Affinity Health Plan

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  • Pharmacy Information For Providers

    Please click on the appropriate section to learn more about drug coverage, prior authorization/coverage determinations, medical benefit drug coverage and other important pharmacy information to help you provide the care needed for Affinity members.

    • Medication Coverage Updates More
    • Helpful Information for Providers More
    • Medical Benefit Utilization Management Drugs More
    • Pharmacy Prior Authorization (ePa) and Prior Authorization Information More
      What are the Benefits of using Cover My Meds?

      Cover My Meds (ePA) allows a provider to:

      • Electronically request prior authorization criteria for a member and a medication
      • Receive the member-specific criteria
      • Submit answers to the criteria
      • Receive a determination often times in less than an hour

      ePA is intended to extend prior authorization process access to a provider’s electronic health record through a real-time request for criteria and delivery of that criteria to your Electronic Health Records system( such as Allscripts, NextGen, etc) for completion. For Medications not found on some of our Formularies, often times an alternative drug will be suggested.

      Cover My Meds Portal
      Available to use for all Affinity Plans. To register for a free CoverMyMeds account, click the link above and create an account. Setting up an account only takes a few minutes. Furthur step-by-step instructions can be found in the Reference Guide. Instructions also include adding a group, for offices with multiple providers for greater ease.

      For Medications not listed on the Formulary
      Providers may follow the same course of action as with a Coverage Determination, also called a Prior Authorization. This can be initiated by having your Provider call 855-582-2022 and request a Coverage Determination for the Medication(s) whether or not it is listed on the Formulary. Should this coverage be denied, an appeal can be made within 60 days of the initial denial by calling 888-543-9069 (choose option 1 for pharmacy appeals) or by having the Provider fax clinical chart notes or a letter of medical necessity to 718-536-3383.

      Medicaid and Child Health Plus
      For prompter service please contact CVS/ Caremark For Prior Authorizations:
      Monday - Friday, 9:00 a.m. - 7:00 p.m.
      1-877-432-6793 (Phone)
      1-866-255-7569 (Fax)


      Enriched Health Plan (HARP)
      For prompter service please contact CVS/ Caremark For Prior Authorizations:
      Monday - Friday, 9:00 a.m. - 7:00 p.m.
      1-877-432-6793 (Phone)
      1-866-255-7569 (Fax)


      Qualified Health Plans
      For prompter service please use the Cover My Meds Portal or you can call CVS:
      Monday - Friday, 9:00 a.m. - 7:00 p.m.
      1-855-582-2022 (Phone)
      1-855-245-2134 (Fax)

      Essential Plan
      For prompter service please use the Cover My Meds Portal or you can call CVS:
      Monday - Friday, 9:00 a.m. - 7:00 p.m.
      1-855-294-5979 (Phone)
      1-855-245-2134 (Fax)

      Medicare
      Please use this online tool to request coverage determinations, Medicare Electronic Medication Request for Prior Authorization (Coverage Determinations and Redeterminations)
      You can also call for coverage determinations:
      Phone: 1-866-362-4002
      Fax: 1-855-633-7673
      TTY: 1-866-236-1069

      Medicaid Standard Prior Authorization Form for Prescription Benefits

      Child Health Plus Standard Prior Authorization Form for Prescription Benefits

      Enriched Health Standard Prior Authorization Form for Prescription Benefits

      Medicare Prior Authorization Form

    • Formularies and Pharmacy Resources More
    • Miscellaneous Medicare Information More

      2017 Formulary Search Tool

      2017 Pharmacy Locator

      2017 Medicare Pharmacy Directory

      Fraud, Waste and Abuse Information and Reporting

      Medicare Mail Order Form: English | Spanish 

      Transition program 

      Coverage Determinations and Exceptions:
      When Affinity receives a request for payment or to provide a Part D drug to a Member, it must determine whether the requested prescription drug is necessary and appropriate and what the Members’ share of the cost is for the drug. These actions by Affinity are known as “coverage determinations”.

