Important Information for 2025 MedMutual Medicare Advantage Plans

Plan Documents and Directories

Annual Notice of Change
Evidence of Coverage
Summary of Benefits
Provider Directory
Pharmacy Directory
Formulary

Medical Plan Information

Medicare Part C Transition Policy
Medicare Part B Prescription Drugs
Utilization Management Coverage Guidelines
Aggregate Number of Prior Authorizations, Appeals, and Grievances
Prior Authorizations and Appeals
Out-of-network Coverage
Grievances
Medicare Ombudsman
Medical Claim Form

Prescription Drug Information

Medicare Prescription Payment Plan
Medication Adherence
Medicare Part D Drug Transition Policy
Quality Assurance
Drug Management Program
Prescription Drug Coverage Determination and Redetermination Request
Request for an Exception
Pharmaceutical Assistance Programs
Vaccine Coverage
Prescription Refills and Mail-order Services
Out-of-network Pharmacy Coverage and Prescription Drug Claim Form
Medication Therapy Management

Other Plan Information

Contact Information
Appointment of Representative
Getting Care During a Disaster
Extra Help from Medicare
Best Available Evidence
Interpreter Services
Disenrollment Information

Plan Documents and Directories

Enter your county below to view:

• Annual Notice of Change
• Evidence of Coverage
• Summary of Benefits
• Provider Directory
• Pharmacy Directory
• Formulary

Medical Plan Information

Medical Mutual Medicare Part C Transition Policy

Beginning Jan. 1, 2025, if you are a new member of your MedMutual Advantage Plan and/or to Medicare and are currently undergoing an active course of treatment, you may qualify for a transition period for Medicare Part C covered drugs and services. For some drugs and services, we require additional information from your provider to determine if the drug or service is medically necessary.

We will cover restricted Medicare Part C drugs or services for the first 90 days of your MedMutual Advantage plan to ensure you do not experience any disruptions. We will work with your provider to get all the information needed to determine if we will continue coverage.

For more information regarding our Medicare Part C Transition Process, please call our Customer Care team toll free at 1-800-982-3117 (TTY: 711 for hearing impaired).

Your provider can start a determination (also known as an organization determination) by contacting the following organizations:

• For Part B drugs, have your provider submit a request to Prime Therapeutics
• For Part C outpatient medical services or items, your prrovider should submit the request via NaviNet. If your provider does not have access to NaviNet, they should fax in your request.

For Medicare Part D Transition policy, call our Pharmacy Customer Service team at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.

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Medicare Part B Prescription Drugs

Medicare Part B prescription drugs may be subject to step therapy requirements, meaning that you may be asked to try a different drug first before we will agree to cover the drug you are asking for. Use the link below to view a list of these drugs.

Medicare Part B Step Therapy

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Utilization Management Coverage Guidelines

When making coverage decisions, Medical Mutual follows applicable Medicare guidelines including statutes, regulations, National Coverage Determinations and Local Coverage Determinations.

In the absence of Medicare Guidelines, Medical Mutual may apply internal coverage criteria approved by our Utilization Management Committee. For more information, please review the policies and guidelines below:

• Medical Policies – Medical Policies provide guidelines for determining coverage for specific procedures, therapies, devices, equipment and services. 
• EviCore Guidelines – EviCore provides guidelines for determining coverage for radiology and radiation oncology services. 
  • Radiation Oncology Guidelines
  • Radiology Guidelines
• MCG Guidelines – MCG provides guidelines for determining coverage for inpatient care as well as specific procedures, devices, equipment and services.

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Aggregate Number of Grievances, Appeals and Exceptions

You can request the aggregate number of grievances, appeals and exceptions by calling 1-800-982-3117 (TTY: 711 for hearing impaired).

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Prior Authorization and Appeals

Medical Mutual requires you or your physician to get prior authorization for certain services and drugs. This means you will need to get approval from MedMutual Advantage in some cases before you receive care or fill prescriptions. If you don’t get approval, MedMutual Advantage may not provide coverage. You should discuss whether your medical service or prescription drug requires prior authorization. If prior authorization is required, your physician may complete our prior authorization form.

