Kansas Health Advantage provides Medicare Part D prescription drug coverage.
For your convenience, there is a complete list of all covered drugs in the plan (a comprehensive formulary). Our Online Drug List (Formulary) lists the Part D drugs covered by Kansas Health Advantage. Our formulary is designed to cover the drugs most needed to treat the special needs of our Members.
If the drug you are taking is not on the list of covered drugs, read your Evidence of Coverage to find out what you can do. This includes instructions for both new and current Members.
If you would like help managing your prescription drugs, read about our Medication Therapy Management program and its eligibility requirements. You can also see a sample of the Personal Medication List.
Member Materials
- Formulary Changes updated 03/19/2024
- Medication Therapy Management Program updated 03/19/2024
- Online Drug List (Formulary) updated 09/24/2024
- Online Drug Search
- Pharmacy Directory updated 03/19/2024
- Pharmacy Directory Search
- Prescription Utilization Management Prior Authorization Criteria updated 09/24/2024
- Prescription Utilization Management Step Therapy Criteria updated 09/24/2024
Member Materials
- Formulary Changes updated 03/19/2024
- Medication Therapy Management Program updated 03/19/2024
- Online Drug List (Formulary) updated 09/24/2024
- Online Drug Search
- Pharmacy Directory updated 03/19/2024
- Pharmacy Directory Search
- Prescription Utilization Management Prior Authorization Criteria updated 09/24/2024
- Prescription Utilization Management Step Therapy Criteria updated 09/24/2024
Last Updated on October 7, 2024
Member Resources
- Prescription Drug Transition Policy uupdated 03/19/2024
- Medicare Prescription Drug Coverage Determination Request Form updated 03/19/2024
- Medicare Prescription Drug Redetermination (Appeals) Request Form updated 03/19/2024
- Online link to Request a Medicare Prescription Drug Coverage Determination or Redetermination
- Online link to Register for access to the Real Time Benefits Tool
Member Materials
- Formulary Changes updated 11/21/2023
- Medication Therapy Management Program updated 11/21/2023
- Online Drug List (Formulary) updated 11/21/2023
- Online Drug Search
- Pharmacy Directory updated 11/21/2023
- Pharmacy Directory Search
- Prescription Utilization Management Prior Authorization Criteria updated 11/21/2023
- Prescription Utilization Management Step Therapy Criteria updated 11/21/2023
Member Materials
- Formulary Changes updated 11/21/2023
- Medication Therapy Management Program updated 11/21/2023
- Online Drug List (Formulary) updated 11/21/2023
- Online Drug Search
- Pharmacy Directory updated 11/21/2023
- Pharmacy Directory Search
- Prescription Utilization Management Prior Authorization Criteria updated 11/21/2023
- Prescription Utilization Management Step Therapy Criteria updated 11/21/2023
Last Updated on October 7, 2024
Member Resources
- Prescription Drug Transition Policy updated 11/21/2023
- Medicare Prescription Drug Coverage Determination Request Form updated 11/21/2023
- Medicare Prescription Drug Redetermination (Appeals) Request Form updated 11/21/2023
- Online link to Request a Medicare Prescription Drug Coverage Determination or Redetermination
- Online link to Register for access to the Real Time Benefits Tool
How to Request a Coverage Determination, Redetermination, or Grievance
A coverage determination is decision made by our plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it.
If a drug is not covered on our plan, you can ask Kansas Health Advantage to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if Kansas Health Advantage turns 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. Kansas Health Advantage will then consider your request.
A coverage determination may be requested by any of the following:
- You or your representative may request a coverage determination.
- Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.
A coverage determination may be requested for any of the following:
- Covering a Part D drug for you that is not on Kansas Health Advantage’s List of Covered Drugs (Formulary).
- You may ask Kansas Health Advantage for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your Kansas Health Advantage’s List of Covered Drugs (Formulary).
- You may ask for an exception if your network pharmacy can’t fill a prescription as written.
- Removing a restriction on Kansas Health Advantage’s coverage for a covered drug.
