Frequently Asked Questions
- How do I sign up for First Health Part D?
- When can I enroll in First Health Part D?
- Can First Health Part D premiums be deducted from my Social Security checks?
- When will my First Health Part D coverage take effect?
- I already belong to another Medicare Prescription Drug Plan. Can I switch to First Health Part D?
- Is there a premium discount for married couples?
- What if I decide to disenroll from my First Health Part D plan?
- What if I move out of the First Health Part D plan service area?
- What if I receive a survey from First Health Part D about a move out of the service area and I haven’t moved?
- What if I change my mind after I sign up?
- Is it better to sign up for a plan that offers both medical and prescription drug coverage?
FILLING YOUR PRESCRIPTIONS
- How much will I pay for covered drugs under First Health Part D?
- What if my drug is not on the First Health Part D Formulary?
- What is a coverage gap?
- How can I keep track of my drug costs?
- Which pharmacies can I use to get prescriptions filled under First Health Part D?
- Will First Health Part D cover drugs purchased from Canada?
- After I sign up for Medicare prescription drug coverage, do I use my red, white, and blue Medicare card to fill prescriptions?
First Health Part D Formulary
- What is a Formulary?
- What Are Cost-sharing Drug Tiers?
- Can The Formulary Change?
- How Can I Request An Exception To The Formulary?
- What is Utilization Management?
THE ADVANTAGE OF FIRST HEALTH PART D
- How can First Health Part D help me save on the cost of my prescriptions?
- Does it pay to join First Health Part D if I take only a few prescriptions each month?
- How do I choose the First Health Part D plan that is right for me?
UNDERSTANDING MEDICARE PART D PLANS
How do I sign up for First Health Part D?
Once you have selected the First Health Part D plan that meets your needs, there are several convenient ways to enroll:
BY PHONE: Call 1-855-893-4696 (TTY/TDD 711 Telecommunications Relay Service), 8 a.m. to 8 p.m., seven days a week, October 1 – February 14; 8 a.m. to 8 p.m. Monday – Friday, February 15 – September 30
ONLINE: You can enroll online and follow the online enrollment instructions.
Medicare beneficiaries may also enroll in our Medicare plans through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
BY MAIL: Download and print an enrollment form. Once completed, mail the enrollment form to:
First Health Part D
PO Box 7763
London, KY 40742-7763
BY FAX: Download and print an enrollment form. Once completed, fax the enrollment form to: Medicare Prescription Drug Plan, Attention: Enrollment Department. Fax number is 1-866-415-2232.
Both the online enrollment form and the printable enrollment form contain detailed instructions on how to complete the form. However, if you have questions about completing either form, please contact us at 1-800-588-3322 (TTY/TDD 711 Telecommunications Relay Service).
When can I enroll in First Health Part D?
If you currently have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance), you can join First Health Part D:
- During your 7 month initial enrollment period that begins 3 months before the month you become eligible for Medicare and ends 3 months after the month you are eligible for Medicare.
- Between October 15 and December 7 of each year.
- Under special circumstances, such as if you move out of your plan’s service area or if you lose your employer group coverage.
- Between January 1– February 14, if you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare. If you switch to Original Medicare during this period, you’ll have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage.Your coverage will begin the first day of the month after your completed enrollment form is received.
Note: If you already have coverage through an employer or union plan, contact the benefits administrator from your current plan before making any changes to your coverage.
Can First Health Part D premiums be deducted from my Social Security checks?
Yes, you can have your First Health Part D premium deducted from your Social Security check (just like your Part B premium).
When will my First Health Part D coverage take effect?
Generally, your coverage will begin on the first day of the month after your completed enrollment form is received.
I already belong to another Medicare Prescription Drug Plan. Can I switch to First Health Part D?
Most people can only enroll in a new plan during certain times of the year.
- Between October 15 – December 7 anyone can join, switch, or drop a Medicare plan.
- In certain situations, you may be able to join, switch, or drop a Medicare plan during a Special Enrollment Period. Examples include:
- If you have Medicaid.
- If you qualify for Extra Help.
- If you live in an institution (like a nursing home).
Is there a premium discount for married couples?
What if I decide to disenroll from my First Health Part D plan?
Disenrollment from our plan means ending your membership with us. You can decide to leave for any reason during the annual open enrollment period (October 15 – December 7) or under certain special circumstances.
You may use any of the following ways to disenroll from your First Health Part D coverage:
- Write a letter or fill out a disenrollment form. Fax it to1-866-415-2232 or send it to the Enrollment Department at: First Health Part D, PO Box 7763, London, KY 40742-7763. All disenrollment requests must be signed by the member or the member’s Power of Attorney (POA)/legal representative. If a disenrollment request is in writing, the letter must include the Member’s Name, Member ID or Account Number, Medicare Claim Number (HICN) and reason for requesting disenrollment.
