Material ID: H5989_HPweb2019 | Last updated 12/10/2019