2014 Plan Information

Web Content Display

Thank you for your membership in Transamerica MedicareRx (PDP), sponsored by Stonebridge Life Insurance Company. Transamerica MedicareRx  provides you with access to a wide variety of prescription drugs. The service area for this plan includes all states except New York and the U.S. Territories.

Our member web site provides you with tools, information, and resources to help you understand your prescription drug benefits.  Click on the links below to easily jump to information on these topics.

Plan Documents and Forms
Summary of Benefits
Evidence of Coverage (EOC)
Errata Sheet (Correction Sheet)
Annual Notice of Change (ANOC)
Formulary Information
Pharmacy Access
Transition Policy & Process
Coverage Decisions, Appeals and Grievances
Rights and Responsibilities
Drug Utilization Reviews
Premium and Low Income Subsidy (LIS) Information
Extra Help
Plan Ratings

 

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information, contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1 of each year. Members must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Limitations, copayments, and restrictions may apply. We also list pharmacies that are in our network but are outside of our plan's service area.

Plan Documents and Forms

To view the plan documents and forms for your preferred plan, please select your state of residence from the drop-down menu below.

Transamerica MedicareRx Classic (PDP)Transamerica MedicareRx Choice (PDP)

 

Many of the links on this page open documents produced in Adobe Portable Document Format (PDF) and require you to have Adobe Reader installed on your computer in order to view them.

Get Adobe Reader

Web Content Display

⤴  Top

Summary of Benefits

Your Summary of Benefits, located in the "Plan Documents and Forms" section above, tells you about some of the features of our plan, such as our plan's service area, as well as a list of benefits, conditions and limitations, premiums, cost-sharing (copays, coinsurance, deductible) and more. It doesn't list every drug we cover, every limitation, nor every exclusion. To get a complete list of our benefits, please review your Evidence of Coverage.

⤴  Top

Evidence of Coverage (EOC)

Your Evidence of Coverage booklet, located in the "Plan Documents and Forms" section above,  gives you the details about your Medicare prescription drug coverage for a given coverage year. It explains how to get the prescription drugs you need, what you must do, your rights, and what you have to do as a member of our plan. This is an important legal document. Please keep it in a safe place.

⤴  Top

Errata Sheet (Correction Sheet)

We send an Errata Sheet, located in the "Plan Documents and Forms" section above, if we need to make corrections to your Evidence of Coverage. This notice is an amendment to your original Evidence of Coverage and replaces certain sections or pages noted in the errata sheet. Please keep this updated information with your member materials for future reference. There is no action required on your part.

⤴  Top

Annual Notice of Change (ANOC)

First time Transamerica MedicareRx members will not receive an ANOC booklet until September 2014.  This booklet will explain any changes to your prescription drug coverage for the following year. 

⤴  Top

Formulary Information

What is the Transamerica MedicareRx Formulary?

A formulary is a list of covered drugs chosen by Transamerica MedicareRx in consultation with a team of health care providers. The Transamerica MedicareRx Formulary, located in the "Plan Documents and Forms" section above, represents the prescriptions believed to be necessary to meet our members' needs. You received a partial (abridged) formulary in your Welcome Kit, which covers the most commonly used drugs.  This website has a full (comprehensive) list of all drugs covered by our plan.  Transamerica MedicareRx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Transamerica MedicareRx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary change?

Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not stop or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when questions about the safety or effectiveness of a drug are released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are taking the drug at that time. The drug will stay available at the same cost-sharing for those members taking it for the rest of the coverage year.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy limits on a drug, or if we move a drug to a higher cost-sharing tier, we must tell affected members of the change at least 60 days before the change occurs, or at the time the member requests a refill of the drug. Please review Transamerica MedicareRx Formulary Updates (Change Notices), located in the "Plan Documents and Forms" section above. .

If the Food and Drug Administration (FDA) decides a drug on our formulary is unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and give notice of this change as soon as possible to members who take the drug. Please review  Formulary Changes Due to Drug Recalls, located in the "Plan Documents and Forms" section above. If mid-year non-maintenance formulary changes occur, affected members will be told of formulary changes in their Monthly Prescription Drug Summary, also called the Part D Explanation of Benefits (EOB).

To get updated information about the drugs covered by Transamerica MedicareRx, please call Member Services.

How do I use the Formulary?

Search within the Transamerica MedicareRx Formulary. To search within the document, you may search by medical condition or alphabetical listing.

  • Medical Condition
    The drugs in this formulary are grouped into categories depending on the type of medical conditions the drugs are used to treat. For example, drugs used to treat a heart condition are listed under the category, "Cardiac Drugs". If you know what your drug is used for, look for the category name in the list. Then, look under that category name for your drug.
  • Alphabetical Listing
    If you are not sure what Medical Condition or category to look under, you should look for your drug in the Index. The Index has an alphabetical list of all of the drugs included in the Formulary. Both brand name drugs and generic drugs are listed in the Index. Next to the name of your drug in the Index, you will see the page number where you can find coverage information. On that page number, you will be able to find the name of your drug in the first column of the table shown.

What are generic drugs?

