2025 Member
Materials
This handbook tells you about your coverage under PHP Care Complete FIDA-IDD Plan (MedicareMedicaid Plan) from the date you are enrolled with PHP Care Complete FIDA-IDD Plan through December 31, 2025.
Annual Notice of Changes to learn about your coverage choices. Key terms and their definitions appear in alphabetical order in the last chapter of the Participant Handbook.
This document is a brief summary of the benefits and services covered by PHP Care Complete FIDA-IDD Plan.
If a medically necessary service or benefit is unavailable within PHP Care Complete FIDA-IDD Plan’s provider network, your care coordination team will authorize the out-of-network services subject to utilization review.
If you wish to name a family member, a friend, or a person whom you trust to act on your behalf to ask to file an appeal or a grievances with Partners Health Plan, both you and the individual you choose must fill out and sign this Appointment of Representative Form (AOR).
Formulary Information and Documents
PHP Care Complete FIDA-IDD Plan has a List of Covered Drugs, also known as a Formulary.
When you get a prescription for any of these covered drugs, PHP Care Complete FIDA-IDD Plan will cover the prescription when you go to a network pharmacy. (Some drugs have limits – see Limits on coverage for some drugs below).
PHP Care Complete FIDA-IDD Plan has more than 5,000 retail pharmacies across their nine-county service area. These include Costco, CVS, Duane Reade, King Kullen, Kinney Drugs, Kmart, Pathmark, Price Chopper, Rite Aid, Sam’s, ShopRite, Stop & Shop, Target, TOPS, Waldbaum’s, Walgreens, Wal-Mart, Wegmans plus many “mom & pop” pharmacies. You can always check our pharmacy directory for a network pharmacy near your home.
PHP has partnered with MedImpact Direct Mail Order to offer participants with a mail-order pharmacy program. If you are on any maintenance medications, you can conveniently have up to a three-month supply delivered to your home. Maintenance medications are used to treat chronic illnesses. Please view the below links for more information on this program, including how to register.
Our Formulary has three tiers and includes drugs covered under Medicare Part D and some prescription and over-the-counter (OTC) drugs covered under your Medicaid benefits. Each tier has a $0 copay. You can contact us at Participant Services 1-855-747-5483 or TTY/TDD: 711 for the most recent drug list.
- Tier 1 covers Generic Drugs that are covered by Medicare Part D.
- Tier 2 covers Brand Drugs that are covered by Medicare Part D.
- Tier 3 covers Medicaid-covered drugs and Medicaid-covered Over-the-Counter Drugs (both generic and brand).
For certain prescription and covered over-the-counter (OTC) drugs, special rules limit how and when we cover them. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective.
1. Step Therapy: Trying a different drug first
In general, we want you to try lower-cost drugs (that often are as effective) before we cover drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, PHP Care Complete FIDA-IDD Plan’s rules may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This is called step therapy.
2. Quantity limits
For some drugs, we limit the amount of the drug you can have. For example, the plan might limit:
- how many refills you can get, or
- how much of a drug you can get each time you fill your prescription.
3. Prior Authorization
For some drugs, we may ask your prescribing doctor to get prior approval from PHP Care Complete FIDA-IDD Plan before we can have the pharmacy dispense the drug to you. This is called prior authorization.
Here are some examples of the limits of coverage for some drugs:
- Digoxin Tabs (Tier 1) requires Prior Authorization
- Avandia (Tier 2) requires Step Therapy
- Abilify Tab (Tier 2) requires Quantity Limit of 30 tabs for 30 days;
- Tamiflu Cap (Tier 2) requires a Quantity Limit of 28 cap over a 180-day period.
- Acne Medication, Allergy Creams, Vitamins are all Tier 3 covered prescriptions.
If you are a new PHP Care Complete FIDA-IDD Plan participant living in the community and are currently taking a drug that is not on PHP’s formulary but otherwise meets the definition of a Part D drug or a non-Part D drug covered by Medicaid (including formulary drugs that require prior authorization or step therapy), PHP will continue to pay for the drug on a temporary basis (i.e., 90 days). During this period, our Pharmacy Coordinator will consult with you and your Interdisciplinary Team about possible alternatives to the drug. We will also notify you and your authorized representative of your right to file for an exception request to continue taking the drug after the transition period has expired.
If you are a new PHP Care Complete FIDA-IDD Plan participant residing in a long-term care facility such as a nursing home or ICF, you can receive at least a 30 day and up to a 31-day supply of non-formulary drugs that otherwise meet the definition of a Part D drug (including formulary drugs that require prior authorization or step therapy) within the first 90 days of coverage unless a lesser amount is requested.
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Formulary Search (formularynavigator.com)
