Medicare Part D & Pharmacy

Medicare Part D is the part of Medicare that pays for prescription drugs. Part D is available to anyone who is entitled to benefits under Medicare Part A and/or enrolled in Part B.

Most of our Medicare Advantage plans offer Part D coverage. Plans may vary in cost for the covered drugs.

Important Part D & Pharmacy Information

Medicare Prescription Drug Formularies
This booklet provides a list of the prescription drugs that are covered by your plan.

Pharmacy Directories
This booklet provides a list of the network pharmacies where you can obtain your prescription drugs.

Low Income Subsidy (LIS) Premium Summary Tables
This table shows you what your monthly plan premium will be if you get extra help from Medicare to help pay for your Part D prescription drug costs.

Prior Authorization Medication List
A list of the prescription drugs that require approval in advance before your plan will cover the drug.

Quantity Limit Medication List
A list of the prescription drugs that have restrictions on the amount of the drug you can have.

Step Therapy Medication List
A list of the prescription drugs that require you to try a different drug first before your plan will cover the drug you are asking for.

Extra Help with Prescription Drug Costs
Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug costs.

Best Available Evidence (BAE)
A list of documents that can be used as proof that you qualify for extra help with your Part D prescription drug costs.

Grievances & Appeals
Information on how to request an appeal or file a grievance with Universal Health Care

How to Appoint a Representative
Information on how to name a representative who can legally act on your behalf, including filing a grievance

• Appointment of Representation Form
• Appointment of Representation Form - Spanish

Medicare Prior Authorization Request Form

Medicare Redetermination-Appeal

Part D Appeal Process

Important Plan Information

• Number of Pharmacies in Network: 63,096
• How Our Plan Meets Access Requirements
  Universal has contracts with pharmacies through its Pharmacy Benefit Manager (PBM) Medco Health Solutions that equal or exceed CMS requirements for pharmacy access in your area.
• Out-of-Network Coverage
• Drug Utilization Management Information
• Part D Transition Supply Policy
• Formulary Transition Process Policy
• Potential for Contract Termination
  All Medicare Advantage plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the Plan accepts Members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
• Your Rights and Responsibilities When Ending Your Membership in our Plan
• If you wish to obtain the aggregate number of grievances, appeals, and exceptions filed with Universal, you may call Member Services at 1-877-562-3421, 8:00 am to 11:00 pm EST, Monday through Friday, or send a written request to:
  Universal Health Care, Inc.
  Pharmacy Department
  100 Central Ave.
  St. Petersburg, FL 33701