Call us at 1-833-CL-CARES | 1-833-252-2737
8AM-8PM Monday-Friday (TTY 711)

Call us at 1-833-252-2737
8AM-8PM Monday-Friday (TTY 711)
Refer a Member | For Providers | Provider Portal
CenterLight Healthcare

Welcome to the Members section of our website. Here, you will find the information you need to manage your healthcare benefits. Please click on the link below to access the materials available to you as a member of our plan.

Plan Information

2017 2018
Annual Notice of Change (ANOC)

2017 ANOC (English) (PDF, 185.8KB) (Updated September 2016)

2017 ANOC (Spanish) (PDF) (Entre de poco)

2018 ANOC (English) (PDF, 228KB) (Updated September 2017)

2018 ANOC (Spanish) (PDF) (Entre de poco)

Summary of Benefits

2017 Summary of Benefits (English) (PDF, 361.2KB) (Updated September 2016)

2017 Summary of Benefits (Spanish) (PDF) (Entre de poco)

2018 Summary of Benefits (English) (PDF, 370KB) (Updated September 2017)

2018 Summary of Benefits (Spanish) (PDF) (Entre de poco)

Evidence of Coverage (EOC)

2017 EOC (English) (PDF, 1.8MB) (Updated September 2016)

2017 EOC (Spanish) (PDF) (Entre de poco)

2018 EOC (English) (PDF, 1.7MB) (Updated September 2017)

2018 EOC (Spanish) (PDF) (Entre de poco)

Formulary
For more information on the CenterLight Healthcare Direct Formulary including Prior Authorization and Step Therapy updates, click here.

2017 Formulary (English) (PDF, 910KB)(Last updated October 2017)

2017 Formulary (Spanish) (PDF) (Entre de poco)

2018 Formulary (English) (PDF, 630KB)(Last updated August 2017)

2018 Formulary (Spanish) (PDF) (Entre de poco)

Low Income Subsidy (LIS) Premium Table

2017 LIS Table (PDF, 43.2KB)

2018 LIS Table (PDF, 630KB)

Pharmacy Network
For more information on the CenterLight Healthcare Pharmacy Directory, click here.

2017 Pharmacy Directory (English) (PDF, 740KB)(Last updated September 2017)

2017 Pharmacy Directory Spanish (PDF) (Entre de poco)

2018 Pharmacy Directory (English) (PDF, 834KB)(Last updated August 2017)

2018 Pharmacy Directory (Spanish) (PDF) (Entre de poco)

Provider Directory

2017 Provider Directory (English) (PDF, 4.5MB) (Last updated September 2016)

2017 Provider Directory (Spanish) (PDF) (Entre de poco)

2018 Provider Directory (English) (PDF, 3.5MB) (Last updated August 2017)

2018 Provider Directory (Spanish) (PDF) (Entre de poco)

Multi-language Interpreter Services

2017 Multi-language Insert (PDF, 211KB)

2018 Multi-language Insert (PDF, 212MB)

 
 



FORMULARY INFORMATION

CenterLight Healthcare's Formulary may change during the year. 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 will notify affected members of the change at least 60 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 60-day supply of the drug. 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. Drugs may also be added to our Formulary. This electronic copy of our Formulary is updated periodically to reflect the removal and addition of drugs, and includes when last updated.


Formulary Updates

CenterLight Healthcare Direct will provide 60 days notice on this website prior to removing a Part D drug from the Formulary or making changes in the preferred or tiered cost sharing status of a covered Part D drug.

Click here to view Prior Authorization updates (PDF, 363KB) (Last updated October 2017). The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

Click here to view Step Therapy updates (PDF, 141KB) (Last updated October 2017). In some cases, the 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.


Please click on the links below for more information about the CenterLight Healthcare Direct Formulary.

Out-of-Network Pharmacy Coverage

How to Contact Social Security or Medicaid for Extra Help

Drug Utilization Review

Compliance Monitoring

Quality Assurance

Tier Cost Sharing

Medication Therapy Management

Formulary Exceptions


Back to top of page





PHARMACY NETWORK

All network pharmacies may not be listed in the CenterLight Healthcare Direct Pharmacy directory. Pharmacies may have been added or removed from the lists after the directory was printed. CenterLight Healthcare has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

In certain situations, prescriptions filled at an out-of-network pharmacy may also be covered. See Chapter 5, Section 3.2 of the Evidence of Coverage for more information about filling a prescription at an out-of-network pharmacy. Please contact CenterLight Healthcare's Member Services Department for more information.

