Affinity Health Plan

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  • Medicare Pharmacy Information

    Formulary (Drug) Information

    You can find information regarding your prescription drugs and how we cover them. Changes will be made periodically throughout the year and posted below.

    Covered Drug List
    (Also called a Comprehensive Formulary, it contains information about Medications that we cover listed by name and/or condition)
    2018: English | Español
    2017: English | Español  

    Abridged Formulary
    (A shortened list of medications we cover)
    2018: English | Español
    2017: English | Español  

    Formulary Search
    (To see if your medication is on the Covered Drug List)
    2018 | 2017  

    Prior Authorization Criteria
    (Guidelines for getting a medication covered)
    2018 | 2017  

    Step Therapy Criteria
    (List of alternative medications to try first)
    2018 | 2017  

    2017 Negative Formulary Changes
    (Medications removed from the Comprehensive Formulary)
    English | Español  

    Drugs Covered by Medicaid for Dual Eligibles
    (A list of Medications covered for our Ultimate and Solution members only)

    Medicare Part D Program(s) Information:

    Programs that we offer to help our Members regarding their prescriptions.

    Transition Program and Policy
    (Information regarding a temporary fill of non-covered medication to prevent a disruption of therapy)
    2018 | 2017  

    Medication Therapy Management
    (Information for those on Multiple Medications and who meet specific criteria. La información también está disponible en español)

    Medicare Pharmacy Directory:

    You can find a pharmacy in your area or use the Pharmacy Locator when out of town.

    Pharmacy Directory
    (For Pharmacies located in NYC, Rockland, Westchester, Orange, Suffolk, and Nassau Counties)
    2018 | 2017  

    Pharmacy Locator
    (Search for a specific type of Pharmacy in your area or when out town)
    2018 | 2017  

    Tools and Resources:

    Information for Members regarding Medicare information.

    Low Income Subsidy (LIS/"Extra Help") Table
    (Information regarding what you will pay for your plan premium if you receive “Extra Help”)
    2018 | 2017  

    Drug Information
    (Use these tools to get drug facts for prescriptions, non-prescription medications, vitamins and supplements. Plus, check drug interactions, identify pills and create your personal medicine list)

    Information for Members on Blood Thinners
    (Safety Information for those on a prescription Blood Thinner)

    Locations for Medication Disposal
    (Department of Health locations for the safe disposal of any unwanted medications)

    Fraud, Waste and Abuse Information and Reporting
    Please refer to tips to prevent fraud, how to spot fraud, and reporting fraud for more information.There you will also find information regarding potential areas where Medicare Fraud may occur. Help keep costs low by being aware of the different types of Medicare Fraud.


    The following forms are printable and may be faxed or mailed in. Forms for Providers are on the Provider Page or in the Coverage Determinations section below.

    For Mail Order Medications through CVS/Caremark Pharmacy
    English | Español  

    Medicare Pharmacy Claim Form
    Please use this form if you have paid an out of pocket cost for a Covered Part D Prescription Medication only.
    English | Español  

    Coverage Determinations and Exceptions:
    Information on how Members and Providers can request a medication to be covered (Also sometimes referred to as a Prior Authorization)
    Electronic Request for Coverage of a Medicare Medication
    (A coverage determinations and redeterminations online tool, for use by Members and Providers)
    Paper Request for Coverage of a Medicare Medication  

    You can also call for Coverage Determinations (Prior Authorizations) or Exceptions:
    Phone: 866.362.4002
    Fax: 855.633.7673
    TTY: 711

    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.

    Read more about information concerning your rights in regards to Pharmacy Grievances and Appeals.

    Appointment of Representative Form
    This form is used when someone who is not the member would like information or assistance on your behalf. Your representative can be a family member, friend, advocate, attorney, doctor or anyone else you would like to act on your behalf:
    English | Español

    Best Available Evidence
    Call Affinity customer service at 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 711; available 24 hours a day, 7 days a week. To view Affinity's Best Available Evidence Policy click here.

    For more information visit the Best Available Evidence page on the Centers for Medicare and Medicaid Services website.

    Multi-Language Interpreter Services
    Find information on free interpreter services to answer any questions you may have about our health or drug plans here.

  • H5991_AffinityMedicarePlanWebsite2018 Pending Last updated 10/08/2017