Transamerica MedicareRx covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient as a brand name drug. Generic drugs usually cost less than brand name drugs and are deemed by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have requirements or limits on their coverage. These requirements and limits may include:

  • Prior Authorization: Transamerica MedicareRx requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Transamerica MedicareRx before you fill your prescriptions. If you don't get approval, Transamerica MedicareRx may not cover the drug.
  • Quantity Limits: For certain drugs, Transamerica MedicareRx limits the amount of the drug that Transamerica MedicareRx will cover. For example, Transamerica MedicareRx provides 18 tablets in 28 days per prescription for the drug Maxalt. This may be in addition to a standard one-month or three-month supply.
  • Step Therapy: In some cases, Transamerica MedicareRx requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Transamerica MedicareRx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Transamerica MedicareRx will then cover Drug B.

You can find out if your drug has any other requirements or limits by looking in the Transamerica MedicareRx Formulary. Your provider can also review our specific clinical criteria for step therapy and quantity limits in the Utilization Management Guidelines, located in the "Plan Documents and Forms" section above.  You can also get more information about the restrictions for specific covered drugs by calling Member Services.

You can ask Transamerica MedicareRx to make an exception to these restrictions or limits. See the question "How do I request an exception to the Transamerica MedicareRx's formulary?" below for information about how to request an exception. You can also refer to Chapter 7 of your Evidence of Coverage.

What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that Transamerica MedicareRx does not cover your drug, you have two options:

  • You can ask Member Services for a list of similar drugs that are covered by Transamerica MedicareRx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Transamerica MedicareRx.
  • You can ask Transamerica MedicareRx to make an exception and cover your drug. See the next question "How do I request an exception to the Transamerica MedicareRx formulary?" below for information about how to request an exception. You can also refer to Chapter 7 of your Evidence of Coverage.

How do I request an exception to the Transamerica MedicareRx Formulary?

You can ask Transamerica MedicareRx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make for a drug.

  • Formulary Exception to Cover a Drug Not on Our Formulary:  You can ask us to cover your drug, even if it is not on our formulary. Generally, Transamerica MedicareRx will only approve your request for a formulary exception if the alternative drug is included on the plan's formulary. If we agree to make an exception and cover a drug that is not on the formulary, you will need to pay the cost-sharing amount that applies to Non-Preferred Brand drugs.
  • Formulary Exception to Remove a Restriction on a Drug:  You can ask us to remove coverage restrictions or limits on your drug. For example, for certain drugs, Transamerica MedicareRx limits the amount of the drug that we will cover.  This is called a Quantity Limit. If your drug has a Quantity Limit, you can ask us to waive the limit and cover more of the drug. Generally, Transamerica MedicareRx will only approve your request for an exception if these restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
  • Changing coverage of your drug to a lower cost-sharing tier.  Every drug on our Formulary is in one of several cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug.  If your drug is in the Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand tier. If your drug is in the Non-Preferred Generic tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Generic tier. This would lower your share of the cost for the drug.  You cannot ask us to change the cost-sharing tier for any drug in the Specialty tier. Please see Chapter 4 of your Evidence of Coverage for your cost-sharing amounts.

You should contact us to ask us for an initial coverage decision for a formulary or tiering exception. You should submit a statement from your prescriber supporting your request. Generally, we must make our decision within 72 hours of getting your doctor's (or other prescriber's) supporting statement. You 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 for a fast decision is granted, we must give you a decision no later than 24 hours after we get your doctor's (or other prescriber's) supporting statement.

For more information

For more detailed information about your Transamerica MedicareRx prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Transamerica MedicareRx, please call Member Services.

⤴  Top

Pharmacy Access

Members must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply. We also list pharmacies that are in our network but are outside of our plan's service area.

What is Transamerica MedicareRx's pharmacy network?

We call the pharmacies on this list our "network pharmacies" because we have made arrangements with them to provide prescription drugs to our plan members.  Transamerica MedicareRx (PDP) has contracts with more than 65,000 pharmacies nationwide that meet or exceed Medicare's requirements for pharmacy access in your area. This ensures easy access to a network pharmacy. As a Transamerica MedicareRx member, you have access to thousands of retail pharmacy locations, as well as convenient and safe mail-order delivery through Postal Prescription Services (PPS). Long-term care and home infusion pharmacies may serve a larger area. Therefore, you may need to look outside of your local area for these types of pharmacies.

A network pharmacy is a pharmacy where members can use the prescription drug benefits provided by Transamerica MedicareRx. In most cases, your prescriptions are covered by Transamerica MedicareRx only if they are filled at a network pharmacy. Once you go to one pharmacy, you are not required to keep going to the same pharmacy to fill your prescription. You can go to any of our network pharmacies. We will fill prescriptions at non-network pharmacies only under certain circumstances described under the question "When can I use an out-of-network pharmacy?" below.

What are my pharmacy options?

Transamerica MedicareRx has options to match your needs.  If you are looking for the local service of a neighborhood pharmacy, you can choose one of our more than 65,000 community network pharmacies.  If you are looking for the ease of having your prescriptions filled and sent to you by mail, you can access our mail-order pharmacy.  Or, if you need drugs of a specialty type, the support of a specialty pharmacy may be of use to you.