There are 3,201 pharmacies in the network in the following counties: Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk and Westchester.

Back to top of page





IMPORTANT FORMS

Click on the links below to access the forms available to you as a member of our plan.


 2018 ▾

Back to top of page





APPEALS AND GRIEVANCES

CenterLight Healthcare's Member Services department is available to answer any questions or concerns or problems you may have regarding your coverage. Please call us at 1-833-CL-CARES (1-833-252-2737), Monday-Friday from 8:00 AM through 8:00 PM. TTY users should call 711.

For information regarding appeals and grievances, please click on the links below.

 MEDICARE PART C INFORMATION ▾

Coverage Decisions

A coverage decision is a decision we make about your benefits and coverage, or about the amount we will pay for your medical services. You can ask us to make a coverage decision on the medical care you or your doctor is requesting. There are two kinds of coverage decisions – standard or fast.

  • A standard decision means we will give you an answer within 14 days after we receive your request. However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If your health requires a quick response, you should ask us to make a “fast decision.”
  • A fast decision means we will answer within 72 hours. However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need to get information to us for the review. If we decide to take extra days, we will tell you in writing. If you ask for a fast decision on your own, without your doctor’s support, our plan will decide whether your health requires that we give you a fast decision.

You or your physician can call our Medical Management Department at 1-800-695-1035. TTY users can contact the plan at 711.

If we say yes to your request, we will authorize or provide the care within 72 hours for a fast decision or within 14 days for a standard decision. If we say no to part or all of your request, we will send you a denial in writing that will explain your right to appeal the denial. Information on the aggregate number of CenterLight Healthcare Direct’s grievances, appeals and exceptions is available by contacting CenterLight Healthcare Direct Member Services at 1-833-CL-CARES (1-833-252-2737) (TTY users call: 711) Monday - Friday, 8:00 a.m. – 8:00 p.m. Please review the Evidence of Coverage (Chapter 9, Section 4 & Section 5) for your particular plan for more detailed information on coverage decisions and appeals requests.


Appeals (Reconsiderations)

A member appeal can be submitted when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a service. An appeal must be filed within 60 calendar days of the coverage decision. Two types of appeals are available to members –- a fast-track appeal and a standard appeal.

  • Members who submit a fast-track appeal must meet criteria that the standard process time frame would jeopardize the member's health status. These fast reviews will be completed within 72 hours.
  • Standard appeal requests will be reviewed within 30 calendar days.

Members can make a fast-track appeal request by calling 1-833-CL-CARES (1-833-252-2737) (TTY users should call 711). If the denial is reversed, we will authorize or provide care within 72 hours for a fast-track appeal or within 30 days for a standard appeal. If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have sent your appeal to the Independent Review Entity for a Level 2 Appeal.

To make an appeal in writing, you can fax to 1-718-944-1529 or mail to:

CenterLight Healthcare
ATTN: Appeals and Grievances Department
1250 Waters Place
Tower 1, Suite 602
Bronx, NY 10461

Please review the Evidence of Coverage (Chapter 9, Section 4 & Section 5) for more detailed information on coverage decisions or appeals.


Grievances

A grievance is any complaint other than one that involves a coverage decision. You would file a grievance if you have any type of problem with CenterLight Healthcare Direct or one of our network providers that does not relate to coverage for a service. If you have a grievance, we encourage you to call Member Services for a prompt response. We will try to resolve any complaint over the phone. You may also send your complaint in writing. To submit a grievance in writing, please mail to:

CenterLight Healthcare
ATTN: Appeals and Grievances Department
1250 Waters Place
Tower 1, Suite 602
Bronx, NY 10461

You can also fax a grievance to: 1-718-944-1529. We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. An expedited grievance can be made orally by calling 1-833-CL-CARES (1-833-252-2737) (TTY users call: 711) Monday - Friday, 8:00 a.m. to 8 p.m.

Please review the Evidence of Coverage (Chapter 9, Section 10) for more detailed information on making complaints.


 MEDICARE PART D INFORMATION ▾

Coverage Determinations/Exception Requests

For situations in which you have a medication that is not on CenterLight Healthcare Direct’s formulary or is part of a tier level designated as non-preferred, but you believe it should be placed in a different tier, an exceptions process has been established by the plan. Exception requests will be reviewed by the Plan for coverage determination.

Your prescribing physician must provide supporting medical information in response to a coverage exception request related to a non-formulary drug or tier placement.

There are two kinds of coverage determination requests – fast and standard.