- You may ask for an exception if you or your prescriber believe that a coverage rule (such as a prior authorization) should be waived.
- Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception).
- You may ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believe you can’t take any of the lower tier drugs for the same condition. Applies if your plan has multiple tiers for your Part D Drugs.
- Request for payment.
- You may ask us to pay for a prescription that you already paid for.
Your doctor or other prescriber must give Kansas Health Advantage a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescriber when you ask for the exception.
Kansas Health Advantage can accept or deny your request.
If Kansas Health Advantage approves your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If Kansas Health Advantage says no to your request for an exception, you can ask for a review of Kansas Health Advantage’s decision by making an appeal. If your health requires a quick response, you must ask Kansas Health Advantage to make a “fast decision”.
A redetermination is also known as an appeal. If Kansas Health Advantage denies a member’s coverage determination/exception, the member may appeal the decision to Kansas Health Advantage by requesting a redetermination.
What Is a Grievance?
A grievance is a type of complaint that does not involve payment or denial of services by Kansas Health Advantage or a Contracting Medical Provider. For example, you would file a grievance if:
- You have a problem with things such as the quality of your care during a hospital stay;
- You feel you are being encouraged to leave your plan;
- Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room;
- Waiting too long for prescriptions to be filled;
- The way your doctors, network pharmacists or others behave;
- Not being able to reach someone by phone or obtain the information you need; or
- Lack of cleanliness or the condition of the office.
Who Can File a Grievance?
A grievance may be filed by any of the following:
- You may file a grievance.
- Your authorized representative.
Why File a Grievance?
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with Kansas Health Advantage or a Network Participating Provider or Pharmacy, especially if such complaints result from misinformation, misunderstanding, or lack of information.
Can I Expedite a Grievance?
Yes. If you disagree with Kansas Health Advantage’s decision to extend the timeframe on your organization determination or reconsideration, or Kansas Health Advantage’s decision to process your expedited request as a standard request. In such cases, you may file an expedited grievance and receive a response within twenty-four (24) hours of receipt.
Where can a Grievance Be Filed?
You may file a standard grievance in writing directly to: Kansas Health Advantage Appeals and Grievances Department, 201 Jordan Road, Suite 200, Franklin, TN 37067 by faxing 1-844-280-5360 or over the phone by contacting our Member Services Department at our toll-free number at 1-800-399-7524; TTY 1-833-312-0046. Our hours are between 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.
If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx.
Quality Measurement & Performance Improvement:
- Continuous improvement and monitoring of medical care, patient safety, and delivery of services
- Data analysis and standard reporting is used in the Annual Quality Improvement Work Plan
Measurable Goals and Health Outcomes for the Model of Care
- Processes and procedures to determine health outcomes are met
Member Satisfaction:
- Assessed annually
Model of Care Evaluation:
- Data is collected, analyzed and evaluated on a monthly, quarterly, and annual basis from each Model of Care domain to monitor performance, identify areas for improvement, and to ensure program goals have been meet
Dissemination of SNP Quality Performance Results
- Results shared within the organization and provider network
Forms and Links
This section provides specific information of particular importance to our Kansas Health Advantage Members receiving Part D drug benefits. Below are links to forms applicable to Part D grievances, coverage determinations (including exceptions) and appeals processes.
Request for a Medicare Prescription Drug Coverage Determination
A Member, a Member’s representative, or a Member’s prescriber may use this model form to request a coverage determination, including an exception, from Kansas Health Advantage.
Request for a Medicare Prescription Drug Redetermination (Appeals)
A Member, a Member’s representative, or a Member’s prescriber may use this model form to request a redetermination (appeal) from Kansas Health Advantage.
Online link to Request a Medicare Prescription Drug Coverage Determination or Redetermination.
A Member, a Member’s representative, or a Member’s prescriber may use this link to request a coverage determination or redetermination, from Kansas Health Advantage.
Best Available Evidence Policy
Federal regulations at 42 CFR § 423.800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.
To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate.
For more information, please view the best available evidence (BAE) policy.