If you have a concern about whether particular medical service or prescription drugs are covered or the way in which they are covered, or related to payment for medical care or prescription drugs, this section describes how you should approach those situations:

If Medical Mutual requires a Prior Authorization on a medical service or drug, review must be completed to determine if Medical Mutual will pay for it. For example, your plan network doctor makes a request for a coverage decision for certain medical care he/she may provide, or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might determine that a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Making an Appeal
If we deny your prior authorization request for a medical service/item or Part B drug, you, Appointment of Representative, or your provider can appeal the decision. An appeal is a formal way of asking us to review and change the initial decision we made. You can file an appeal within 60 calendar days of the date you get the original denial letter from us. This is considered a Level 1 appeal. You may be able to get more time to appeal if you can show a good reason for missing the deadline. You or you doctor may also ask for an expedited, or fast, appeal. Your appeal will be reviewed by someone who did not make the prior decision about your case. You may ask for copies of documents, records, clinical guidelines and other information we used to make a decision on your appeal. There is no charge to appeal.

If we say no to all or part of your Level 1 Appeal for medical services/items or Part B drugs your Level 2 Appeal will be automatically forwarded to an independent organization that is not connected to us to review. Either Medical Mutual or the independent organization will notify you about the Level 2 Appeal. In the case of termination of inpatient hospital services, skilled nursing facility, or home health care services you submit your Level 1and Level 2 Appeal requests directly to the independent organization (see information below). If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

Types of Appeals
We review two types of appeals: standard appeals and expedited appeals. There is also a special fast-track appeal for discharge from a skilled nursing facility or home health agency or comprehensive outpatient rehabilitation facility services or inpatient hospital services. These types of special appeals are reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contracted by the federal government. You will get information about your rights for fast-track appeals when you get the advance notice of discharge from the facility.

Standard Appeals – Medical Services/Items and Medical Drug
To file a standard appeal of an organizational determination for medical care, send your request in writing.

You may use our appeal form by logging in to My Health Plan. The member appeal form is found under the Resources and Tools/ Member Forms tab. Your request should include:

• Your name and the patient’s name (if different)
• Address
• Member identification number (on your health ID card)
• Claim number
• Date of service
• Reason for appeal

You may also include medical records, doctor’s letters and other documents to support your appeal. You can upload supporting information if you are using our website. The use of our appeal form is not required. You may fax your request in any format and any documentation you would like us to consider toll free to 1-844-606-5394 (TTY: 711 for hearing impaired). You can also mail your request to:

Medical Mutual Member Appeals and Grievances Department
P.O. Box 94563
Cleveland, OH 44101-4563

We will notify you of our decision within 30 calendar days for service/item denials and within 60 calendar days for payment denials from the date we receive your request.

For service/item denials, our decision might take longer if you ask for an extension or if we need more information about your case. If we need more time, we will tell you and explain why more time is needed.

Please note: For decisions related to Part B medical drugs (drugs you receive while in a hospital outpatient facility or at a doctor's office), we will notify you of our decision within 72 hours. For a more detailed explanation of service and payment denials, please see the Evidence of Coverage (EOC).

Expedited Appeals – Medical Services/Items and Medical Drugs (Part B)
If you or your doctor believes using the standard appeal timeframe could seriously jeopardize your life, health or ability to regain the ability to do normal everyday tasks, you may be able to request an expedited appeal. Expedited appeals are only available before you get a service/item. We will automatically give you an expedited appeal if a doctor requests one for you.

If you ask for an expedited appeal without support from a doctor, we will decide if your request requires an expedited appeal. To request an expedited appeal, please call us at 1-855-887-2273 (TTY: 711 for hearing impaired) or fax your information to 1-800-221-2640. If your request qualifies for an expedited appeal, we will give you a decision as soon as your health condition requires, but within 72 hours after we receive your appeal request. If your request doesn’t qualify for an expedited appeal, we will give you a decision within 30 calendar days.

Please note: For decisions related to Part B medical drugs (drugs you receive while in a hospital outpatient facility or at a doctor's office), we will give you a decision within 24 hours. If we determine that your request does not need to be expedited, we will give you a decision within 72 hours.

If Your Appeal Is Denied
If Medical Mutual denies any part of your Part C appeal for items or services or Part B drugs you think should be covered, provided, or continued by your health plan, known as an organizational determination, we may inform you of our decision and automatically send your case to MAXIMUS Federal Services to make sure we made the right decision. MAXIMUS is an independent reviewer. MAXIMUS will contact you to let you know how to reach them and to give you information about other rights you may have. You may send MAXIMUS additional information to support your appeal.

MAXIMUS will notify you in writing when they have made a decision on your case, including the reasons for that decision. If they deny any part of your appeal, they will send you information about any remaining appeal rights you have.