  • A member can request a fast coverage determination, which will be decided within 24 hours. The request for a fast coverage determination must meet criteria that the standard coverage determination review process time frame would jeopardize the member’s health status.
  • For standard coverage determination requests, notification will occur 72 hours after receipt of the request or written documentation of medical necessity from the physician.

Non-formulary drugs approved for coverage will be covered at the non-preferred brand level. Biotech and specialty non-formulary products approved for coverage will be covered at the specialty level. A fast coverage determination or exception request can be made verbally by calling 1-800-935-7195 (TTY/TDD users call: 1-800-855-2881) Monday - Sunday, 8:00 a.m. – 8:00 p.m. To make a coverage determination request or an exception request, see instructions and forms below

Prescription Drug Coverage Determination Form (PDF, 26.8KB)

Information on the aggregate number of CenterLight Healthcare Direct’s grievances, appeals and exceptions is available by contacting CenterLight Healthcare Direct Member Services at 1-833-CL-CARES (1-833-252-2737) (TTY users call: 711) Monday - Friday, 8:00 a.m. – 8:00 p.m.

Please review the Evidence of Coverage (Chapter 9, Section 4 & Section 5) for your specific plan for more detailed information on coverage determination, exception requests and appeals requests.


Appeals (Redetermination and Reconsideration)

A member appeal can be submitted when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. An appeal must be filed within 60 calendar days of the coverage determination. Two types of appeals are available to members – a fast-track appeal and a standard appeal.

  • Members who submit a fast-track appeal must meet criteria that the standard process time frame would jeopardize the member's health status. These fast reviews will be completed within 72 hours.
  • Standard appeal requests will be reviewed within 7 calendar days.

Members can make a fast-track appeal request by calling 1-877-226-8500 (TTY users should call 711). To make a standard appeal request, see instructions and attached forms below.

Prescription Drug Coverage Determination Form (PDF, 26.8KB)

To make an appeal in writing, you can fax to 1-718-944-1529 or mail to:

CenterLight Healthcare
ATTN: Appeals and Grievances Department
1250 Waters Place
Tower 1, Suite 602
Bronx, NY 10461

Please review the Evidence of Coverage (Chapter 9, Section 4 & Section 6) for more detailed information on coverage decisions or appeals.


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 another person to be your representative, call Member Services and ask for the form that will give that person permission to act on your behalf. You can also get the form from the link below. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.

Appointment of Representative Form (PDF, 75KB)
Appointment of Representative Form (Spanish) (PDF, 88.9KB)

Grievances

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with CenterLight Healthcare Direct or one of our network pharmacies that does not relate to coverage for a prescription drug. If you have a grievance, we encourage you to call Member Services for a prompt response. We will try to resolve any complaint over the phone. You may also send your complaint in writing. To submit a grievance in writing, please mail to:

CenterLight Healthcare
ATTN: Appeals and Grievances Department
1250 Waters Place
Tower 1, Suite 602
Bronx, NY 10461

Please review the Evidence of Coverage (Chapter 9, Section 10) for more detailed information on making complaints.


Prior Authorization Criteria

You will need authorization before filling prescriptions for the drugs shown in the Prior Authorization Criteria, found in the Formulary page. We will only provide coverage after it is determined that the drug is being prescribed according to the criteria specified in the chart. You, your pharmacist or your physician can request prior authorization by calling Medco toll-free at 1-800-753-2851, 8:00 a.m. to 9:00 p.m. Eastern Time, Monday through Friday. Customer Service is available in English and other languages. TTY/TDD users should call 1-800-716-3231.


Best Available Evidence of Low-Income Subsidy Status

If you believe that you are paying too much for your prescription drugs because CenterLight Healthcare 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.


For assistance with Medicare issues, you may visit www.medicare.gov or use the Medicare Complaint Form by clicking here. You may also get help with your rights and protections from the Medicare Ombudsman.

Back to top of page





MEMBER RIGHTS AND RESPONSIBILITIES

As a CenterLight Healthcare Direct beneficiary, we must honor your rights as a member of our plans.

  • We must provide information in a way that works for you (in languages other than English that are spoken in the plan service area, in Braille, in large print, or other alternate formats, etc.)
  • We must treat you with fairness and respect at all times.
  • We must ensure that you get timely access to your covered services and drugs.
  • We must protect the privacy of your personal health Information. We must give you information about the plan, its network of providers, and your covered services.
  • We must support your right to make decisions about your care.