Community Pharmacies

Transamerica MedicareRx has more than 65,000 community pharmacies for your use, including most chain drug stores and many independent pharmacies. At home or on vacation, you can find a pharmacy by calling Transamerica MedicareRx Member Services.  For your convenience, you may get an extended day supply of your prescription drugs at many of our retail pharmacies under our Choice90Rx® program. See your Pharmacy Directory or call Member Services for more details about which pharmacies participate in the Choice90Rx program.

Mail-Order Pharmacy

Ordering prescriptions by mail is like having a pharmacy at your door. It can save you trips to the pharmacy while giving you added privacy. You may also see copayment savings.Postal Prescription Services (PPS) is your Transamerica MedicareRx mail order pharmacy. Within 10 days of placing an order, you will receive up to a 90-day supply of your prescription(s) in your mailbox. It's as simple as that!

To get started in the Postal Prescription Services mail order program, choose from one of the three ways listed below to get your order quickly and conveniently.

How to use the Mail Order Pharmacy:
By Phone: You may call Postal Prescription Services Customer Service at 1-800-552-6694.
By Mail: Complete and mail in the Postal Prescription Services order form found with your post-enrollment information or in the "Plan Documents and Forms" section above. Once you have completed the mail order form, mail it along with your prescription(s) and payment (if applicable) to the mail service pharmacy address as indicated.
On the Web: Go to www.ppsrx.com and create a user ID and password.

If you have questions about mail order, contact either your mail service pharmacy or Transamerica MedicareRx's Member Services.

Specialty Pharmacy Services

If you are taking a medication that is on the Specialty tier of your prescription benefit, you may use any specialty pharmacy in Transamerica MedicareRx's specialty pharmacy network. 

Only you know what pharmacy options best suit you. Transamerica MedicareRx is pleased to offer you the choice of local pharmacies, prescriptions by mail, and specialty pharmacies that support you and your specific needs. If you have questions on any of these pharmacy options or your Transamerica MedicareRx, our Member Services staff is here to help you.

Other pharmacies are available in our network.

How do I find a Transamerica MedicareRx network pharmacy in my area?

To find a participating pharmacy in your area, view or download our national Pharmacy Directory, located in the "Plan Documents and Forms" section above. Please be aware that this directory has over 1,000 pages, so printing is not advised. You can also refer to your Welcome Kit for the pharmacy directory for your state. If you would like to request a printed copy of a pharmacy directory for another state, please call Member Services.

Can the list of network pharmacies change?

The pharmacies listed in our directory are current as of date the directory was last updated, but this does not guarantee that a pharmacy continues to participate in your plan's network.

To get a complete description of your prescription drug coverage, including how to fill your prescriptions, please review your Evidence of Coverage. Transamerica MedicareRx may add or remove pharmacies from our pharmacy network. To get current information about Transamerica MedicareRx network pharmacies in your area, call Member Services.

You may also write to:
Transamerica MedicareRx
P.O. Box 509099
San Diego, CA 92150

When can I use an out-of-network pharmacy?

In most cases, your prescriptions are covered under this plan only if they are filled at a network pharmacy. Covered Part D drugs are available at out-of-network pharmacies in special situations, including illness while traveling outside the plan's service area where there is no retail network pharmacy. Please note that the pharmacies in our network may change. For the most up-to-date information, contact Member Services.

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

  • If you are traveling and you become ill, you lose, or you run out of your covered Part D prescription drugs, and cannot access a network pharmacy.
  • If you are trying to fill a covered prescription drug that is not regularly stocked at a network retail or mail-order pharmacy (these drugs include orphan drugs or other specialty drugs).
  • If you are unable to get a Part D covered drug in a timely manner within our service area. For example, because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
  • You are provided covered Part D drugs dispensed by an out-of-network institution-based pharmacy while you are a patient in an emergency department, provider-based clinic, outpatient surgery center, or other outpatient setting.
  • During any State or Federal disaster declaration or other public health emergency declaration in which you are evacuated or otherwise displaced from where you live and cannot reasonably be expected to get covered Part D drugs at a network pharmacy.
  • In unforeseen circumstances where normal distribution channels are unavailable, we will apply out-of-network policies to help give you access to medications.
  • Health care provider's office access: You are getting a vaccine that is medically necessary but is not covered by Medicare Part B and is appropriately dispensed and administered in a health care provider's office. Note: You may self-pay the provider for the vaccine cost and submit a paper claim requesting reimbursement. It is also permissible for a third party administrator to assist beneficiaries with the submission of out-of-network claims for vaccines administered in a health care provider's office.

For more information about submitting these claims, contact Member Services.Or, you may refer to the process described in the next question below labeled "How do I ask for reimbursement from the plan?".

If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our network mail-order pharmacy service or through a retail network pharmacy that offers an extended supply. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. We will not reimburse members for Part D medications obtained from an Excluded Provider. We will not routinely allow more than a month's supply of medication to be dispensed at the out-of-network pharmacy. (See the table entitled Payment Requests in Chapter 2, Section 1, of your Evidence of Coverage for the address where you may send reimbursement requests.)

Before you fill your prescription in any of these situations, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your coinsurance or co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. For more information on how to submit a paper claim, please refer to the next section labeled "How do I ask for reimbursement from the plan?" or refer to Chapter 5 of your Evidence of Coverage in the section labeled "How to ask us to pay you back."

How do I ask for reimbursement from the plan?

