Sentara Medicare Rx (PDP)

If you have any questions, please call the Pharmacy Help Desk at 1-866-603-7514 (TTY users call 711), 24 hours a day, 7 days a week.

If you learn that Sentara Medicare Rx does not cover your drug, you have two options:

• You can ask for a list of similar drugs that are covered by Sentara Medicare Rx. Show this list to your doctor to discuss alternative options.
• You can ask Sentara Medicare Rx to make an exception and cover your drug. See below for information about how to request an exception.

• You can ask Sentara Medicare Rx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Sentara Medicare Rx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Sentara Medicare Rx will only approve your request for an exception if the alternative drugs are included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition, and/or would cause you to have adverse medical effects.

You or your prescriber should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you or your prescriber request a formulary tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You or your prescriber can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

Coverage determination request form

Complaints (grievances)

A grievance is a complaint and does not involve a request for payment, a request for authorization for services or a request for an appeal of denied services by Sentara Medicare Rx. For example, you would file a grievance if:

• You are unhappy with the quality of care, such as the care you got in the hospital.
• You think that someone did not respect your right to privacy or shared information about you that is confidential.
• A health care provider or staff was rude or disrespectful to you.
• Sentara Health staff treated you poorly.
• You think you are being pushed out of the plan.
• You cannot physically access the healthcare services and facilities in a doctor or provider’s office.
• You are having trouble getting an appointment or were/are waiting too long to get it.
• You think the clinic, hospital, or doctor’s office is not clean
• Your doctor or provider does not provide you with an interpreter during your appointment.
• You think we failed to give you a notice or letter that you should have received.
• You believe that we are not meeting our deadlines for making a coverage decision or answering your appeal.

How to file a complaint (grievance)

• Contact the Pharmacy Help Desk at 1-800-927-6048 (TTY: 711), 24 hours a day, 7 days a week within 60 days of the occurrence. If you call, a representative will try to resolve your complaint over the phone. They may ask you for additional information so that they can research your issue. If we cannot resolve your complaint over the phone, they will start a formal process.
• You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing:

Express Scripts

Attn: Medicare Appeals

P.O. Box 66588

St. Louis, MO 63166-6588

• Grievances and appeals fax number: 1-877-251-5896

If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.

• Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest, or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint
• If we do not agree with some or all of your complaint, we will tell you and give you our reasons. We will respond whether we agree with the complaint or not.

Coverage redetermination request form

You can have someone help you file a complaint, request a coverage decision, or file an appeal. If you do not have someone with a durable power of attorney, as your court-appointed guardian or healthcare proxy, you can appoint a representative such as a relative, friend, advocate, or attorney. To appoint a representative, complete the Medicare form below or write a letter with all of the same information in this form. 

Appointment of representative form on CMS.gov

Send the form or letter along with legal documents (power of attorney or for your court-appointed guardian or healthcare proxy) to us with the completed form for the correct process below (see sections on complaints, coverage decisions, and appeal).

The doctor that is treating you can file a complaint, request a coverage decision, or file an appeal on your behalf without having to be appointed as your representative.

To fill your prescription, show your plan ID card at the network pharmacy. The network pharmacy will bill the plan for our share of the cost of your covered prescription drug. Depending on your prescription benefit, you may need to pay the pharmacy cost-share. If you do not have your plan ID card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information. If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. You can then ask us to pay you back for our share. If you cannot pay for the drug, contact Pharmacy Help Desk right away.

To learn how to ask us to pay you back, complete the Prescription Drug Member Reimbursement Form or contact the Pharmacy Help Desk at 1-866-603-7514 (TTY: 711), 24 hours a day, 7 days a week.

Prescription drug member reimbursement form

Yes, home delivery from Express Scripts Pharmacy is a convenient and cost-effective way for you to order up to a 90-day supply of your long-term medication.

• Convenient: Your long-term medications will be delivered to your home, office, or another location of your choosing.
• Cost Effective: Standard shipping is no additional charge to you and you can save money when you order a 90-day supply of your medications for home delivery.

How to use home delivery through Express Scripts Pharmacy

Ask your doctor to write a prescription for a 90-day supply of your long-term medication. Once you have your prescription, fill out an order form. Write your member ID, patient name, and patient date of birth on the back of each prescription.

You can begin getting your new or existing prescription by either:

• Mailing the form, prescription(s) and co-payment to:

Express Scripts Pharmacy
P.O. Box 66577
St. Louis, MO 63166-6577

• Visit our website: sentarahealthplans.com/members; or
• Call Express Scripts Pharmacy at 1-855-388-0354 (TTY: 711).

