Pharmacy Benefit

About Alterwood Advantage's Medicare Part D Prescription Plans

What does Alterwood Advantage offer?

Alterwood Advantage has three (3) plans that offer prescription drug benefits. These plans are:

These plans are Medicare Advantage plus Prescription Drug plans that include medical coverage for medical services such as hospital expenses, doctor visits, and prescription drug coverage.

 

What drugs are covered?

Each plan has a formulary, which is a CMS approved list of medications covered by Alterwood Advantage. The formulary drugs covered are similar from plan to plan, but your out-of-pocket copay or coinsurance for a prescription will vary.

All formularies offer you and your doctor a variety of choices to treat your condition. You may view or download a copy of the formularies we offer by selecting the links below. In addition, you may search for your drug(s).

Some drugs on our formularies are subject to a coverage determination (also known as prior authorization), step-therapy, and or quantity limits. These are utilization management tools we use to ensure appropriate and medically necessary use of these drugs. More information about these utilization management tools can be found here.

When transitioning into our plan, you may be on drug(s) that are not on the Alterwood Advantage formulary. We have made arrangements with the network pharmacies to provide you a transition supply that will allow you to contact your prescriber(s) to transitioning you to similar drug(s) on our formulary that treats your condition(s). More information regarding our Transition Policy can be found here.

 

What is Extra Help?

If you have limited income and resources, you may qualify for Extra Help to pay for your prescription drugs. You may apply or get more information by calling your local Social Security Administration (SSA) office or call 1-800-772-1213 (TTY 1-800-325-0778 using specialty TTY equipment) between 8:00 AM and 7:00 PM Monday through Friday or visiting the Social Security Administration website. You may find the phone number to your local SSA office by using their Social Security Office Locator. SSA also has a variety of online services.

 

Does my plan cover other items such as OTC?

Over-the-counter (OTC) drugs and products are not covered under the Part D benefit. However, you may be enrolled in a plan that covers OTC drugs and products through a supplemental benefit. More information about the OTC supplemental benefit can be found here.

 

Does my plan cover other items such as diabetic supplies and vaccines?

Diabetic supplies and certain vaccines are covered under your medical or Part C benefit and are not covered under your Part D benefit. For your convenience, Alterwood Advantage is allowing certain diabetic supplies and Part B vaccines to be available at network pharmacies for greater access. Note: Please contact your network pharmacy to determine if they have these diabetic supplies in-stock and/or have qualified pharmacist(s) to administer these vaccines. More information is provided in your Evidence of Coverage (EOC).

 

Diabetic Supplies

Alterwood Advantage covers certain Abbott and LifeScan diabetic supplies such as blood glucose monitors, blood glucose test strips, and lancets at network pharmacies with a valid prescription. Quantity limits are defined by CMS and more details can be found in your EOC.

Alterwood Advantage does not cover other manufacturers of diabetic supplies at network pharmacies. Other brands of diabetic supplies may also be available at network DME providers with a valid provider order.

 

Vaccines

Coverage of vaccines vary depending on the vaccine, what it is being used for, and where you get the vaccine.

The following Part D vaccines are available at certain network pharmacies and covered by Alterwood Advantage:

  • Shingles
  • Human papillomavirus (HPV)
  • Measles, mumps, rubella (MMR)
  • Diphtheria
  • Pertussis

Part D vaccinations do have a cost-share that varies depending on where you get vaccinated. Part D vaccines obtained at a network pharmacy will usually have a lower cost-share amount. If you get a Part D vaccine at your doctor’s office, your cost-share can vary, and you will need to submit for reimbursement. More information can be found in your EOC.

The following Part B vaccines are available at certain network pharmacies and covered by Alterwood Advantage:

  • Influenza (flu shot)
  • Pneumococcal pneumonia
  • Hepatitis B*

*Subject to a coverage determination to ensure use for intermediate or high-risk individuals only.

Part B vaccinations do not have a cost-share. These vaccinations are available at network providers and certain network pharmacies.

 

Where can I get my prescription(s)?

Alterwood Advantage has a national network of pharmacies. For your convenience, the network pharmacies in Maryland are listed in our Provider & Pharmacy Directory that you can access below. In addition, you may search our pharmacy network in Maryland and out-of-state by selecting Search Pharmacies.

View or Download Provider & Pharmacy Directory

Search Pharmacies

If you wish to obtain your prescription(s) that you take regularly through the mail, we have partnered with Elixir Pharmacy for this service. You would simply place a completed mail order form with your prescription(s) into an envelope and mail it to Elixir Pharmacy, LLC, 7835 Freedom Ave. NW, North Canton, OH 44720.

 

What happens if you go to an out-of-network pharmacy?

Alterwood Advantage offers over 60,000 network pharmacies across the country. If you need to get your prescription(s) from a pharmacy not in our network, you may send us a copy of your prescription receipt(s) with a completed Direct Member Reimbursement form.

We will only reimburse you for up to a ten (10) days supply of your out-of-network prescriptions under certain circumstances. These circumstances can be found in your EOC.

 

What is Medication Therapy Management?

Alterwood Advantage’s Medication Therapy Management Program (MTMP) is available to members who meet certain qualifying parameters. You may find out more about our program by selecting MTMP.

Who do I call if I have any questions regarding my Part D benefit, prescription drugs, and/or pharmacy, including mail order?

You may contact us at 667-261-8050 or 866-267-3144 (TTY: 711). We are available 24 hours a day, 7 days a week.


Various prescription related Part D forms can be found here.