If you use an out of network pharmacy or if you purchased a covered medication without the use of your pharmacy benefit card (for example, you forgot your member ID card and the pharmacy is unable to confirm your information), or you received a Part D vaccine for which you paid the administration fee, you will generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription.  You can ask us to reimburse you for our share of the cost. (Chapter 5, Section 2.1 of your Evidence of Coverage explains how to ask the plan to pay you back.)

Network pharmacies automatically submit your claim electronically to us. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to verify your benefits and submit the claim directly to us, so you will have to pay the full cost of your prescription and request reimbursement.

To submit a claim for direct member reimbursement, you may access and print the Direct Member Reimbursement (Claims) Form in the "Plan Documents and Forms" section above or you may call Members Services to request that the form be mailed to you. Using the form and including a copy of your prescription receipt(s) will allow us to process your claim more quickly, but you are not required to do so.

Simply submit your reimbursement form and your receipt(s) to the address provided on the form. Upon receipt, we will make an initial coverage determination on the claim. Notification will be made either directly to you or your authorized representative. If the coverage determination is favorable and the payment is authorized, a check will be mailed directly to you within fourteen days of receipt of the coverage determination request.

If payment is denied, written notification will be mailed within fourteen days from the receipt of the request for coverage determination. You will also receive a communication regarding your right to request a standard redetermination (appeal).

⤴  Top

Transition Policy & Process

Under certain circumstances, Transamerica MedicareRx (PDP) can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your drug coverage must be one of the following types of changes:
The drug you have been taking is no longer on the plan's Drug List
-- or -- the drug you have been taking is now restricted in some way
2. You must be in one of the situations described below:

  • For those members who are new to the plan and aren't in a long-term care facility:
    We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 31 days, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
  • For those members who are new to the plan and reside in a long-term care facility:
    We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31 days, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
  • For those members who have been in the plan for more than 90 days and reside in a long-term care facility and need a supply right away:
    We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
  • Current enrollees that are prescribed non-formulary drugs as a result of a change in level of care can be placed in a transition period. A one-time fill in these scenarios may be accommodated via a manual override at point-of-sale. Level of care changes include the following changes from one treatment setting to another:
    • Entering a long-term care facility from a hospital or other settings;
    • Leaving a long-term care facility and returning to the community;
    • Discharge from a hospital to a home;
    • Ending a stay in a skilled nursing facility covered under Medicare Part A (including pharmacy charges), and revert to coverage under Part D;
    • Reverting from hospice status to standard Medicare Part A and B benefits; and
    • Discharge from a psychiatric hospital with medication regimens that are highly individualized.

To ask for a temporary supply, please call Member Services.

During the time when you are getting a temporary supply of a drug, you should talk with your prescriber to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. (See the question in the next section below labeled "How do I request an exception to the Transamerica MedicareRx Formulary" for more information about these options.)

⤴  Top

Coverage Decisions, Appeals and Grievances

The process for coverage decisions and appeals is for problems related to your benefits and coverage for prescription drugs, including problems about payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered. The process for complaints, also called grievances, deals with problems about quality of care, waiting times, and customer service. For more information about coverage decisions, appeals and complaints/grievances, see Chapter 7 of your Evidence of Coverage.

If you have additional questions about this process, about the status of your coverage decision, appeal or grievance, or to get a summary of the grievances, appeals and exceptions filed with our plan, see the contact information listed at the bottom of this section.

COVERAGE DECISIONS

What is a coverage decision?

A coverage decision is a decision we make about the coverage of or the amount we will pay for your prescription drugs. This includes asking our plan to make an exception to how we cover a drug.

How do I request a coverage decision?

Start by calling, writing, or faxing us to make your request. (Scroll to the bottom of this section for contact information.) If you would like to submit a request in writing, you may download the Coverage Decision Request Form, located in the "Plan Documents and Forms" section above.

You can also submit a coverage decision request online. Include your name, address, Member ID Number, the reason for your request, and any additional information/evidence you wish to provide. You, your representative, or your doctor (or other prescriber) can do this. For the form to be completed by your doctor (or other prescriber), download the Coverage Decision Request Form for Prescribers, located in the "Plan Documents and Forms" section above. If your health requires a quick response, you must ask us to make a "fast decision" when you call. When a "fast decision" is requested, you will get an answer within 24 hours (or less if your health requires us to do so). To ask for a "fast decision", you must be asking for coverage for a drug you have not yet received and using the standard timeline for a decision could cause serious harm to your health or hurt your ability to function. If your doctor or prescriber tells us your health requires a "fast decision", we will automatically give you a fast decision.

If you do not ask for a "fast decision", we will use the standard decision timeline. With a standard decision, we will give you an answer within 72 hours if your request is about a drug you have not yet bought and within 14 calendar days if it is about a drug you have already bought. If you made a payment request and we agree with your request, we must make payment to you within 30 calendar days.

In some cases, we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

How do I request an exception for a drug?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception." An exception is a type of coverage decision and the above timelines apply. Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception before we will consider your request.

