As a member of Gold Coast Health Plan Total Care Advantage (HMO D-SNP), we are happy to provide you with comprehensive pharmacy benefits and services through our pharmacy benefit manager, Prime Therapeutics.
We created a drug list (formulary) to meet your health care needs at low costs. We pay a share of the cost of your covered drugs, and you also pay a share. Your share is called the copay. The copay depends on your income, whether the drug is generic or brand name, whether you qualify for “Extra Help” with Medicare, and where you pick up your medication. Some of your drugs might need to be approved before you can get them (called “prior authorization”).
Prescription drug co-pays range from:
- $0, or $1.60 or $5.10 for generic drugs
- $0, or $4.90 or $12.65 for brand-name drugs
Because you’re eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your drug plan costs. You don’t need to do anything to get this “Extra Help.”
Total Care Advantage has a drug list (formulary) that lists the drugs that we cover and any restrictions that apply which may require prior authorization before you can get your drug at the pharmacy.
Drug List/Formulary (English and Spanish)
To find a pharmacy that you can use near you, please visit this page.
For certain kinds of drugs, you can use our plan’s network mail-order services. Generally, drugs available through mail-order are drugs that you take on a regular basis for a chronic or long-term medical condition.
Our plan’s mail-order service allows you to order at least a 30-day supply of the drug and no more than a 100- day supply. A 100-day supply has the same copay as a one-month supply.
To get information about filling your prescriptions by mail, you can call Member Services at 1.855.681.7966 (TTY: 711).
The MyPrime Member Portal gives you real-time information about your drug coverage and other important information to help you get your drugs.
Total Care Advantage has a program to help members with complex health needs. In such cases, you may be eligible to get services, at no cost to you, through a medication therapy management (MTM) program. This program is voluntary and free. This program helps you and your provider make sure that your medications are working to improve your health. If you qualify for the program, a pharmacist or other health professional will give you a comprehensive review of all your medications and talk with you about:
- How to get the most benefit from the drugs you take
- Any concerns you have, like medication costs and drug reactions
- How best to take your medications
- Any questions or problems you have about your prescription and over-the-counter medication
Medicare MTM program services may have limited eligibility criteria. They are available for the following conditions:
- Take at least eight medicines covered by Medicare Part D.
- Have expected Medicare Part D medicine costs greater than $1,276 per year.
- Have a diagnosis of three or more of the following medical conditions:
- Alzheimer’s disease
- Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
- Chronic congestive heart failure (CHF)
- Diabetes
- Dyslipidemia
- End-stage renal disease (ESRD)
- Human immunodeficiency virus /acquired immunodeficiency syndrome (HIV/AIDS)
- Hypertension
- Mental health (including depression, schizophrenia, bipolar disorder, and chronic/disabling mental health conditions)
- Respiratory disease (including asthma, chronic obstructive pulmonary disease (COPD), and chronic lung disorders)
You may also qualify for the program if you’re in a drug management program to help you better manage and safely use medications such as opioids and benzodiazepines.
For more information, visit MyPrime or call 1.855.681.7966 (TTY: 711).
Medicare Part D Coverage Determination and Redetermination Request Forms
Exception Request Form: As a new Total Care Advantage member, you might be taking drugs that aren’t on our drug list (formulary) or have some restrictions. You can ask your doctor about switching to a drug we cover or submit a request for an exception by filling out this form.
Member Prescription Reimbursement
If you pay the full cost of a prescription, Total Care Advantage will reimburse you under certain circumstances, such as when you:
- Fill a prescription in an emergency situation at a non-network pharmacy
- Need a specialized drug that is not available at a network pharmacy
- Need a drug that is only available, by law, at specific pharmacies
Note that Total Care Advantage will not reimburse you for your Part D prescription co-pay.
To request reimbursement:
Prescription reimbursement requests for Total Care Advantage covered drugs and items should be submitted within one year (365 days). To request a prescription reimbursement, send us your bill and proof of any payment you have made (proof of payment can be a copy of the check you wrote or a receipt from the provider).
