Prescription Drug Frequently Asked Questions (FAQs)

What if my drug is not on the drug list (formulary)?

First, contact Member Services and ask if your drug is covered. If Member Services says your drug is not covered, you have 2 options:

• You can ask Member Services for a list of similar drugs that are covered by First Choice VIP Care Plus (Medicare-Medicaid Plan). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by First Choice VIP Care Plus.
• You can ask First Choice VIP Care Plus to make an exception and cover your drug. For more information please see the section below titled "How do I request an exception to the First Choice VIP Care Plus Drug List?”

A coverage determination is any decision (an approval or denial) that First Choice VIP Care Plus makes when you ask for coverage or payment of a drug that you believe First Choice VIP Care Plus should provide.

• You or your primary care provider (PCP) and other prescribers can ask for a coverage determination.
• You can also appoint someone (such as a relative) to request a coverage determination for you.
• You can ask for a standard coverage determination. First Choice VIP Care Plus will give you a decision in 72 hours.
• You can also ask for a fast coverage determination (also called an "expedited" determination) if you or your PCP or other prescriber believes that your health could be seriously harmed by waiting up to 72 hours for a decision. First Choice VIP Care Plus will give you an answer in 24 hours.

How to contact us when you are asking for a coverage decision about your Part D prescription drugs:

Request for Medicare prescription drug coverage determination

Log in to the Member Portal to submit online (click "My pharmacy benefits", then click "Pre Authorization") or fill out the paper form (PDF).

Fax, standard: 1-855-825-2711
Fax, urgent: 1-855-825-2712
Call us: 1-888-978-0862 (TTY/TDD 711), 8 a.m. to 8 p.m. ET, seven days a week.

Write us:
First Choice VIP Care Plus
Attn: Pharmacy Prior Authorization/Member Prescription Coverage Determination
200 Stevens Drive
Philadelphia, PA 19113

If First Choice VIP Care Plus denies your coverage determination you have the right to request a redetermination appeal. You may fill out a paper Request for Redetermination of Medicare Prescription Drug Denial (PDF) and mail or fax it to:

First Choice VIP Care Plus
Attn: Appeals Department
P.O. Box 80109
London, KY 40742-0109
Fax: 1-855-221-0046

You may also fill out the online Request for Redetermination. Please see chapter 9 of your Member Handbook (PDF) for information about your appeal and grievance rights.

Generally, if you are taking a drug on our 2024 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2025 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Please check the webpage for the most up to date version of the drug list.

If we remove drugs from our drug list or add prior authorization requirements, quantity limits, and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will remove the drug from our drug list and provide notice to members who take the drug.

Prior authorization means that you will need to get approval from First Choice VIP Care Plus before you fill your prescriptions for some drugs. If you do not get approval, First Choice VIP Care Plus may not cover the drug. You can find out which drugs require prior authorization by reviewing the First Choice VIP Care Plus Drug List. Usually, your physician or other prescribers will have to give us information about your medical condition or previous prescriptions to receive prior authorization.

Log in to the Member Portal Opens a new window to submit online (click "My pharmacy benefits", then click "Pre Authorization") or fill out the paper form (PDF) Opens a new window.

Mail or fax the completed form to:
First Choice VIP Care Plus
Attn: Pharmacy Prior Authorization/Member Prescription Coverage Determination
200 Stevens Drive
Philadelphia, PA 19113
Fax, standard: 1-855-825-2711
Fax, urgent: 1-855-825-2712

Prior authorization exception

You and/or your PCP or other prescriber can request an exception to the First Choice VIP Care Plus Drug List. Generally, your PCP or other prescriber must provide a statement of medical necessity that explains why the listed drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Log in to the Member Portal to submit online (click "My pharmacy benefits", then click "Pre Authorization") or fill out the paper form (PDF).

Mail or fax the completed form to:
First Choice VIP Care Plus
Attn: Pharmacy Prior Authorization/Member Prescription Coverage Determination
200 Stevens Drive
Philadelphia, PA 19113

Fax, standard: 1-855-825-2711
Fax, urgent: 1-855-825-2712

In-network pharmacy claims: direct member reimbursement

Download the Claim Reimbursement Form (PDF).

Please read the instructions on the form carefully, complete the form, and mail it to:
First Choice VIP Care Plus
Attn: Direct Member Reimbursement
P.O. Box 516
Essington, PA 19029

Out-of-network pharmacy claims: direct member reimbursement

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Before you fill your prescription at an out-of-network pharmacy, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. You may also access the First Choice VIP Care Plus Pharmacy Directory.