You or your doctor or other prescriber can ask us to make any of the following exceptions:

  • Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary). If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to the Non-Preferred Brand tier. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. Excluded drugs cannot be covered.
  • Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our Formulary. For example, you may ask us to waive the quantity limit for a certain drug.
  • Changing coverage of your drug to a lower cost-sharing tier.  Every drug on our Formulary is in one of several cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug.  If your drug is in the Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand tier. If your drug is in the Non-Preferred Generic tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Generic tier. This would lower your share of the cost for the drug.  You cannot ask us to change the cost-sharing tier for any drug in the Specialty tier. Please see Chapter 4 of your Evidence of Coverage for your cost-sharing amounts.

Our plan is not required to grant any of these exception requests.

What if I disagree with your decision?

If you disagree with a coverage decision we make, you can appeal our decision. There are several levels of appeal, described below.

Contact Information for Coverage Decisions:

Member Services is open 24 hours a day, 365 days a year.

Call:

1-888-672-7206. TTY/TDD users should call 711.  

TTY/TDD:

711

Fax:

1-858-790-7100

Write:

Attn: Prior Authorization Department
Transamerica MedicareRx
10680 Treena Street, Stop 5
San Diego, CA 92131

APPEALS/REDETERMINATIONS

What is an appeal/redetermination?

If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision (also known as asking for a redetermination). An appeal is a formal way of asking us to review and change a coverage decision we made. This includes a decision to deny coverage or payment for prescription drugs you have already received and paid for.

How do I appeal a decision?

You have up to 60 calendar days to file your appeal, but it is best to file your appeal as soon as you decide you disagree with the decision our plan has made. We may give you more time if you have a good reason for missing this deadline. Start by calling, writing, or faxing us to make your request. (Scroll to the bottom of this section for contact information.)

You may download the Redetermination Request Form, located in the "Plan Documents and Forms" section above, or you may submit your request online.

Include your name, address, Member ID Number, the reason for your request, and any additional information/evidence you wish to provide. You, your representative, or your doctor (or other prescriber) can do this.

You may request a "fast appeal" in writing or over the phone if you are appealing a decision we made about a drug you have not yet received and using the standard timeline for an appeal could cause serious harm to your health or hurt your ability to function. If you request a "fast appeal", you will receive a decision from us within 72 hours of receipt of the appeal.

If you do not request a "fast appeal", we will use the standard appeal timeline and you will receive a response from us within 7 calendar days. We do not accept standard appeals by phone.

What happens when I make an appeal?

When you make an appeal, we review the coverage decision we made to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision in writing.

What if I disagree with your decision about my first appeal?

If we say no to your appeal, we will send you a written explanation of our Level 1 decision along with instructions on how to make a Level 2 Appeal. You choose whether to accept our Level 1 decision or continue by making another appeal. If you decide to make another appeal, your appeal will go on to Level 2 of the appeals process where our decision will be reviewed by the Independent Review Organization. This organization is not connected with us in any way and decides whether our decision should be changed or not. To make a Level 2 Appeal, you must contact the Independent Review Organization and ask for a review of your case. When you make a Level 2 Appeal, we will send the information we have to the Independent Review Organization.

If your health requires it, you can ask the Independent Review Organization for a "fast appeal". If the organization agrees to a "fast appeal", they must give you an answer within 72 hours after they receive your appeal. If the organization says yes to all or part of what you requested in your appeal, we must provide the drug coverage that was approved within 24 hours. If you have a standard appeal, the organization must give you an answer within 7 calendar days after they receive it. If the organization says yes to all or part of what you requested in your appeal, we must provide the drug coverage within 72 hours. If a payment request for a drug you have already paid for is approved by the organization, we must send you payment within 30 calendar days.

How many appeals can I make?

If you disagree with the Level 2 Appeal decision you can continue to Level 3, but the dollar value of the drug coverage you are requesting must meet a minimum amount. The notice you get following your Level 2 Appeal will tell you if your appeal meets that dollar amount. If the dollar amount of the coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final.

If your appeal qualifies for Level 3, an Administrative Law Judge will review your appeal and give you an answer. If the judge says no to your appeal, the notice you will get tells you what to do next if you choose to continue with your appeal. At Level 4, the Medicare Appeals Council, who works for the federal government, will review your appeal and give you an answer. If you disagree with the Level 4 decision, you may be able to continue to the next level of appeal. At Level 5, a judge at the Federal District Court will review your appeal. This is the last step of the appeals process.

Contact Information for Appeals:

Member Services is open 24 hours a day, 365 days a year.

Call:

1-888-672-7206. TTY/TDD users should call 711.*

TTY/TDD:

711

Fax:

1-858-790-6060

Write:

Attn: Appeals Department
Transamerica MedicareRx
P.O. Box 509099
San Diego, CA 92150

*We do not accept standard appeals by telephone call. Standard appeals must be submitted in writing.

COMPLAINTS/GRIEVANCES

What is a complaint/grievance?

The formal name for making a complaint is "filing a grievance". The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times (including those for coverage decision or appeals responses), and the customer service you receive. We encourage you to let us know right away if you have questions, concerns or problems related to your prescription drug coverage. You cannot be disenrolled or penalized for making a complaint.

How do I make a complaint?

Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. (Scroll to the bottom of this section for contact information.)

What happens when I make a complaint?

