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Medicare Part D (Pharmacy) Information


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:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week; or
  • The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
  • Your State Medicaid Office (See Evidence of Coverage (PDF) for contact information).

Prescription Drug Benefits

Formulary Information:


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)

Formulary Changes:


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 memblers 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:


  • New generic drugs. We may immediately remove a brand name drug on our formulary if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.
  • If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the Formulary Exception section of this website.


  • Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.


  • Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30 day supply of the 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.

Generic Drugs:

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:


  • Prior Authorization: Health Pointe Direct Complete Plan requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Health Pointe Direct Complete Plan before you fill your prescriptions. If you don’t get approval, Health Pointe Direct Complete Plan may not cover the drug.
  • Quantity Limits: For certain drugs, Health Pointe Direct Complete Plan limits the amount of the drug that Health Pointe Direct Complete Plan will cover. This may be in addition to a standard one-month or three-month supply.
  • Step Therapy: In some cases, Health Pointe Direct Complete Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Health Pointe Direct Complete Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Health Pointe Direct Complete Plan will then cover Drug B


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:

  • Drug-Drug Interactions
  • Drug-Disease
  • Drug-Age precautions
  • Drug-Gender precautions
  • Drug-Pregnancy precautions
  • Drug-Allergy precautions
  • Incorrect dosage precautions
  • Incorrect duration of drug therapy
  • Therapeutic duplication
  • Excessive use precautions
  • Prescription limitations

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.

Quality Assurance

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: 

  • Bone Disease-Arthritis-Osteoporosis
  • Chronic Heart Failure (CHF)
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Mental Health-Bipolar
  • Mental Health-Depression
  • Mental Health-Schizophrenia
  • Respiratory Disease-Asthma
  • Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD)
  • Hepatitis C

And,

  • Take at least 8 covered Part D medications, AND
  • 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:

  • Medication Action Plan (MAP): The action plan has steps you should take to help you get the best results from your medications. 
  • Personal Medication List (PML): The medication list will help you keep track of your medications and how to use them the right way.

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 1-844-269-3442 or, 711 for TTY users.

Formulary Exceptions

Coverage Decisions

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.

  • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.You can ask us to cover a formulary drug at a lower cost-sharing level.
  • If approved this would lower the amount you must pay for your drug.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Health Pointe Direct Complete Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

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:

  • Call Member Services at 1-844-269-3442 (TTY users should call 711)
  • Submit Fax Request to 1-855-668-8550
  • Send Mail Requests to PO BOX 1039, Appleton, WI 54912-1039

Request for Medicare Prescription Drug Coverage Determination Form (PDF)

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:

  • Call Member Services at 1-844-269-3442 (TTY users should call 711)
  • Submit Fax Request to 212-858-5735
  • Send Mail Requests to 810 7th Avenue, Suite 801, New York, NY 10019

Request for Redetermination of Medicare Prescription Drug Denial (Appeal) (PDF)

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)

Grievances

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”:


Quality of your medical care

Example:

  • Are you unhappy with the quality of the care you have received (including care in the hospital)?


Respecting your privacy

Example:

  • Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?


Disrespect, poor customer service, or other negative behaviors

Examples:

  • 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?


Waiting times

Example:

  • 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.


Cleanliness

Examples:

  • Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office?


Information you get from us

Examples:

  • 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?


Timeliness (These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals)

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:

  • If you have asked us to give you a “fast coverage decision” or a “fast appeal,” and we have said we will not, you can make a complaint.
  • If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.
  • When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain medical services or drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.
  • When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint.

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:

  • Call Customer Service at 1-844-269-3442 (TTY users should call 711)
  • Send written grievances via mail to 810 7th Avenue, Suite 801, New York, NY 10019


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 1-844-269-3442. 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. The Health Pointe Direct Complete Plan formulary has one tier:

  • Tier 1: Formulary- Brand and Generics Drugs

Transition Policy

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.


Transition Policy (PDF)

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 of new enrollees into prescription drug plans following the annual coordinated election period;
  • The transition of newly eligible Medicare beneficiaries from other coverage;
  • Enrollees who switch from one plan to another after the start of the contract year;
  • Current members affected by negative formulary changes across contract years;
  • Enrollees residing in LTC facilities;
  • Expediting transitions to formulary drugs for members who change treatment settings due to changes in level of care.

The transition process is applicable to:

  • Part D drugs that are not on Part D/Plan Sponsor’s Part D formulary
  • Part D drugs that are on Part D/Plan Sponsor’s Part D formulary but require prior authorization, exceed quantity limits or require step therapy

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:

  • Edits to help determine Part A or B versus Part D coverage;
  • Edits to prevent coverage of non-Part D drugs (i.e., excluded drugs or formulary drugs being dispensed for an indication that is not medically accepted); and
  • Utilization Review Edits to promote safe utilization of a Part D drug (i.e. member-level opioid claim edit, quantity limits based on FDA maximum recommended daily dose, early refill edits)

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.

Transition Period

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.