If you do go to an out-of-network pharmacy you may have to pay the full cost when you fill your prescription. You can ask us to pay you back (reimburse you) for our share of the cost by submitting a direct reimbursement claim form.

However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price may be higher than what a network pharmacy would have charged. You should always submit a claim to us if you fill a prescription at an out-of-network pharmacy, since any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage.

Download the Claim Reimbursement Form (PDF).

Please read the instructions on the reimbursement form carefully, complete the form, and mail it to:
First Choice VIP Care Plus
Attn: Direct Member Reimbursement
P.O. Box 516
Essington, PA 19029

We try to make your drug coverage work well for you, but sometimes a drug might not be covered in the way that you would like it to be. For example:

• The drug you want to take is not covered by the plan.
• The drug is not on the drug list.
• A generic version of the drug is covered, but the brand name version you want to take is not.
• A drug is new and we have not yet reviewed it for safety and effectiveness.
• The drug is covered, but there are special rules or limits on coverage for that drug. Some of the drugs covered by the plan have rules that limit their use. In some cases, you or your prescriber may want to ask us for an exception to a rule.

There are things you can do if your drug is not covered in the way that you would like it to be.

Getting a temporary supply

In some cases, the plan can give you a temporary supply of a drug when the drug is not on the drug list or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask the plan to cover the drug.

To get a temporary supply of a drug, you must meet the two rules below:
1. The drug you have been taking either:

• Is no longer on the plan's drug list.
• Was never on the plan's drug list.
• Is now limited in some way.

2. You must be in one of these situations:

• You were in the plan last year and do not live in a long-term care (LTC) facility.
  We will cover a temporary supply of your drug during the first 180 days of the calendar year. This temporary supply will be for at least a 30-day supply for Part D drugs and a 90-day supply for non-Part D drugs. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication for Part D drugs and 90 days of medication for non-Part D drugs. You must fill the prescription at a network pharmacy.
• You are new to the plan and do not live in an LTC facility.
  We will cover a temporary supply of your drug during the first 180 days of your membership in the plan. This temporary supply will be a 30-day supply for Part D drugs and a 90-day supply for non-Part D drugs. You must fill the prescription at a network pharmacy.
• You were in the plan last year and live in an LTC facility.
  We will cover a temporary supply of your drug during the first 180 days of the calendar year. The total supply will be for up to a 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31 days. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
• You are new to the plan and live in an LTC facility.
  We will cover a temporary supply of your drug during the first 180 days of your membership in the plan. The total supply will be for up to a 31-day supply for Part D drugs and a 31-day supply for non-Part D drugs. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of the number of days allowed. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
• You have been in the plan for more than 180 days and live 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.

• Members who have a change in level of care (setting) will be allowed up to a one-time, 30-day transition supply per drug. For example, members who:
  • Enter LTC facilities from hospitals, who are sometimes accompanied by a discharge list of medications from the hospital formulary with very short-term planning taken into account (often under eight hours).
  • Are discharged from a hospital to home.
  • End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
  • End a long-term care facility stay and return to the community.

If a member has more than one change in level of care in a month, the pharmacy must call our plan to request an extension of the transition policy.

Asking for a temporary supply

To ask for a temporary supply of a drug, call Member Services.

When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:

1. You can change to another drug.
   There may be a different drug covered by the plan that works for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. The list can help your provider find a covered drug that might work for you.
   
   
2. You can ask for an exception.
   You and your provider can ask the plan to make an exception. For example, you can ask the plan to cover a drug even though it is not on the drug list. Or you can ask the plan to cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.

If you need help asking for an exception, you can contact Member Services or your Care Coordinator.

Yes. For certain kinds of drugs, you can use the plan's network mail-order services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan's mail-order service are marked as "mail-order" drugs in our drug list. Our plan's mail-order service requires you to order a 90-day supply. If you use a mail-order pharmacy not in the plan's network, your prescription will not be covered. Usually a mail-order pharmacy order will get to you in no more than 14 days.

However, sometimes your mail-order may be delayed. If you need to start your medications right away, but the mail-order is delayed, ask your doctor for a 30-day supply (prescription) to be filled at your local pharmacy.

View the mail order form (PDF) and brochure with directions (PDF).