Drug Coverage

Drug Coverage

The drugs covered by RiverSpring Star (HMO SNP) are described on the List of Covered Drugs (Drug List or Formulary). You generally must use pharmacies in the RiverSpring Star (HMO 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 SNP) up-to-date List of Covered Drugs online at www.RiverSpringStar.org or by calling RiverSpring Star (HMO SNP) Pharmacy Services toll-free at 1-855-898-1482. 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 SNP) Member Services or read the RiverSpring Star (HMO SNP) 2019 Evidence of Coverage. 2018 Evidence of Coverage

Drug List or Formulary

2019

2018

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 SNP) Plan before you fill your prescription. For details, please read our

2019 Prior Authorization Criteria.

2018 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

2019 Step Therapy Criteria.

2018 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 Drug List 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 SNP) to approve the drug.

During the first 90 days of your membership in RiverSpring Star (HMO SNP), we will cover a temporary supply (or supplies) of your drug for at least 30 days if you do not live in a long-term care facility, or up at least 31 days if you live in a long-term care facility.

If you have been a member in our plan for more than 90 days, live in a long-term care facility, or have been admitted or discharged from a hospital or long-term care facility, and need a supply right away, then we will cover a 31 day supply, or less if your prescription is written for fewer days. For details, please read our Drug Transition Policy.

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

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 December 12, 2018