Whether you choose to call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If you are making a complaint because we denied your request for a "fast decision" about a coverage decision or appeal, we will automatically give you a "fast complaint" and give you an answer within 24 hours. Whenever possible, we will answer you right away. Most complaints are answered within 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 days total) to answer your complaint. If we do not agree with all or part of your complaint or don't take responsibility for the problem you are complaining about, our response will include our reasons. Our plan must respond whether we agree with your complaint or not.

What if my complaint is about quality of care?

When your complaint is about quality of care, you can make your complaint by using the process outlined above. You also have two extra options.

  • You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint directly to this organization without making a complaint to us.
  • Or, you can make your complaint to both at the same time.

To find the name and contact information for the Quality Improvement Organization for your state, see Exhibit B of your Evidence of Coverage.

Contact Information for Complaints/Grievances:

Member Services is open 24 hours a day, 365 days a year.

Call:

1-888-672-7206. TTY/TDD users should call 711.

TTY/TDD:

711

Fax:

1-858-790-6000

Write:

Attn: Grievance Department
Transamerica MedicareRx
P.O. Box 509099
San Diego, CA 92150

APPOINTING A REPRESENTATIVE

What is an appointed representative?

You, your prescribing physician, or someone you name may act for you to request a coverage determination or file a grievance or appeal. The person you name would be your "appointed representative." You may name a relative, friend, lawyer, doctor, or anyone else to act on your behalf. Other persons may already be authorized under State law to act for you.

If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative.

You may use CMS' Appointment of Representative form (Form CMS-1696) which can be obtained by contacting Member Services or you may download Form CMS-1696 (Appointment of Representative Form) from CMS' website or from the "Plan Documents and Forms" section above. You may also use an equivalent notice that satisfies the requirements of Form CMS-1696.

By signing the form, the representative shows his/her acceptance of being appointed as your representative. If any information is missing from the form, we will contact the individual attempting to act as your representative and provide a description of the missing information. Unless the missing information is provided, the representative does not have the authority to act on your behalf and is not allowed to receive any information related to your coverage determination, grievance or appeal, including the decision.

⤴  Top

Rights and Responsibilities

As a member of Transamerica MedicareRx, you have Rights and Responsibilities, located in the "Plan Documents and Forms" section above.  We must honor your rights as a member of the plan.  You also have some responsibilities as a member of our plan.  The document above is part of your Evidence of Coverage.

⤴  Top

Drug Utilization Reviews

Transamerica MedicareRx (PDP) conducts drug utilization reviews for all of our members to make sure they are getting the right care safely. These reviews are most important for members who have more than one health care provider prescribing their medications.

We conduct drug utilization reviews each time you fill a prescription and on a regular basis following a review of our records. During these reviews, we look for medication problems such as:

  • Possible medication errors
  • Duplicate drugs that are not necessary because you are taking another drug to treat the same medical condition
  • Drugs that are inappropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking
  • Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your health care provider to correct the problem. We also look for opportunities to lower your drug costs and will consult with your health care provider to decide if less expensive alternatives are right for you. Should you have questions about drug utilization review or any other questions about our plan, please call Member Services.

⤴  Top

Premium and Low Income Subsidy (LIS) Information

Premium Summary Tables

2014 Plan Premium* Table

Transamerica MedicareRx Classic (PDP)

Alabama

$48.40

Alaska

$44.10

Arizona

$39.70

Arkansas

$42.90

California

$46.90

Colorado

$46.90

Connecticut

$40.90

Delaware

$40.00

District of Columbia

$40.00

Florida

$44.00

Georgia

$43.50

Hawaii

$29.20

Idaho

$48.10

Illinois

$44.60

Indiana

$50.70

Iowa

$48.30

Kansas

$49.80

Kentucky

$50.70

Louisiana

$46.60

Maine

$41.40

Maryland

$40.00

Massachusetts

$40.90

Michigan

$45.50

Minnesota

$48.30

Mississippi

$46.10

Missouri

$47.70

Montana

$48.30

Nebraska

$48.30

Nevada

$46.00

New Hampshire

$41.40

New Jersey

$36.20

New Mexico

$42.60

North Carolina

$44.90

North Dakota

$48.30

Ohio

$43.90

Oklahoma

$48.30

Oregon

$45.10

Pennsylvania

$45.20

Rhode Island

$40.90

South Carolina

$38.40

South Dakota

$48.30

Tennessee

$48.40

Texas

$45.80

Utah

$48.10

Vermont

$40.90

Virginia

$46.00

Washington

$45.10

West Virginia

$45.20

Wisconsin

$51.70

Wyoming

$48.30

2014 Plan Premium* Table

Transamerica MedicareRx Choice (PDP)

Alabama

$58.00

Alaska

$53.30

Arizona

$50.10

Arkansas

$52.20

California

$57.50

Colorado

$56.80

Connecticut

$51.70

Delaware

$51.10

District of Columbia

$51.10

Florida

$53.90

Georgia

$53.40

Hawaii

$44.80

Idaho

$57.60

Illinois

$54.60

Indiana

$60.10

Iowa

$55.70

Kansas

$58.70

Kentucky

$60.10

Louisiana

$56.50

Maine

$49.60

Maryland

$51.10

Massachusetts

$51.70

Michigan

$51.50

Minnesota

$55.70

Mississippi

$56.20

Missouri

$56.50

Montana

$55.70

Nebraska

$55.70

Nevada

$57.50

New Hampshire

$49.60

New Jersey

$51.30

New Mexico

$54.00

North Carolina

$54.80

North Dakota

$55.70

Ohio

$52.80

Oklahoma

$58.40

Oregon

$54.30

Pennsylvania

$55.20

Rhode Island

$51.70

South Carolina

$54.00

South Dakota

$55.70

Tennessee

$58.00

Texas

$54.70

Utah

$57.60

Vermont

$51.70

Virginia

$55.80

Washington

$54.30

West Virginia

$55.20

Wisconsin

$59.90

Wyoming

$55.70


*This does not include any Medicare Part B premium you may have to pay.