Mail your request for payment together with any bills or receipts to:
Total Care Advantage
Attn: Member Services
P.O. Box 9176
Oxnard, CA 93031
Information on enrollees’ and Part D sponsors’ rights and responsibilities upon disenrollment
Your right to leave our plan
No one can make you stay in our plan if you don’t want to.
- You have the right to get most of your health care services through Original Medicare or another Medicare Advantage (MA) plan.
- You can get your Medicare Part D prescription drug benefits from a prescription drug plan or from another MA plan.
- Refer to Chapter 10 of the Member Handbook for more information about when you can join a new MA or prescription drug benefit plan and for information about how you’ll get your Medi-Cal benefits if you leave our plan.
The Medicare Prescription Payment Plan is a payment option that works with your current drug coverage to help you manage your drug out-of-pocket costs for drugs covered by our plan by spreading them out through the calendar year (January - December). Anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage plan with drug coverage) can use this payment option. This payment option might help you manage your expenses, but it doesn’t save you money or lower your drug costs.
If you’re participating in the Medicare Prescription Payment Plan and stay in the same plan, you don’t need to do anything to continue this option. "Extra Help" from Medicare and help from your State Pharmacy Assistance Program and AIDS Drug Assistance Program, for those who qualify, is more advantageous than participation in this payment option, no matter your income level, and plans with drug coverage must offer this payment option. To learn more about this payment option, call Prime Member Services at 1.855.681.7966 (TTY: 711) or visit https://www.medicare.gov/prescription-payment-plan or https://www.medicare.gov/publications/12211-whats-the-medicare-prescription-payment-plan.pdf
When members who join the Medicare Prescription Payment Plan fill prescriptions for drugs covered by Medicare Part D, they do not pay copays to the pharmacy (including mail order and specialty pharmacies). Instead, they get a bill each month with all their copays for the month. (Members who have a plan premium also get a separate bill for prescription drugs rather than paying the pharmacy).
Members who do not pay these monthly bills get reminder letters. There are no fees or interest charged on late payments. Members who do not pay within 60 days are dropped from the Medicare Prescription Payment Plan but remain enrolled in Total Care Advantage.
Sign up in three ways
- By phone: Call 1.855.681.7966 (TTY: 711)
- By mail: Download the Participation Request form (English) / (Spanish), print it, complete it, and mail it to:
Gold Coast Health Plan Total Care Advantage
Attn: M3P Elections
9450 SW Gemini Drive, Ste. 87234
Beaverton, OR 97008-7105 - Online: Click here to sign up online.
Opting out of the Medicare Prescription Payment Plan
Members can quit the Medicare Prescription Payment Plan at any time by calling Total Care Advantage at 1.888.301.1228 (TTY: 711) 24 hours a day, 7 days a week. Opting out of the Medicare Prescription Payment Plan does not change members’ Medicare benefits, including drug coverage.
Once members opt out, they are not charged any more out-of-pocket costs. However, they still need to pay any new out-of-pocket costs charged by the pharmacy. Outstanding balances can either be paid all at once or monthly as bills are received.
As a Gold Coast Health Plan Total Care Advantage (HMO D-SNP) member, your injectable or infused medicines you get at your doctor's office, clinic or outpatient hospital will be covered through your Medicare Part B benefit. Some of the Part B drugs will need an approval by GCHP Total Care Advantage before you can get them from your doctor, known as a “prior authorization” request.
Total Care Advantage reviews Prior Authorization requests submitted by your doctor and decides which medicines, and how much, will be covered to make sure you get the right care. You can find the list of Total Care Advantage Medicare Part B medications that need approval here. You can find updates and changes to the Medicare Part B Drug List here. Total Care Advantage updates this information four times a year.
If you have any questions or want a copy of the Part B Drug list and what Total Care Advantage needs to cover the medicines through this benefit, please call Total Care Advantage's Member Services Department at 1.888.301.1228, Monday through Friday, 8 a.m. to 8 p.m. (except holidays). If you use a TTY, call 711.