  • This 90 day timeframe applies to retail, home infusion, long term care and mail order pharmacies.
  • Since certain members may join a plan at any time during the year, this requirement will apply beginning on a member’s first effective date of coverage, and not only to the first 90 days of the contract year.
  • If an enrollee leaves a plan and re-enrolls during the original 90 day transition period, the transition period begins again with the new effective date of enrollment. However, if there is no gap in coverage, there is no new transition period.
  • This 90 day timeframe assists those beneficiaries transitioning from other prescription drug coverage who obtained extended (i.e., 90-day) supplies of maintenance drugs prior to the last effective date of their previous coverage.

Transition Supply

  • Outpatient Setting (Retail Pharmacies) – The temporary supply of non-formulary Part D drugs, including Part D drugs that require prior authorization, exceed quantity limits, or require step therapy, must be for at least a month’s supply of medication.
  • Long-Term Care (LTC) Setting – The temporary supply of non-formulary Part D drugs, including Part D drugs that require prior authorization, exceed quantity limits, or require step therapy, for a new member in a LTC facility for at least a month’s supply consistent with the dispensing increments (unless the prescription is written for less), with refills provided if needed during the first 90 days of a beneficiary's enrollment in our plan, beginning on the enrollee's effective date of coverage.

Emergency Supply for Current Members

  • During the first 90 days after a member’s enrollment, he/she will receive a transition supply. However, to the extent that a member in an LTC setting is outside his/her 90-day transition period, we will provide an emergency supply of non-formulary Part D drugs, including Part D drugs that are on the formulary that would otherwise require prior authorization, exceed quantity limits, or require step therapy, while an exception or prior authorization is requested.
  • These emergency supplies of non-formulary Part D drugs will be for at least 31 days of medication, regardless of dispensing increments, unless the prescription is written by a prescriber for less than 31 days.

Level of Care Changes

  • Health Pointe Direct Complete Plan’s transition process provides for other circumstances that exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on our formulary. These circumstances usually involve the level of care changes for a member that is changing from one treatment setting to another, such as:
  • 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
  • These circumstances often result in members and/or providers utilizing the exceptions and/or appeals processes. For these unplanned transitions, we make coverage determinations and re-determinations as expeditiously as the member’s health condition requires.
  • Our transition process ensures appropriate medication reconciliation for member upon discharge from LTC facilities or other facilities, so that an effective transition of care can be accomplished.
  • Claims data is utilized to determine if the member has experienced a level of care change and allows a transition fill where applicable. When claims data cannot be used to determine a level of care change, a pharmacy may need to call Member Services to process a point-of-sale override in order to effectuate this type of transition fill.

Transition Extension

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.

  • Current Enrollees: Where we can identify objective information demonstrating that a meaningful transition has occurred or the enrollee lacks documented ongoing therapy, we do not have to provide access to a transition supply in the new contract year for that member. However, if we are unable to identify such objective evidence, we will provide a transition supply in the new contract year and provide the required transition notice
  • Objective information includes:
  • Processing an exception request
  • Evidence of a new prescription claim for a formulary alternative processed prior to the start of the contract year
  • Greater than 108 days of eligibility with no claims history in the last 180 days from the prescription date of service
  • New Enrollees: We also extend the transition policy across contract years where a member enrolls into one of our plans with an effective enrollment date of either November 1st or December 1st and that member needs access to a transition supply. Members with a November 1st or December 1st effective enrollment date will be sent an ANOC as soon as practicable after the effective enrollment date. The ANOC will still serve as advance notice of any formulary or benefit changes in the following contract year.

Transition Notices

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
  • Instructions for working with Health Pointe Direct Complete Plan and the prescribing clinician to satisfy utilization management requirements or to identify appropriate therapeutic alternatives that are on the respective Part D formulary
  • An explanation of the member’s right to request a formulary exception including processing timeframes and the member’s right to request an appeal if the exception decision is unfavorable
  • A description of the procedure for requesting a formulary exception
  • For long-term care residents dispensed multiple supplies of a Part D drug in increments of 14-days-or-less, the written notice must be provided within 3 business days after adjudication of the first temporary fill.

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.

LIS Premium Summary Chart (PDF)

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

Pharmacy Network

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 1-844-269-3442.


Pharmacy Directory (PDF)

Pharmacy Directory (PDF) - Spanish

Contact Us:

Toll-Free: 1.844.269.3442 

TTY: 711

Mailing Address:

Health Pointe of New York

810 Seventh Avenue - Suite 801

New York, New York 10019

Please contact our Member Services number at 1-844-269-3442 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 1.844.269.3442 / TTY: 711

Health Pointe of New York is an HMO I-SNP with a Medicare Contract. Enrollment in Health Pointe of New York depends on contract renewal.

CMS Material ID: H1722_HPweb2019 | Last updated 01/17/2020

Health Pointe of New York COVID-19 Statement – H1711

Health Pointe of New York is closely monitoring the COVID-19 (Coronavirus) outbreak.

Click on the following links for the most up-to-date information from NYC.gov and The New York State Department of Health websites.

If you have any questions, please call Member Services at 844-269-3442.

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