Your doctor can also order a prescription for you by calling the above number or by faxing your prescription to 1-888-327-9791. In order to be legally valid, the fax must originate from the physician’s office. All state laws apply.

You will receive your order within 14 days from the time Express Scripts Pharmacy receives your prescription(s). If you do not receive your order within 14 days, contact Express Scripts Pharmacy toll-free at 1-866-388-0354.

Do you need your medication right away? Ask your doctor for two prescriptions. The first one can be taken to your local pharmacy and the second can be sent to Express Scripts Pharmacy.

Express Scripts home delivery - prescription drug order form

For more information on if you qualify for low-income subsidy, please visit CMS.gov

Better therapeutic outcomes for members with multiple conditions

Our Medication Therapy Management Program (MTMP) is focused on improving therapeutic outcomes for Medicare Part D members. This program is administered by Express Scripts, our pharmacy benefits manager. Sentara Medicare Rx members can participate in this program at no cost. There is no change to insurance benefits, co-pays/coinsurance, prescription coverage, or available doctors or pharmacies while in this program.

To qualify for MTMP, a member must meet all of the following criteria:

• Members must have filled eight (8) or more chronic Part D medications; and
• Members must have at least three (3) of the following chronic conditions: asthma; chronic obstructive pulmonary disease (COPD); congestive heart failure (CHF); depression; diabetes, dyslipidemia, HIV/AIDs, hypertension, osteoporosis, and/or rheumatoid arthritis; and
• Members may likely incur an annual spend equal to or greater than $5,330 for 2024 for all covered chronic Part D medications. OR
• Are in a drug management program to help better manage and safely use medications such as opioids and benzodiazepines.

The success of our MTMP is built upon our proven experience using a wide range of services designed to help members with multiple conditions by:

• Ensuring they take their medications correctly
• Improving medication adherence
• Detecting potentially harmful medication uses or combinations of medications
• Educating members and healthcare providers

Our programs are evidence-based and can integrate both pharmacy and medical data, when available, and are built upon multiple measures that demonstrate positive clinical outcomes for members like you. Pharmacists, physicians, and PhDs develop, manage and evaluate the programs for effectiveness.

One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their healthcare provider.

Comprehensive medication review (CMR)

The Centers for Medicare & Medicaid Services (CMS) require all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of MTMP. If you meet the criteria outlined above, you will receive an MTMP enrollment mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members’ prescribers may receive a member-specific report.

The CMR includes three components:

1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or "behind the scenes" by a qualified provider and/or using computerized, clinical algorithms.
2. An interactive, person-to-person consultation performed by a qualified provider at least annually to all MTM-eligible members.
3. An individualized, written summary of the consultation for the member, including but not limited to, a personal medication list (PML), reconciled medication list, action plan, and recommendations for monitoring, education, or self-management.

Personal medication list

Sentara Health Plans has contracted with Express Scripts to deliver MTM services to eligible members. If you would like more information or do not want to take part in the program, please call the Express Scripts MTM Department at 1-844-866-3730 (TTY: 711), Monday through Friday from 9:00am to 7:00pm Central Standard Time.

The Member Bill of Rights and Responsibilities assures that all members are treated in a manner consistent with the health plan’s mission, goals and objectives. It also assures that members are aware of their obligations and responsibilities upon joining the health plan, throughout their membership with the health plan, and at the end of their enrollment with the plan.

When you join our Plan as a new member, you may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. You should talk with your doctor to determine what is best for your care. During the first 90 days of your new membership, Sentara Medicare may provide a temporary supply of a drug which is not on our formulary or which has restrictions. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary refill supply for the drug during the first 90 days of the new plan year.

We will provide a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy for a Part D drug that is not on our formulary or that is subject to restrictions, such as prior authorization or step therapy. You can only receive one temporary 30-day supply as part of our transition process. After you receive the temporary 30-day supply, we will provide you with a written notice explaining the steps you can take to request an exception and how to work with your doctors if you should switch to a drug we cover.

For members in a long-term care facility (like a nursing home)

If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary transition supply (unless you have a prescription written for fewer days). The first supply will be for a maximum of 98-days, or less if your prescription is written for fewer days. If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan, when that member is a resident of a long-term-care facility. If a new member, who is a resident of a long-term-care facility and has been enrolled in our Plan for more than 90 days, 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 34-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. This is in addition to the initial transition supply provided.

If a current member transitions to a different level of care, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days) and cover more than one refill during the first 90 days if the member transitions into a long-term care facility. If the transition is out of a long-term care facility, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when the member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). 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.