Information on your right to file appeals is also included in your Evidence of Coverage. If you have questions you can also call us toll free at 1-800-982-3117 (TTY: 711 for hearing impaired) for help. We are open 8 a.m. to 8 p.m. seven days a week from October 1 to March 31 (excluding Thanksgiving and Christmas Day). From April 1 to September 30, we are open Monday through Friday from 8 a.m. to 8 p.m.

You may also contact the Medicare Rights Center at 1-800-333-4114 (TTY: 711 for hearing impaired) for help. The Medicare Rights Center is a non-profit organization providing counseling and advocacy services to support access to affordable healthcare. Or you may contact Medicare directly at 1-800-MEDICARE, 24 hours a day, seven days a week. (TTY: 1-877-486-2048 for hearing impaired).

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Out-of-network Coverage

Out-of-network Providers - PPO Plans

As a member of a PPO plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.

Other important things to know about using out-of-network providers:

• If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive, except for emergency care. 
• You don't need to get a referral or prior authorization when you get care from out-of-network providers, however, you may want to ask for a pre-visit coverage decision to confirm that the services you are getting are covered and are medically necessary. It is important to ask for a pre-visit coverage decision.
• If it is later determined that the out-of-network services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the entire cost. If we say we will not cover your services, you have the right to appeal our decision not to cover your care.
• It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends you a bill that you think we should pay, you can send it to us for payment.
• If you are using an out-of-network provider for emergency care, urgently needed services, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount.

Please review your Evidence of Coverage for complete information about out-of-network provider coverage.

Out-of-network Providers - HMO Plans

It is important to know which providers are part of our network. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Medical Mutual authorizes use of out-of-network providers.

If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. For this medical care, your provider must obtain approval from the plan before you seek care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider.

The Signature HMO-POS and Secure HMO-POS plans include point-of-service/out-of-network coverage for certain benefits.

Please review your Evidence of Coverage for complete information about out-of-network provider coverage.

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Grievances

Filing a Complaint or Grievance

If you have a concern about some aspect of our plan and it is not about decisions related to benefits, coverage, or payment, then this section will help you understand what steps you can take.

When you file a grievance, you are asking us to investigate a complaint which includes but is not limited to issues related to timeliness, appropriateness, access to and/or the setting in which you received or tried to receive a healthcare service.

A complaint about the quality of care you received from a hospital, doctor or other healthcare provider may also be forwarded to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for review.

You can file a grievance either by voice or in writing within 60 days of the event. Please call us at the Customer Care phone at 1-800-982-3117 (TTY: 711 for hearing impaired). You may also fax your grievance to 1-844-606-5394 or put it in writing and mail it to:

Medical Mutual Member Appeals and Grievances Department
P.O. Box 94563
Cleveland, Ohio 44101-4563

You also have the option to submit a complaint directly to Medicare with their online Medicare Complaint Form.

Standard Grievance

We will review your complaint and do a full investigation of the grievance as quickly as your case requires. We will notify you of our decision within 30 calendar days after we get your request, unless federal regulations allow for an extended timeframe. If, as permitted under the regulations, we decide it is in your best interest to take an extension, we will notify you promptly and let you know the reason for the extension. This extension will not be more than 14 calendar days.

Expedited Grievance

Under certain circumstances that require a faster response, we will respond to your grievance within 24 hours. See your Evidence of Coverage for more information about the conditions for a faster response to a grievance.

Please see your Evidence of Coverage (EOC) for more information about coverage determinations and appeals.

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Medicare Ombudsman

The Medicare Ombudsman helps you with Medicare-related complaints, grievances and other information. Learn more by visiting the Medicare website.

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Medical Claim Form

Sometimes when you receive medical care, you may need to pay the full cost right away. In some instances, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back. To submit a request asking us to pay for our share of the cost for medical care you have received, complete the medical claim form and send to us at Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018.

For more information on situations in which you may need to ask us for reimbursement or to pay a bill you have received from a provider, see Chapter 7 of your Evidence of Coverage.

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Prescription Drug Information

Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, 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. All plans offer this payment option and participation is voluntary.

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Medication Adherence

Taking medications as directed by your doctor or healthcare provider is often referred to as medication adherence. Filling your prescriptions and taking medications as directed by your doctor or healthcare provider are important parts of managing your health. To prevent serious complications, you should take your medications exactly as prescribed — even if you don’t feel any symptoms. Many common generic medications for treating high blood pressure, high cholesterol and diabetes have low or $0 copay for up to a 90-day supply at preferred network pharmacies, including Express Scripts home delivery. Show your MedMutual Advantage card at the pharmacy and ask that they use it for all medications covered by your plan.

