TotalCare (HMO D-SNP) Pharmacy

Members must take their prescriptions to a pharmacy in the TotalCare network. To find a pharmacy, search the TotalCare Provider and Pharmacy Directory.

For mail order pharmacy services, contact Birdi (MedImpact’s mail order pharmacy). You can call toll-free at 855-873-8739 or send prescriptions electronically. Mail order prescriptions are only eligible for 60-100 days’ supply.

TotalCare partners with MedImpact to develop and maintain the TotalCare formulary and review prior authorization requests. The formulary is a list of covered drugs developed and managed by MedImpact’s physicians and pharmacists in collaboration with MedImpact’s Pharmacy and Therapeutics (P&T) Committee.

To find out if a particular drug is covered, please refer to the TotalCare Formulary.

Drugs that are not covered in the formulary, or drugs in the formulary with restrictions such as prior authorization (PA), step therapy or quantity limits, may require a prior authorization review to determine coverage for medical necessity.

Prior authorization requests, including formulary exception and step therapy exception requests, must be submitted to MedImpact, not to TotalCare. If faxed or mailed, prior authorization requests must be submitted with the Part D Coverage Determination Form.

PA requests must be submitted to MedImpact via one of the following methods:

• MedImpact’s online form.
• MedImpact’s Electronic Prior Authorization (ePA) Program.
• Phone: 800-788-2949.
• Fax: 858-790-7100.
• United States (US) Mail:

MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131

Physician-administered drugs (PADs) that are covered by Medicare Part B should be billed by the physician or clinic that provides and administers the drug, with claims submitted to TotalCare. Certain PADs may require a prior authorization, including drugs that are not included on the PAD list, do not meet coverage restrictions or exceed set limits.

Prior authorization reviews are conducted using:

• Local and national coverage determinations.
• MCG care guidelines.
• Medical evidence documented in standard compendia.
• National clinical guidelines from professional organizations.

Prior authorization (PA) criteria are developed in accordance with recommendations from the Alliance Pharmacy and Therapeutics (P&T) Committee. If a PAD does not have PA criteria, it will be reviewed for medical necessity based on Alliance and TotalCare policies and nationally recognized standards. For more information, please see the TotalCare Physician-Administered Drug List.

When a new TotalCare member tries to fill a non-formulary drug or a drug with a utilization management restriction within the first 90 days of enrollment, they will be eligible for a temporary one-time transition fill (up to one month’s supply) in the retail pharmacy network. This also applies to the following members:

• Members in long-term care (LTC).
• Renewing members when there is a formulary change between benefit years.
• Members who change treatment settings due to a change in their level of care.

TotalCare’s prescription drug transition process promotes continuity of care and prevents interruptions in drug therapy while:

• Switching to a therapeutically equivalent drug.
• Completing an exception request to maintain coverage of an existing drug based on medical necessity.

For more information, please see Policy 403-1156: TotalCare Pharmacy Part D Drugs Transition Process for D-SNP members.

Medication therapy management (MTM) refers to the analytical, consultative, educational and monitoring services provided by pharmacists to TotalCare members to help them achieve positive therapeutic and economic results. Pharmacists collaborate with physicians and other prescribers to:

• Enhance quality of care.
• Improve medication adherence.
• Address medication needs.
• Provide health care to members in a cost-effective manner.

TotalCare contracts with a vendor, Aspen RxHealth, to administer TotalCare MTM services. MTM services include:

• Comprehensive medication review (CMR).
• Prescriber communications.
• Member adherence consultations.
• Member education and monitoring.

If members ask about MTM, please let them know that it is a legitimate program sponsored by TotalCare and encourage them to utilize this service at no cost to them.

Comprehensive medication review (CMR)

CMR is performed at least once a year. During the CMR, a pharmacist will review the member’s prescription and nonprescription medications, vitamins, minerals, herbal products and dietary supplements for potential interactions. As part of the review, a personal medication list template will be provided to the member to bring to future office visits.

Prescriber communications

Prescriber communications assist physicians and other prescribers to coordinate care and resolve potential medication-related complications. These communications may include a phone call or fax to the prescriber’s office with information and/or recommendations concerning a member’s drug therapy regimen.

Member adherence consultations

MTM pharmacists monitor members for adherence to prescribed medications. When an overuse, underuse or administration issue is identified, the pharmacist will educate the member on the importance of adherence and monitor the member to ensure that adherence improves.

Member education and monitoring

Member education and monitoring is performed when a member is prescribed a new medication therapy or experiences a change in therapy. MTM pharmacists monitor the member to see if they adhere to the therapy, have any side effects and show improvement in reportable symptoms.