Prescription Drug Benefits

Prescription Coverage Information

Part D Coverage Information

Below you will find information on the prescription drug benefits for all plans of HealthSun. Medicare Part D covered drugs are listed on the plan’s formulary and are available only by prescription.  You must generally use network pharmacies to use your prescription drug benefit.  The formulary may change at any time and you will receive notice when necessary. Click here to find additional information on how to file grievances, coverage determinations, and appeals t

Drug Formulary

Over the Counter Order Forms (OTC)

2017 Plans

2017 Plans

Prior Authorization Criteria

Step Therapy Criteria

2017 Plans

2017 Plans

 

 How do I request an exception to the HealthSun Drug Formulary?

You can ask HealthSun to make the following exceptions to our Prescription Drug coverage rules:

  • Cover a drug that is not on our Formulary. If approved, it will be covered at a pre-determined cost-sharing level and will not be allowed to a lower cost-sharing level.
  • Cover a Formulary drug at a lower cost-sharing level if it is not on the specialty tier. If approved, this would lower the cost of your drug.
  • Waive coverage restrictions or limits on your drug. For example, for certain drugs, HealthSun limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, HealthSun will only approve your request for an exception if the alternative drug is included on our Formulary.  The lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact our Member Services Department to ask us for an initial coverage decision for an exception on the Formulary, tiers or a utilization restriction. You should also submit a statement from your prescriber or physician supporting your request.  Generally, we must make our decision within 72 hours of getting your 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 to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

HealthSun Health Plans
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 form Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This does not include any Medicare Part B Premium you may have to pay. You must continue to pay your Medicare Part B premium.

HealthSun Health Plans premium includes coverage for both medical services and Part D prescription drug. For additional information regarding the HealthSun MediMax Plan monthly premiums please click here to find our Summary of Benefits or contact our Member Services Department

This table shows you what your monthly plan premium will be if you get extra help in 2017:

Your level of extra help Monthly Premium for HealthSun SunPlus Advantage Plan (HMO) (Miami-Dade)

Monthly Premium for HealthSun MediMax (Miami-Dade and Broward)  

Monthly Premium for HealthSun HealthAdvantage Plan (HMO) (Broward) 
 100%  $0  $0  $0
 75%  $0  $7.30  $0
 50%  $0  $14.50  $0
 25%  $0  $21.80  $0

  

If you have any questions, please call Member Service at 877-207-4900 or 305-234-9292 from 8:00 a.m. to 8:00 p.m. Monday through Friday.  TTY 877-206-0500. 

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

  • 1-800-Medicare, 24 hours a day, 7 days a week.  TTY 1-877-486-2048 
  • Your State Medical Office or the Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday.  TTY 1-800-325-0778. 

Limitations, copayments, and restrictions may apply.  The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.  Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.