- Call First Health Part D Member Services at the toll-free number 1-888-736-0486 to request a disenrollment form.
- Call 1-800-MEDICARE (1-800-633-4227) (TTY/TDD users should call 1-877-486-2048) 24 hours a day, seven days a week.
- Completed disenrollment forms must be received by the last day of the month for the disenrollment to be effective for the 1st of the following month. If you are requesting a disenrollment after the 15th of the month, it is suggested that the form be faxed to 1-866-415-2232 to ensure that the form is received by the end of the month.
- If you want to be disenrolled, please file your disenrollment in one of the defined manners above. Please do not stop making monthly premiums payments.
- You will receive notice regarding your disenrollment/cancellation request. Requests can be either approved, denied or require additional information to process.
- If it is prior to your effective date with First Health Part D, you do not need to fill out a disenrollment form. You can verbally request a cancellation of your enrollment by calling First Health Part D Member Services at 1-888-736-0486.
What if I move out of the First Health Part D plan service area?
You must live in our service area to remain a member of our plan. Please notify us immediately if you move. If you move outside of a plan’s service area you will be disenrolled for the 1st of the following month.
Coventry offers prescription drug coverage in all 50 states. To continue coverage with Coventry, you need to enroll in a plan that offers coverage in your new service area. You need to complete a new enrollment application for this enrollment to take place – we are unable to automatically transfer you from one plan to another.
Things to expect if you decide to continue coverage with Coventry:
- You need to complete an enrollment application for a plan in your new service area. Please call us for assistance in completing an enrollment application. The call will take approximately 10-15 minutes.
- It is helpful to have your red, white, and blue Medicare card available when placing this call.
- Please advise that you are requesting enrollment in a new plan because you have moved in or out of a service area.
- You will receive a confirmation of disenrollment letter from the plan in your previous service area AND a confirmation of enrollment letter from the plan in your new service area. This information is to confirm that you were appropriately disenrolled from your old plan and now enrolled in your new plan.
What if I receive a survey from First Health Part D about a move out of the service area and I haven’t moved?
In an effort to ensure that our records are as accurate as possible, please complete and return the form. Completing this form will help ensure there is no interruption to your coverage. You may also respond to our request for information by calling us.
What if I change my mind after I sign up?
Most people can only make changes to their Medicare coverage during the annual open enrollment period (October 15 – December 7). Between October 15 – December 7 anyone can join, switch, or drop a Medicare plan. Any changes you make during this time will be effective January 1.
Certain individuals, such as those who get extra help, can make changes at other times.
Is it better to sign up for a plan that offers both medical and prescription drug coverage?
The choice is up to you. Coventry Health Care offers a full range of plans serving Medicare beneficiaries that provide both medical and prescription drug coverage. These types of plans are called Medicare Advantage plans and include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) options. Availability varies by service area. For more information, visit our Medicare Advantage section.
FILLING YOUR PRESCRIPTIONS
How much will I pay for covered drugs under First Health Part D?
The amount you pay for your prescriptions depends on several factors including; which tier your drug is in, the pharmacy you use, whether you get extra help, and the drug stage that you are in. To estimate costs for a specific drug, please visit our drug finder tool.
What if my drug is not on the First Health Part D Formulary?
If your drug is not included in our formulary, you should first contact Customer Service and confirm that your drug is not covered. There may be times when a single strength or dosage form is not posted on the formulary. If you learn that First Health Part D does not cover your drug, you have two options:
- You can ask Customer Service for a list of similar drugs that are covered. When you receive the list, show it to your doctor or other prescriber and ask him or her to prescribe a similar drug that we cover. You can also take your formulary to your next doctor’s appointment and ask if another drug on the formulary list could be used for your condition.
- You can ask First Health Part D to make an exception and cover your drug. Click on the First Health Part D formulary for more information on the exceptions and appeals process.
What is a coverage gap?
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary limit on what the drug plan will cover for drugs. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2013, once you enter the coverage gap, you pay 47.5% of the plan’s cost for covered brand name drugs and 79% of the plan’s cost for covered generic drugs until you reach the end of the coverage gap. Not everyone will enter the coverage gap. First Health Part D offers plans that provide coverage through the gap for certain medications.
How can I keep track of my drug costs?
First Health Part D will send you a monthly statement whenever you use your prescription drug benefit. This information will outline your prescription drug expenses for the year.
Which pharmacies can I use to get prescriptions filled under First Health Part D?
First Health Part D offers you a nationwide network of more than 62,000 pharmacies, including retail chains and local neighborhood drug stores. To locate a pharmacy, please visit our pharmacy finder tool.
Will First Health Part D cover drugs purchased from Canada?