Learn More

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Medical Mutual's Medicare Part D Drug Transition Policy

New members in our health plan may be taking drugs that are not on our formulary (list of drugs) or that are subject to certain restrictions, such as prior authorization, quantity limits or step therapy. Current members may also be affected by changes in our formulary from one year to the next. If your drug is not on the Drug List or is restricted, here are things you can do:

• You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
• You can change to another drug.
• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

You may be able to get a temporary supply.

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:
   • The drug you have been taking is no longer on the plan's Drug List.
   • or -- the drug you have been taking is now restricted in some way.
2. You must be in one of the situations described below:
   • For those members who are new or who were in the plan last year:
     • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.  (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
   • For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
     • We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.
   • For those members who have been in the plan for more than 90 days and experience a level of care change (from one treatment setting to another):
     • We will provide up to a one-month supply of a Non-Formulary Drug and/or a drug that may be restricted in some way, or less if your prescription is written for fewer days.
   • Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescription written for fewer days) include:
     • When you enter a long-term care facility
     • When you leave a long-term care facility
     • When you are discharged from a hospital
     • When you leave a skilled nursing facility
     • When you cancel hospice care

The plan will send you a letter within three business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.

Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover, such as drugs used for erectile dysfunction or drugs for weight loss.

For more information regarding our Medicare Part D Transition Process please call our Pharmacy Customer Service team at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.

You and/or your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan's Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 of the Evidence of Coverage tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. 

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Quality Assurance

MedMutual Advantage's Quality Assurance and Utilization Management Program was created to help ensure appropriate use of prescription drugs covered under Medicare Part D, and most importantly, keep our members safe.  The program is designed to reduce drug interactions and adverse drug events, optimize medication utilization, and provide clinically appropriate incentives to help keep drug costs down as much as possible to save our members money.  This program is offered at no additional cost to members and providers. 

Our Quality Assurance Program uses a range of tools to ensure high quality prescription drug coverage for all of our members.  These tools include, but are not limited to: prior authorizations, quantity limitations, step therapy requirements, drug utilization reviews and clinical edits. 

Drug Utilization Review

We use utilization review (DUR) systems to screen every prescription billed by your pharamcy, both retrospectively and at the point of sale. These edits help your dispensing pharmacist catch any potential drug interactions and address any issues before you receive the medication to keep you safe.

The clinical issues addressed by DUR include, but are not limited to:

• Duplication of therapy
• Misuse
• Abuse
• Overutilization or underutilization
• Drug interactions that are clinically significant
• Incorrect or inappropriate drug therapy
• Contraindications that are patient specific 

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Drug Management Program

Medical Mutual is committed to ensuring the safe use of all prescription medications. The Medical Mutual Drug Management Program (DMP) focuses on the safe use of opioids, benzodiazepines and other frequently abused drugs. This program helps coordinate care for Medicare members who get opioid prescriptions from multiple doctors or pharmacies.

Throughout the year, Medical Mutual will review opioid medication usage and identify members who would benefit from our DMP. If we find possible unsafe usage or overuse of prescription opioids, benzodiazepines and other frequently abused drugs we typically contact your prescriber to better coordinate care. Based on these discussions and the outcome of this review, we may add certain limits on your coverage for these types of drugs. For example, members may be required to get these medications from certain doctors or pharmacies. You will be notified in writing if this occurs.

If you think that we’ve made a mistake or would like to appeal this determination, you, your doctor or authorized representative can file an appeal. You should review the information contained in your notification letter for more information about how to request an appeal or visit our Coverage Redetermination or Appeal section.

For more information about the DMP or how to submit an appeal, call Customer Care at 1-800-982-3117 (TTY: 711 for hearing impaired).   

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Prescription Drug Coverage Determination and Redetermination Request

Coverage Determination

A coverage determination is a decision we make about your benefits and coverage, or about the amount we will pay for your Part D prescription drugs.

You, your appointed representative or your prescriber have the right to request a coverage determination in the following ways:

• Call 1-800-935-6103 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.
• Complete the Medicare Coverage Determination Request Form and either:
• Fax the form to 1-877-251-5896
• Mail the form to:
  
  Express Scripts
  Attn: Medicare Reviews
  P.O. Box 66571
  St. Louis, MO 63166-6571

Expedited Coverage Determination
If you or your prescriber believes that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.

For more information on asking for coverage decisions about your Part D prescription drugs, please see Chapter 9 of your Evidence of Coverage.