LIS Premium Summary Tables

Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

The Transamerica MedicareRx Classic (PDP) and Transamerica MedicareRx Choice (PDP) tables below show you what your monthly plan premium will be if you get extra help.

Transamerica MedicareRx Classic (PDP)

Your Level of Extra Help

Your Monthly Premium for Plan*

100%

75%

50%

25%

Alabama

$18.70

$26.10

$33.60

$41.00

Alaska

$7.00

$16.30

$25.60

$34.80

Arizona

$12.20

$19.10

$26.00

$32.80

Arkansas

$12.90

$20.40

$27.90

$35.40

California

$18.80

$25.80

$32.80

$39.90

Colorado

$20.00

$26.70

$33.40

$40.20

Connecticut

$12.90

$19.90

$26.90

$33.90

Delaware

$7.70

$15.70

$23.80

$31.90

District of Columbia

$7.70

$15.70

$23.80

$31.90

Florida

$21.90

$27.40

$32.90

$38.50

Georgia

$14.20

$21.50

$28.80

$36.20

Hawaii

$3.50

$9.90

$16.40

$22.80

Idaho

$9.10

$18.80

$28.60

$38.30

Illinois

$16.00

$23.20

$30.30

$37.50

Indiana

$15.70

$24.50

$33.20

$42.00

Iowa

$16.10

$24.10

$32.20

$40.20

Kansas

$15.60

$24.10

$32.70

$41.20

Kentucky

$15.70

$24.50

$33.20

$42.00

Louisiana

$14.80

$22.80

$30.70

$38.70

Maine

$13.60

$20.60

$27.50

$34.50

Maryland

$7.70

$15.70

$23.80

$31.90

Massachusetts

$12.90

$19.90

$26.90

$33.90

Michigan

$13.00

$21.20

$29.30

$37.40

Minnesota

$16.10

$24.10

$32.20

$40.20

Mississippi

$15.50

$23.20

$30.80

$38.50

Missouri

$16.50

$24.30

$32.10

$39.90

Montana

$16.10

$24.10

$32.20

$40.20

Nebraska

$16.10

$24.10

$32.20

$40.20

Nevada

$23.20

$28.90

$34.60

$40.30

New Hampshire

$13.60

$20.60

$27.50

$34.50

New Jersey

$0.00

$9.00

$18.10

$27.10

New Mexico

$22.70

$27.70

$32.60

$37.60

North Carolina

$16.60

$23.70

$30.80

$37.80

North Dakota

$16.10

$24.10

$32.20

$40.20

Ohio

$15.00

$22.20

$29.40

$36.70

Oklahoma

$18.10

$25.70

$33.20

$40.80

Oregon

$10.30

$19.00

$27.70

$36.40

Pennsylvania

$9.70

$18.60

$27.40

$36.30

Rhode Island

$12.90

$19.90

$26.90

$33.90

South Carolina

$4.50

$13.00

$21.50

$29.90

South Dakota

$16.10

$24.10

$32.20

$40.20

Tennessee

$18.70

$26.10

$33.60

$41.00

Texas

$18.10

$25.00

$31.90

$38.90

Utah

$9.10

$18.80

$28.60

$38.30

Vermont

$12.90

$19.90

$26.90

$33.90

Virginia

$16.70

$24.00

$31.30

$38.70

Washington

$10.30

$19.00

$27.70

$36.40

West Virginia

$9.70

$18.60

$27.40

$36.30

Wisconsin

$14.70

$23.90

$33.20

$42.40

Wyoming

$16.10

$24.10

$32.20

$40.20

*This does not include any Medicare Part B premium you may have to pay.

Transamerica MedicareRx Choice (PDP)

