Prescription Drugs (Prescription Coverage Information)
For our members convenience we have included a high resolution printable version of the HealthSun Health Plans, Inc. Formulary in Adobe PDF format.
2013
Additional Documents
Appointment of Representative (AOR)
Medicare rules allow a beneficiary to appoint a representative in the grievance, coverage decisions and/or appeals process.
A member may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or
her representative and file an appeal on his or her behalf. To be appointed by a member, both the enrollee making the
appointment and the representative accepting the appointment must sign, date, and complete a representative form.
The appointment is valid for one year from the date the form is signed by the member and representative.
Due in part to the incapacitated or legally incompetent status of a member, a representative is not required to produce
a representative form. Instead, he or she must produce other appropriate legal papers supporting his or her status as
the member’s authorized representative.
CMS' Appointment of Representation form can be found at:
English (PDF)
Spanish (PDF)
How to file a Grievance
You can file a grievance in one of two ways:
Verbally by calling Member Services: You can contact Member Services at the number provided at the end of this page.
In writing: You can put your complaint in writing and send it to us at the address listed at the end of this page.
If you submit your complaint in writing, we will respond to your complaint in writing.
Whichever way you choose to communicate your complaint to us; if you ask for a written response, file a written grievance and/or
your complaint is related to the quality of care received, we will respond in writing to you. The grievance process generally
takes 30 calendar days and in some instances can take 14 more days if you ask for more time or if we need additional information
that may benefit you.
Whether you call or write, you should contact Member Services as in most cases we will try to resolve your complaint over the phone.
Your appointed representative may file a grievance.
You can make complaints about quality of care to the Quality Improvement Organization (QIO) instead of filing your complaint with the plan or
you may file your complaint to the QIO and to our plan. If you file a complaint with the QIO we will work together with them to resolve your
complaint. To obtain information to the QIO contact our Member Services Department at the number provided at the end of this page.
How to file a Coverage Decision
You can ask for a Coverage Decision by calling, writing, or faxing to our plan your request of the type of coverage decision you want.
You, your physician, or a representative can do this.
If your health requieres a quick response,you should ask the plan to make a fast decision. To get a fast decision; you must be asking for coverage
for medical care or a drug you have not yet received and indicate that using the standard timeframe for a coverage decision could cause serious
harm to your health or impair your ability to function.
If your physician tells us that your health requires a Fast Decision, the plan will automatically agree to give you a Fast Decision.
Otherwise if you ask for a Fast Decision on your own, the plan will decide if your health requires a Fast Decision. Unless you ask for a Fast
Decision, the plan will use the standard decision deadlines.
This table shows you the decision deadlines of when you can expect our decision
|
Decision About
Medical Care |
Decisions about Part D
Prescription Drugs |
| Standard Decision |
14 Days |
72 Hours |
| Fast Decision |
72 Hours |
24 Hours |
If you disagree with the coverage decision the plan has made, you can appeal the decision.
For more information contact our Member Service Department at the phone numbers indicated
at the end of this page.
Coverage Determination Form for Prescription Drug Request
Click here to obtain a Coverage Determination form
.However, please note that this form is not required to be completed when requesting a coverage determination request
How to file an Appeal
You can request a standard appeal for denial of payment, in writing, to the address indicated at the end of this page. This appeal request needs to be signed.
You or your appointed representative may request an appeal. The plan will provide you with a decision within 60 days from the date we received your request.
You can request a standard appeal for denial of a service you have not received and we will give you an answer within 30 days from the date the plan received your request.
This appeal request needs to be sent in writing. In some instances we can take 14 more days if you ask for more time or if we need additional information that may benefit you.
If we decide to take 14 more days to make a decision, we will tell you in writing.
You can request an expedited appeal for denial of a service you have not received and we will give you an answer within 72 hours from the date and time your request was
received. However, in some instances we can take 14 more days if you ask for more time or if we need additional information that may benefit you. If we decide to
take 14 more days to make a decision, we will tell you in writing.
You can request an expedited appeal for a prescription drug and we will give you an answer
within 72 hours from the date and time your request was received. If you are requesting a standard appeal for a prescription drug, the plan will give you an answer
within 7 days from the date the plan received your request.
Appeal Form
Click here to obtain a redetermination form.
However, please note that this form is not required to be completed when requesting an appeal request.
Information on how to obtain aggregate numbers of Grievances, appeals and Exceptions
As a Medicare Advantage Organization, HealthSun Health Plans must disclose grievance, appeals and exceptions data,
upon request, to individuals eligible to elect a Medicare Advantage organization. By appeals data we mean all appeals
filed with HealthSun Health Plans that are accepted for review, or withdrawn upon the member’s request, but excludes
appeals that HealthSun Health Plans forwards to CMS’ Independent Review Entity (IRE) for dismissal.
Requests can be made by contacting our Member Services Department at the number provided at the end of this page.
CMS' Best Available Evidence Policy and Procedure
Providers
Request for Medicare Prescription Drug Determination Form (PDF)
Members
Model Coverage Determination Request Form (PDF)
MTM information and drug and/or utilization management information
HealthSun Health Plans offers a Medication Therapy Management (MTM) Program to members at no additional cost. Members must have a minimum of two chronic diseases such as: Alzheimer’s disease,
Bone Disease-Arthritis-Osteoporosis, Diabetes, Dyslipidemia and/or Hypertension and take at least eight covered Part D drugs. This program was developed by a team of pharmacists and doctors.
You may be identified to participate in the program designed for your specific health and pharmacy needs. It is recommended that you take full advantage of this if you are selected.
Contact HealthSun Health Plans Member Services Department at the number provided at the end of this page for more details.
Drug Management Programs
For certain prescription drugs, we have 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/or pharmacists developed these requirements and limits for our plan to help us provide quality coverage to our members.
Please contact our Member Services Department at the number provided at the end of this page or review the formulary on our website for more information about these requirements and limits.
The requirements for coverage or limits on certain drugs are listed as follows:
-
Prior Authorization:
We require you to get prior authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription.
If we don't get the necessary information to satisfy the prior authorization, we may not cover the drug.
-
Quantity Limits:
For certain drugs, we limit the amount of the drug that we will cover per prescription
-
Step Therapy:
In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
Contact numbers that members and physicians can use for process or status questions:
HealthSun Health Plans
3250 Mary Street, Suite 300
Coconut Grove, FL 33133
Tel: (305) 448-8100 / (305) 234-9292
Fax: (305) 448-9980
Toll Free: 1 (877) 207-4900
TTY: 1 (877) 206-0500
Hours of Operation: 8:00am – 6:00pm
Members
Appeals: (305) 447-4451
Grievances and Coverage Decisions: (305) 447-4458 / (877) 336-2069
Providers
Appeals: (305) 447-4451
Coverage Decisions: (305) 447-4458 / (877) 336-2069
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