      Coverage determinations include exception requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower copayment. If you request an exception, your doctor must provide a statement to support your request. Once we receive a statement from your doctor, we must make a coverage determination. We must make coverage determinations and notify the affected Member within 72 hours of receiving the request or sooner if their health condition requires more immediate action. If immediate action is necessary, you or your physician can request that we review your situation in 24 hours.

      Grievance & Appeal rights:

      Grievances
      A grievance is a complaint about any problem you had with Affinity or one of our network pharmacies. Grievances do not relate to payment for or approval of a prescription drug, which are known as coverage determinations.

      If you (your appointed representative) have a grievance, please call our Customer Services number at 1-866-362-4002, 24 hours a day, seven days a week. TTY users can call 1-866-236-1069. t. We will try to resolve your complaint over the phone. You may also fax your grievance to 1-866-633-7673 or mail it to the following address:
      CVS Caremark Inc
      Part D Services
      MC109
      P.O. Box 52000
      Phoenix, AZ 85072-2000

      Expedited Grievances

      If you are grieving the decision by Affinity not to expedite an initial determination or an appeal, you can request an expedited grievance. In these situations, Affinity will respond to you within 24 hours.

      Appeals

      Once Affinity notifies you of a decision regarding a coverage determination request, you may or may not agree with it. You (or your authorized representative) can ask us to reconsider our decision. This is known as filing an appeal. Similar to coverage determinations, there is a fast track and routine process for handling appeals. The chart below explains how these different time frames work.

      You have a right to appeal if you think Affinity:

      • Decided not to cover a drug, vaccine, or other Part D benefit
      • Decided not to reimburse you for a Part D drug that you paid for
      • Reimbursed you less than you feel you should have received
      • Asked you to pay a different cost-sharing amount than you think you are
      • Required to pay for a prescription
      • Denied your exception request

      We will consider your appeal thoroughly and promptly. The time frames listed above will give you an idea of when you can expect a response from Affinity. It is important to let us know as soon as possible that you wish to file an appeal. If you wish to file a standard appeal, you must send written request within sixty (60) days from the date of the notice of coverage determination.

      You may fax your Appeal request to 1-866-633-7673 or mail it to the following address:

      CVS Caremark Inc
      Part D Services
      MC109
      P.O. Box 52000
      Phoenix, AZ 85072-2000

      To request a fast appeal, you may call 1-866-362-4002, 24 hours a day, seven days a week. TTY users can call 1-866-2356-1059

      If your complaint is regarding a quality of care issue (for example, you believe our pharmacist provided you with the incorrect dose of a prescription) you may also file a complaint with the Quality Improvement Organization (QIO), called Island Peer Review Organization (IPRO) by calling 1-800-331-7767 or for TTY, 1-866-446-3507. A QIO is a group of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. The Quality Improvement Organization review process is designed to help stop any improper medical practices.”

      Who May Ask for a Grievance or an Appeal?

      You or someone you name to act for you (your appointed representative) may request a grievance or an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others may already be authorized under State law to act for you. Please fill out the Appointment of Representative form and send it to us with your request. You can call us at 1-877-234-4499 or for TTY at 1-800-662-1220 if you need help filling out the form or want to learn more about appointing a representative.

      Appointment of Representative Form

      Medication Therapy Management Program

      Call Affinity customer service at 1-877-234-4499 if you have proof that your medication co-pay should be lower. We are open Monday to Friday, 8:00 a.m. to 8:00 p.m. (TTY/TDD 1-800-662-1220; available 24 hours a day, 7 days a week). For more information visit CMS website at www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Best_Available_Evidence_Policy.html*.

      *Please note that clicking on this link will take you away from the Affinity Medicare website.

    • Specialty Drugs for Essential and Qualified Health Plans More

      Specialty Medication Information
      Specialty medications are high-cost, injectable, oral, infused or inhaled medications that are typically self-administered.

      Specialty Guideline Management (SGM)
      SGM is our utilization management program; administered by CVS Caremark, that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. SGM is designed to ensure safety and efficacy while preventing off-guideline utilization. Prescribers may call 1-800-237-2767 to enroll patients in the Specialty plan design.