Your Level of Extra Help

Your Monthly Premium for Plan*

100%

75%

50%

25%

Alabama

$28.30

$35.70

$43.20

$50.60

Alaska

$16.20

$25.50

$34.80

$44.00

Arizona

$22.60

$29.50

$36.40

$43.20

Arkansas

$22.20

$29.70

$37.20

$44.70

California

$29.40

$36.40

$43.40

$50.50

Colorado

$29.90

$36.60

$43.30

$50.10

Connecticut

$23.70

$30.70

$37.70

$44.70

Delaware

$18.80

$26.80

$34.90

$43.00

District of Columbia

$18.80

$26.80

$34.90

$43.00

Florida

$31.80

$37.30

$42.80

$48.40

Georgia

$24.10

$31.40

$38.70

$46.10

Hawaii

$19.10

$25.50

$32.00

$38.40

Idaho

$18.60

$28.30

$38.10

$47.80

Illinois

$26.00

$33.20

$40.30

$47.50

Indiana

$25.10

$33.90

$42.60

$51.40

Iowa

$23.50

$31.50

$39.60

$47.60

Kansas

$24.50

$33.00

$41.60

$50.10

Kentucky

$25.10

$33.90

$42.60

$51.40

Louisiana

$24.70

$32.70

$40.60

$48.60

Maine

$21.80

$28.80

$35.70

$42.70

Maryland

$18.80

$26.80

$34.90

$43.00

Massachusetts

$23.70

$30.70

$37.70

$44.70

Michigan

$19.00

$27.20

$35.30

$43.40

Minnesota

$23.50

$31.50

$39.60

$47.60

Mississippi

$25.60

$33.30

$40.90

$48.60

Missouri

$25.30

$33.10

$40.90

$48.70

Montana

$23.50

$31.50

$39.60

$47.60

Nebraska

$23.50

$31.50

$39.60

$47.60

Nevada

$34.70

$40.40

$46.10

$51.80

New Hampshire

$21.80

$28.80

$35.70

$42.70

New Jersey

$14.20

$23.50

$32.70

$42.00

New Mexico

$34.10

$39.10

$44.00

$49.00

North Carolina

$26.50

$33.60

$40.70

$47.70

North Dakota

$23.50

$31.50

$39.60

$47.60

Ohio

$23.90

$31.10

$38.30

$45.60

Oklahoma

$28.20

$35.80

$43.30

$50.90

Oregon

$19.50

$28.20

$36.90

$45.60

Pennsylvania

$19.70

$28.60

$37.40

$46.30

Rhode Island

$23.70

$30.70

$37.70

$44.70

South Carolina

$20.10

$28.60

$37.10

$45.50

South Dakota

$23.50

$31.50

$39.60

$47.60

Tennessee

$28.30

$35.70

$43.20

$50.60

Texas

$27.00

$33.90

$40.80

$47.80

Utah

$18.60

$28.30

$38.10

$47.80

Vermont

$23.70

$30.70

$37.70

$44.70

Virginia

$26.50

$33.80

$41.10

$48.50

Washington

$19.50

$28.20

$36.90

$45.60

West Virginia

$19.70

$28.60

$37.40

$46.30

Wisconsin

$22.90

$32.10

$41.40

$50.60

Wyoming

$23.50

$31.50

$39.60

$47.60

*This does not include any Medicare Part B premium you may have to pay.

If you aren't getting extra help, you can see if you qualify by calling:

  • 1-800-Medicare or TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
  • Your State Medicaid Office (see Exhibit C of your Evidence of Coverage), or
  • The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions, please call Member Services.

⤴  Top

Extra Help

Information about programs to help people pay for their prescription drugs

Medicare provides "Extra Help" to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan's monthly premium and prescription copayments or coinsurance. This Extra Help also counts toward your out-of-pocket costs. People with limited income and resources may qualify for Extra Help. Some people automatically qualify for Extra Help and don't need to apply. Medicare mails a letter to people who automatically qualify for Extra Help.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help or to check the status of your application, call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
  • The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
  • Your State Medicaid Office. (see Exhibit C of your Evidence of Coverage)

If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper co-payment level, or, if you already have the evidence, to provide this evidence to us. There are several different documents that Medicare allows as Best Available Evidence (BAE) to show you qualify for Low Income Subsidy (LIS), the "Extra Help" program that helps people with limited resources pay for their drugs. The document must show you were eligible for Medicaid during a month after June of the previous calendar year. These documents include:

  • Copy of your Medicaid card, which includes member name and eligibility date;
  • Copy of a state document that confirms active Medicaid status;
  • Print-out from the State electronic enrollment file showing Medicaid status;
  • Screen print from the State's Medicaid systems showing Medicaid status;
  • Other documentation provided by the State showing Medicaid status;
  • Report of contact, including the date a verification call was made to the State Medicaid Agency and the name, title and telephone number of the state staff person who verified the Medicaid status;
  • Remittance from a long term care facility showing Medicaid payment for a full calendar month for that individual;
  • Copy of a State document that confirms Medicaid payment to a long term care facility for a full calendar month on behalf of the individual;
  • Screen print from the State's Medicaid systems showing that individual's institutional status based on at least a full calendar month's stay for Medicaid payment purposes;
  • Supplemental Security Income (SSI) Notice of Award with an effective date
  • An Important Information letter from Social Security Administration (SSA) confirming that the beneficiary is "...automatically eligible for extra help..."

You may provide one of these documents to us by mail (P.O. Box 152289, Tampa, FL 33684) or fax (1-800-300-9323) as evidence showing your copayment level. When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn't collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state.

For more information about Best Available Evidence (BAE):

  • To visit the section of CMS' website regarding BAE policy, click here.
  • See Chapter 2 of your Evidence of Coverage, or call Member Services.

⤴  Top

Plan Ratings

The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients, and customer service). If you have access to the web, you may use the web tools on www.medicare.gov and select "Health and Drug Plans" then "Compare Drug and Health Plans" to compare the plan ratings for Medicare plans in your area.

To learn more, view our Plan Ratings document, located in the "Plan Documents and Forms" section above.

Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

⤴  Top