Coverage Redetermination or Appeal

If your coverage determination for a prescription drug was denied, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

A redetermination or appeal is a formal way of asking us to review and change a coverage decision we have made.

You, your appointed representative or your prescriber have the right to request a coverage redetermination in the following ways:

• Call 1-800-935-6103 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.
• Complete the Medicare Redetermination Request Form and either:
• Fax the form to 1-877-852-4070
• Mail the form to:
  
  Express Scripts
  Attn: Medicare Appeals
  P.O. Box 66588
  St. Louis, MO 63166-6588

Expedited Redetermination
If you or your prescriber believes that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

For more information on asking for a coverage redetermination or appeal a decision about your Part D prescription drugs, please see Chapter 9 of your Evidence of Coverage.

If Your Appeal Is Denied

If Medical Mutual denies any part of your appeal request for a coverage or payment review of a Part D prescription drug, we will inform you of our decision, and explain your further appeal rights, which will instruct you how to exercise those rights. Part D prescription drug appeals must be requested by you for review at C2C Innovative Solutions, Inc. Requests for an independent review of Part D prescription drug appeals must come from you.

C2C will notify you in writing when they have made a decision on your case, including the reasons for that decision. If they deny any part of your appeal, they will send you information about any remaining appeal rights you have.

Information on your right to file appeals is also included in your Evidence of Coverage. If you have questions you can also call us toll free at 1-800-982-3117 (TTY: 711 for hearing impaired) for help. We are open 8 a.m. to 8 p.m. seven days a week from October 1 to March 31 (excluding Thanksgiving and Christmas Day). From April 1 to September 30, we are open Monday through Friday from 8 a.m. to 8 p.m.

You may also contact the Medicare Rights Center at 1-800-333-4114 (TTY: 711 for hearing impaired) for help. The Medicare Rights Center is a non-profit organization providing counseling and advocacy services to support access to affordable healthcare. Or you may contact Medicare directly at 1-800-MEDICARE, 24 hours a day, seven days a week. (TTY: 1-877-486-2048 for hearing impaired).

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Request for an Exception

You can ask Medical Mutual to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:

• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the plan 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 more.
• You can ask us to cover a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.

Generally, the plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Members may contact us to ask for an initial coverage decision for a formulary exception. When you are requesting an exception, you should submit a statement from your doctor supporting your request. Generally, we must make our decision within 72 hours of your request.

For more information on how to request an exception, please review Chapter 9 of your Evidence of Coverage.

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Pharmaceutical Assistance Programs

Pharmaceutical Assistance Programs (PAPs) are sometimes available to help relieve financial burden by providing free or discounted medications to qualifying patients. These programs are medication specific and may be available to you through various organizations. See if a program is available for your medication.

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Vaccine Coverage

Preventive vaccines can be covered under Medicare Part D Prescription Drug Coverage or under the Part B Medical Coverage. It’s important to know what vaccines are covered, your potential out-of-pocket costs, and where to get it.

Part B Covered Vaccines

• Covered Medicare Part B services include the following and are covered (in-network) with no coinsurance, copayment, or deductible:
• Pneumonia vaccine
• Flu shots (once each flu season in the fall and winter, with additional flu shots if medically necessary)
• Hepatitis B vaccine (if you are at high or intermediate risk of getting Hepatitis B)
• COVID-19 vaccine
• Other vaccines if you are at risk and they meet Medicare Part B coverage rules

Where should I get my Part B vaccines?

You can obtain these vaccines through your network physician. You can also get your flu and COVID-19 shots at one of our network pharmacies.

Part D Covered Vaccines

Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. You are responsible for any deductible, copay, coinsurance or administration fee that may apply for the vaccine. Call Member Services for more information.

Medicare Part D covers vaccines not covered by Part B (medical) as long as the vaccine is reasonable and necessary to prevent illness

• A few examples of Part D covered vaccines include Shingrix (Shingles) vaccine, Tetanus vaccine, and MMR (measles, mumps, rubella) vaccine. You can find these vaccines in the plan's List of Covered Drugs (Formulary).

Where should I get my preventive Part D vaccines?

The amount you have to pay for vaccinations covered by Part D will depend on your particular Part D drug plan, where you get the vaccine and who gives you the vaccine.