No. As established by the Centers for Medicare & Medicaid Services (CMS), only drugs sold in the United States are eligible for Medicare Prescription Drug coverage.
After I sign up for Medicare prescription drug coverage, do I use my red, white, and blue Medicare card to fill prescriptions?
No. We will send you a member identification (ID) card that you should use to fill your prescriptions.
First Health Part D Formulary
What is a Formulary?
A formulary is a list of drugs selected by First Health Part D in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. First Health Part D will generally cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed.
Both brand-name drugs and generic drugs are included on our formulary. A generic drug has the same active-ingredient formula as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs.
What Are Cost-sharing Drug Tiers?
Drugs on our formulary are organized into different cost-sharing drug tiers, or groups of different drug types. The amount you pay for each prescription depends, in part, on which drug tier your medication is in.
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 discontinue or reduce coverage during the year unless a new, less expensive generic drug becomes available or if new information about the safety of a drug is released.
Medicare allows plans to make some changes to their formulary throughout the year. If we remove a drug from our formulary or a negative maintenance change is made, we will notify affected members of the change at least 60 days before the change becomes effective. If the Food and Drug Administration (FDA) determines a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary for your safety and provide notice to members who take the drug shortly after the removal.
How Can I Request An Exception To The Formulary?
You can ask us to make an exception to our coverage rules. Generally, First Health Part D will only approve your request for an exception if the alternative drugs included on the plan's formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Your prescriber must contact our clinical prior authorization department to request an exception.
What is Utilization Management?
For certain prescription drugs, First Health Part D has additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for First Health Part D to help us to provide quality care to our members. Examples of utilization management tools are described below:
- Prior Authorization: Requires you to get prior authorization for certain drugs. This means that you will need to get approval from First Health Part D before you fill your prescription. If you don't get approval, First Health Part D may not cover the drug.
- Quantity Limits: For certain drugs, First Health Part D limits the amount of the drug that we will cover per prescription or for a defined period of time.
- Step Therapy: In some cases, First Health Part D requires you to first try one drug 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, First Health Part D may require your doctor to prescribe Drug A first. If Drug A does not work for you, First Health Part D will then cover Drug B.
THE ADVANTAGE OF FIRST HEALTH PART D
How can First Health Part D help me save on the cost of my prescriptions?
First Health Part D has negotiated discounts on thousands of brand name and generic drugs on your behalf. Those savings are passed on to you by way of affordable premiums and lower cost-sharing amounts.
Does it pay to join First Health Part D if I take only a few prescriptions each month?
Even if you don’t take many prescriptions now, you should consider joining a Medicare drug plan. If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty if you join a plan later.
How do I choose the First Health Part D plan that is right for me?
Please visit our plan finder tool to assist in locating the right First Health Part D plan for you.
UNDERSTANDING MEDICARE PART D PLANS
How do Medicare prescription drug plans work?
Medicare prescription drug coverage is provided by private insurance companies – such as Coventry Health Care – who have contracted with Medicare to provide coverage. There are 2 ways to get Medicare prescription drug coverage:
- Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
- Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA PDs.”
What if I have prescription drug coverage through an employer or union plan?
If you already have coverage through an employer or union plan, contact the benefits administrator from your current plan before making any changes to your coverage.
What happens if I do not sign up for a Medicare prescription drug plan as soon I am eligible?
If you do not join a Medicare Part D plan when you first become eligible, you may have to pay a 1% late enrollment penalty.
The late enrollment penalty is an amount that’s added to your Part D premium. You may owe a late enrollment penalty if at any time after your initial enrollment period is over, there’s a period of 63 or more days in a row when you don’t have Part D or other creditable prescription drug coverage.
What if I cannot afford to pay for a Medicare prescription drug plan?
Did you know that many Medicare beneficiaries – especially those with limited incomes – may be missing out on assistance from federal, state and local programs that can help with prescription drugs, nutrition, utilities and much more? Coventry, in partnership with the National Council on Aging (NCOA), provides a comprehensive tool to help you identify whether or not you qualify for these services. Simply log on to http://www.BenefitsCheckup.org to begin.
In addition, some people with an income at or below a set amount and with limited assets (including their savings and stocks, but not counting their home) will qualify for extra help. People who qualify will receive help paying for their monthly premium, and/or for some of the cost they would normally have to pay for their prescriptions. If you think you may qualify for extra help, you may also contact your local Social Security Administration or Medicaid office. For more information, contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048 or visit www.medicare.gov; and/or contact Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778.
Online Request Forms
Member Request for Coverage Determination
Member Request for Redetermination (Appeal)
Medicare Complaint Form
Best Available Evidence for Low-Income Subsidy
Prior Authorizations & Exceptions
Medication Therapy Management Program
Transition Policies and Exceptions Process
Quality Assurance Policies and Procedures