You have the right to know your treatment options and participate in decisions about your health care.

You have the right to get full information from your doctors and other health care providers when you go for medical care.

You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:

  • To know about all of your choices.
  • To know about the risks.
  • The right to say “no.”
  • To receive an explanation if you are denied coverage for care.

You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself.

You have the right to make complaints and to ask us to reconsider decisions we have made.

The following are your responsibilities as a CenterLight Healthcare Direct member:

Get familiar with your covered services and the rules you must follow to get these covered services.

If you have any other health insurance coverage or prescription drug coverage besides our plan, you are required to tell us.

Tell your doctor and other health care providers that you are enrolled in our plan.

  • Help your doctors and other providers help you, by giving them information, asking questions and following through on your care.
  • Be considerate.
  • Pay what you owe.
  • Tell us if you move.
  • Call Member Services at 1-833-CL-CARES (1-833-252-2737) (TTY 711) for help if you have questions or concerns.

Please view the Evidence of Coverage for your CenterLight Healthcare Direct plan for more detailed information on all Member Rights and Responsibilities.

Back to top of page




OUT OF NETWORK PHARMACY COVERAGE

CenterLight Healthcare Direct members must use a network pharmacy to receive plan benefits. CenterLight Healthcare Direct has established a reliable and convenient network of 63,500 pharmacies in our service area.

If you use an out-of-network pharmacy, CenterLight Healthcare Direct may not pay for your prescriptions, except in certain cases. Covered Part D drugs are available at out-of-network pharmacies in special circumstances, including illness while traveling outside of the CenterLight Healthcare Direct service area where there is no network pharmacy. In this situation, you will have to pay the full cost rather than just your co-payment when you fill your prescription. Additionally, you may be required to pay the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescriptions. You can request CenterLight Healthcare Direct to reimburse you for our share of the cost by submitting a paper claim.

Back to top of page





HOW TO CONTACT SOCIAL SECURITY OR MEDICAID FOR EXTRA HELP

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 FREE (1-800-633-4227 FREE). TTY/TTD users should call 1-877-486-2024 FREE, 24 hours a day/7days a week); or

The Social Security Administration at 1-800-772-1213 FREE between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778 FREE; or

Your State Medicaid Office.

Additionally, important information about CenterLight Healthcare Direct’s prescription drug plan can be found below.

Back to top of page





DRUG UTILIZATION REVIEW

CenterLight Healthcare Direct 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
Back to top of page





COMPLIANCE MONITORING

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 our plan’s Pharmacy and Therapeutic Committee and First Data Bank Criteria. Based on this review, the attending pharmacist and/or physician can make the most beneficial decision regarding the pharmaceutical care for the patient.

Back to top of page





QUALITY ASSURANCE

CenterLight Healthcare Direct 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 improve medication utilization. These measures include making sure that providers comply with pharmacy practice standards, drug utilization review, internal medication error identification systems, medical therapy management programs, and pharmacy and therapeutics committees. CenterLight Healthcare Direct also partners with state Quality Improvement Organizations (QIO), that are contracted with Medicare to collect, analyze and report data based on medication therapy practices.

Back to top of page





TIER COST SHARING

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 CenterLight Healthcare Direct formulary has two tiers:

Tier 1: Formulary-Preferred Generics and Certain Low-Cost Brand Name Drugs

Tier 2: Preferred Brand Drugs and Certain High-Cost Generic Drugs.

Back to top of page





MEDICATION THERAPY MANAGEMENT PROGRAM


 2017 MEDICATION THERAPY MANAGEMENT INFORMATION ▾

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 CenterLight Healthcare, Inc. 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 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 Centerlight Healthcare, Inc.’s MTM program, you must meet ALL of the following criteria:

  1. Have at least 3 of the following conditions or diseases:
    • Bone Disease-Arthritis-Osteoporosis
    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia
    • End-Stage Renal Disease (ESRD)
    • Hypertension
    • Mental Health-Bipolar
    • Mental Health-Depression
    • Mental Health-Schizophrenia
    • Respiratory Disease-Asthma
    • Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD)
    • Dementia
    • Hepatitis C

  2. Take at least 8 covered Part D medications

  3. Are likely to have medication costs of covered Part D medications greater than $3,919 per year.

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:

  1. Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, by phone or mail, and/or your doctor if we detect a potential problem.

