Drug Coverage

The drugs covered by RiverSpring Star (HMO I-SNP) are described on the List of Covered Drugs (Drug List or Formulary). You generally must use pharmacies in the RiverSpring Star (HMO I-SNP) network to obtain your medications.

The Drug List and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. You can always check RiverSpring Star’s (HMO I-SNP) up-to-date List of Covered Drugs online at www.RiverSpringhealthplans.org or by calling RiverSpring Star (HMO I-SNP) Pharmacy Services toll-free at 1-855-898-1482, TTY/TDD:711. If there is a change to coverage for a drug you are taking, we will send you a notice. Normally, we will let you know at least 60 days before the change.

Limitations and restrictions may apply. For more information, call RiverSpring Star (HMO I-SNP) Member Services or read the RiverSpring Star (HMO I-SNP) Evidence of Coverage and List of Covered Drugs (Formulary).

Restrictions and Limitations on Drug Coverage

Some drugs have coverage rules, or limits on the amount you can get. In some cases, you must do something before you can get the drug.

Prior authorization: For some drugs, you or your doctor must get approval from RiverSpring Star (HMO I-SNP) Plan before you fill your prescription. For details, please read our

2020 Prior Authorization Criteria

Quantity limits: The amount of a drug that you can get may be limited. Please refer to the List of Covered Drugs for details.

Step therapy: Sometimes, you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. For details, please read our

2020 Step Therapy Criteria.

Prescription Drug Transitions: In some cases, the Plan can give you a temporary supply of a drug when the drug is not on the List of Covered Drugs (Formulary) or when it is limited in some way. This         gives you time to talk with your provider about getting a different drug or to ask RiverSpring Star (HMO I-SNP) to approve the drug.

We may cover a 30-day supply of your drug during the first 90 days you are a member of RiverSpring Star (HMO I-SNP). If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30 days of medications.

If you have been in the plan for more than 90 days, live in a long-term care facility, we will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new RiverSpring Star (HMO I-SNP) member. This is in addition to the temporary supply during the first 90 days you are a member of RiverSpring Star (HMO I-SNP). For details, please read our Drug Transition Policy 2020.

To ask for a temporary supply of a drug, you or your appointed representative, or the prescriber may call RiverSpring Star (HMO I-SNP) Pharmacy Services toll-free at 1-855-898-1482 or fax the request to 1-855-898-1483.

Opioid Drug Management Program

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. These amounts do not include any Medicare Part B Premium you may have to pay.

Last updated on April 9, 2020