Part D Prescription Drug Benefit

Part D Prescription Drug Benefit

For people with Medicare, AbilityCare includes Medicare Part D (prescription drug) coverage. The AbilityCare Part D List of Covered Drugs (also known as the formulary) is shown on this page in different formats. You may search our online formulary to see what is covered (click here to go to the online formulary). You may also download and view or print a copy of the List of Covered Drugs from the Member Materials box on the right side of this page. Sometimes the List of Covered Drugs changes, so call Member Services if you have questions. If your current prescription drugs are not on the List of Covered Drugs or are limited in some way, South Country has a Part D Transition Policy (pdf) which explains what happens in certain situations. AbilityCare's pharmacy network equals or exceeds CMS requirements for pharmacy access in your area. You can find network pharmacies here in two ways: You may download and view or print a copy of the pharmacy section from the Provider and Pharmacy Directory, located on the Provider Directory page. You may also search the online listing to find a pharmacy near you (click here to go to the pharmacy search). If you have Medicare, and depending on your income and institutional status, your prescription drug copay will be:

  • For generic drugs: $0, $1.30, or $3.70
  • For brand name drugs: $0, $4.00, or $9.20

For more information on prescription drug coverage, see your Evidence of Coverage. For Part D exceptions and appeals information, visit our Part D Coverage Determination, Appeals, and Exceptions page.

You must use network pharmacies to access your prescription drug benefit, except under certain circumstances. For more information about this, out-of-network coverage, or if your pharmacy leaves the network, see your Evidence of Coverage. Free printed copies of both the List of Covered Drugs (Formulary) and the Provider and Pharmacy Directory are available upon request by calling Member Services.

 

Medicare's Extra Help Program

Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources.

As long as you are eligible for Medical Assistance, you qualify for and are getting Extra Help paying your prescription drug plan costs. You do not need to do anything further to get this Extra Help.

If you have questions about 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;
  • The Social Security Office at 1-800-772-1213, between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or
  • Your State Medicaid Office, the Minnesota Department of Human Services at 651-431-2670 (Twin Cities metro area) or (800) 657-3739 (outside Twin Cities metro area) TTY users should call 711. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Medication Therapy Management

What is this program about?

Medication Therapy Management (MTM) ensures South Country Health Alliance members are using the right drugs to treat their medical conditions. The program helps reduce the risk for potential drug issues and helps members learn how to get the most from their medications. Pharmacists are available to answer questions about prescription medicines and over-the-counter products. The MTM program is available to all eligible members at no additional cost.

What can I expect?

  • A review of your medicines
  • Personalized medicine lists
  • Help in understanding how your medicines work and their side effects
  • Educational materials about your conditions and prescriptions

How do I start?

If you meet the eligibility criteria below, you will be automatically enrolled. (Note: The MTM program is voluntary. You may opt out at any time.) You may choose to only take part in the services you find most valuable. Your drug benefits will not change if you do or do not participate in all or part of the program.

Eligibility Criteria

You can participate in the MTM program if you meet all the following criteria:

  1. Have 3 or more of the following chronic conditions:
    • Chronic Heart Failure (CHF)
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Diabetes
    • Dyslipidemia
    • End-Stage Renal Disease (ESRD)
    • Hypertension
    • Mental-Health – Chronic/Disabling Mental Health Conditions
    • Osteoporosis
    • Respiratory Disease – Asthma
    • Rheumatoid Arthritis (RA)
  2. Take 5 or more medications in the following Part D-covered drug classes:
    • ACE Inhibitors
    • Angiotensin II Receptor Blockers (ARBs)
    • Antidepressants
    • Antihyperlipidemics
    • Antihypertensives
    • Antipsychotics
    • Beta Blockers
    • Bisphosphonates
    • Bronchodilators
    • Calcimimetics
    • Calcium Channel Blockers
    • Cardiac Glycosides
    • Colony Stimulating Factors
    • Disease Modifying Antirheumatic Drugs (DMARDs)
    • Diuretics
    • Glucagon-Like Peptide 1 Receptors
    • Glucocorticosteroids
    • Inhaled Corticosteroids
    • Insulins
    • Neprilysin Inhibitors
    • NSAIDs
    • Oral Hypoglycemics
    • Phosphate Binders
    • Selective Serotonin Reuptake Inhibitors (SSRIs)
    • Vitamin D Analogs
  3. Spend more than $1094 in the previous quarter on your medications

How does it work?

You will receive an engagement packet that includes the following:

  • Information about the MTM program
  • An offer to schedule a comprehensive medication review
  • A questionnaire that will ask about other medications you use (including over-the-counter or supplements) and any medication allergies you may have
  • Information on how to dis-enroll from the MTM program
  • A health education newsletter focused on one of your chronic conditions

If you choose to have a comprehensive medication review phone call:

  • A pharmacist, registered nurse, licensed practical nurse, or pharmacy intern under the direct supervision of a pharmacist will review your medications, history, and any information collected from the engagement packet questionnaire. The pharmacist will then call you or your caregiver via phone or telehealth to conduct a medication review consultation.
  • The pharmacist will look for drug therapy problems including medication adherence, therapeutic duplication, drug-drug interactions, drug-disease interactions, and appropriate dosing and polypharmacy.
  • The pharmacist will write and mail a summary of consultation including a medication action plan and personal medication list and send it to you or your caregiver.

We will regularly review our claims data for all MTM participants to see if a targeted medication review is needed. Targeted medication reviews are performed by a pharmacist, registered nurse, licensed practical nurse, or pharmacy intern under the direct supervision of a pharmacist for certain medication and chronic condition issues. If we find problems, we may contact your health care provider. You will also receive a medication guide specific to your chronic condition that explain when and how to take your medications, along with possible side effects to watch for.

You may be referred to the South Country Health Alliance care coordination team if additional assessment, facilitation, health care coordination, evaluation, and advocacy for options and services are identified.

We hope you will participate in our program.

Remember: There is no added cost for the MTM program, and you may leave the program at any time. This service is not considered a benefit.

South Country Health Alliance members: If you want more information about the MTM program or are interested in getting copies of service documents, call 1-888-349-0501 (TTY users call 1-888-765-6351) between 9:30 a.m. and 6 p.m. CST, Monday through Friday. If you are not a South Country Health Alliance member, call Member Services.

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AbilityCare Member Materials
Enrollment FormPDF
Evidence of CoveragePDF
Annual Notice of ChangesPDF
Summary of BenefitsPDF
Pre-Enrollment ChecklistPDF
List of Covered Drugs (Formulary)PDF
Formulary UpdatesPDF
Provider and Pharmacy DirectoryWeb Page
Medicare Star RatingsPDF
LIS Premium Summary ChartPDF
CMS Best Available Evidence CoverageWeb Page (external link)
Covered Diabetic Testing SuppliesPDF

Last Updated on 07/15/2021 by Chris Gartner

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