  2. Comprehensive medication review: at least once a 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 SinfoníaRx through their licensed pharmacies operated by the University of Arizona Medication Management Center and The Ohio State University College of Pharmacy Medication Management Program. These services are provided on behalf of CenterLight Healthcare, Inc. 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, 47.4KB). A Spanish version can be downloaded by clicking here (PDF, 95.5KB).

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 our Member Services Department at 1-833-CL-CARES (1-833-252-2737) Monday-Friday from 8:00 AM through 8:00 PM. TTY users should call 711.

Back to top of page

 2018 MEDICATION THERAPY MANAGEMENT INFORMATION ▾

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 Centerlight Healthcare, Inc. 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 Centerlight Healthcare, Inc.’s MTM program, you must meet ALL of the following criteria:

  1. Have at least 3 of the following conditions or diseases:
    • Bone Disease-Arthritis-Osteoporosis
    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia
    • End-Stage Renal Disease (ESRD)
    • Hypertension
    • Mental Health-Bipolar
    • Mental Health-Depression
    • Mental Health-Schizophrenia
    • Respiratory Disease-Asthma
    • Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD)
    • Dementia
    • Hepatitis C
  2. Take at least 8 covered Part D medications
  3. Are likely to have medication costs of covered Part D medications greater than $3,967 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, by phone or mail, and/or your doctor if we detect a potential problem.
  • Comprehensive medication review: at least once a 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 SinfoníaRx through their licensed pharmacies operated by the University of Arizona Medication Management Center and The Ohio State University College of Pharmacy Medication Management Program. These services are provided on behalf of Centerlight Healthcare, Inc. 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, 47.4KB). A Spanish version can be downloaded by clicking here (PDF, 95.5KB).

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 our Member Services Department at 1-833-CL-CARES (1-833-252-2737) Monday-Friday from 8:00 AM through 8:00 PM. TTY users should call 711.


Back to top of page





FORMULARY EXCEPTIONS

If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” 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. To request a formulary exception, contact us at 1-833-CL-CARES (1-833-252-2737),Monday-Friday from 8:00 AM through 8:00 PM. TTY users should call 711.

Back to top of page





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 at 1-833-CL-CARES (1-833-252-2737) (TTY 711), Monday-Friday, 8:00 a.m. to 8:00 p.m., and ask for the “Appointment of Representative” form, or download by clicking on the links provided below. 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.

Appointment of Representative Form (PDF, 75KB)

Appointment of Representative Form (Spanish) (PDF, 88.9KB)

Back to top of page





HOW TO GET CARE FROM OUT-OF-NETWORK PROVIDERS

You generally must receive your care from a network provider. In most cases, care you receive from an out of network provider (a provider who is not part of our plan’s network) will not be covered.

Here are two exceptions:

  • The plan covers emergency care or urgently needed care that you get from an out-ofnetwork provider.
  • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Authorization should be obtained from the plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.

If you need care that our plan covers and our network providers cannot give it to you, you can get permission from CenterLight Healthcare DIRECT to get the care from an out-of-network provider. In this situation, we will cover the care as if you got it from a network provider and at no cost to you. To get approval to see an out-of-network provider, contact us at 1-833-CL-CARES (1-833-252-2737) Monday-Friday from 8:00 AM through 8:00 PM. TTY users should call 711.

Please note: If you need to go to an out-of-network provider, please work with CenterLight Healthcare DIRECT to get approval to see an out-of-network provider and to find one that meets applicable Medicare or Medicaid requirements. If you go to an out-of-network provider without first getting Plan approval, you may have to pay the full cost of the services you get.

Back to top of page





Transition Policy

New members in our plan may be taking drugs that aren't on our Formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our Formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a Formulary exception in order to get coverage for the drug. See Section 5 of your Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact Member Services if your drug is not on our Formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our Formulary next year, and you need help switching to a different drug that we cover or requesting a Formulary exception.

During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-Formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a Formulary change from one year to the next, we provide you with the opportunity to request a Formulary exception in advance for the following year.

When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn't on our Formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

If a new member is a resident of a long-term care facility (such as a nursing home), we will cover a temporary 91 to a 98-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the 90 days a new member is enrolled in our Plan. If the resident has been enrolled in our Plan for more than 90 days and needs a drug that isn't on our Formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 91 to a 98-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a Formulary exception.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access. See Section 10 of your Evidence of Coverage for information about non-Part D drugs.

You may also view the Spanish language version of this document by clicking on the following link:

Política de Transición (PDF) (Entre de poco)

Back to top of page
Name *
Name
Phone Number
Phone Number

Can't Open a PDF?

You will need to leave this site to download the software.