• Recommended method: Your local pharmacy provides and administers the vaccine. Getting your Part D covered vaccine at participating network retail pharmacies like Discount Drug Mart, Marc’s, Kroger, Walgreens and Walmart may save you the most money. You are responsible for your deductible, the copay or coinsurance (if applicable) for the vaccine and administration. Your MedMutual Advantage plan will pay for the remaining costs. Find a pharmacy near you by using our Pharmacy Directory. 
• Your primary care provider’s (PCP) office has the vaccine and administers it. If you receive your vaccine at your PCP office, you are responsible for the entire upfront cost of the vaccine and administration of the vaccine. Some PCP offices will also charge office visit fees. You may ask Medical Mutual to reimburse you for the vaccine and administration. The amount you will be reimbursed will depend on the benefit stage you are in and the amount your provider billed. You will only be reimbursed up to the allowed amount. Any amount over the allowed amount that does not get reimbursed will apply to your Part D true out-of-pocket costs for the year.
• You buy the vaccine from the pharmacy and take it to your PCP to administer it. If you go this route, you will be responsible for your deductible and the copay or coinsurance (if applicable) for the vaccine at the pharmacy. Additionally, once you take the vaccine to your PCP, you will have to pay the entire cost for the vaccine administration, as well as the office visit. You may ask Medical Mutual to reimburse you for a portion of what you paid. The amount you will be reimbursed for the administration fee will depend on the benefit stage you are in and the amount your provider billed. You will only be reimbursed up to the allowed amount. Any amount over that does not get reimbursed will apply to your Part D true out-of-pocket costs for the year. You will not be reimbursed for any costs associated with the office visit.

How do I ask Medical Mutual to pay me back or to pay a bill I have received?

To ask Medical Mutual to reimburse you for a Part D covered vaccine administered by your PCP, send us a claim form along with your bill and documentation of any payment you have made. For more information about this process, see Chapter 7 of your Evidence of Coverage.

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Prescription Refills and Mail-order Services

For certain kinds of drugs, you can use the plan's preferred mail-order pharmacy, Express Scripts. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan's mail-order service are marked as "mail-order" drugs in our Drug List.

Your plan's mail-order benefit allows you to order up to a 90-day supply.

To get order forms and information about filling your prescriptions by mail, please call Customer Service (phone numbers are on the front of your card).

Usually, a mail-order pharmacy order will get to you in no more than 14 days. Delays can occur for various reasons such as weather conditions, mail carrier issues, or action is required by you or your prescriber. If you have not received your order within 14 days, it's best to contact your Part D Customer Service toll free at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired) to determine the reason for the delay. Additionally, we do not want you to have an interruption in therapy, so be sure to also discuss any options you have in obtaining a short-term supply at your local pharmacy while you wait for your mail order supply.

New Prescriptions the Pharmacy Receives Directly from Your Doctor's Office

The pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without checking with you first, if either:

• You used mail order services with this plan in the past, or
• You sign up for automatic delivery of all new prescriptions received directly from health care providers. You may request automatic delivery of all new prescriptions now or at any time by providing consent on your first new home delivery prescription sent in by your doctor or health provider.

If you receive a prescription automatically by mail that you do not want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund.

If you used mail order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please contact us by calling Part D Customer Service 1-844-404-7947.

If you have never used our mail order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if necessary, allow you to cancel or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping.

To opt out of automatic deliveries of new prescriptions received directly from your health care provider's office, please contact us by calling Part D Customer Service toll free at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired).

Refills on Mail-order Prescriptions

For refills of your drugs, you have the option to sign up for an automatic refill program. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use our auto refill program, please contact your pharmacy 14 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.

To opt out of our program that automatically prepares mail order refills, please contact us by calling the number on the back of your member ID card so the pharmacy can reach you to confirm your order before shipping, please make sure to let the pharmacy know the best ways to contact you. You may provide our mail-order vendor with your preferred contact information by calling Part D Customer Service toll free at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired).

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Out-of-network Pharmacy Coverage and Prescription Drug Claim Form

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.

If you cannot use a network pharmacy, these are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• If the prescriptions are related to the care of a medical emergency or urgently needed care, they will be covered. In this situation, you will have to pay the full cost (rather than paying just the copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary and reasonable (UCR). Any amount you pay over the UCR will be applied to your TrOOP (True Out-Of-Pocket cost). 
• If you are traveling within the United States, but outside the plan's service area, and you become ill or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy (if you follow all other coverage rules identified within your Evidence of Coverage and a network pharmacy is unavailable). In this situation, you will have to pay the full cost (rather than paying just the copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary, and reasonable (UCR). Any amount you pay over the UCR will be applied to your TrOOP. 
• If you are unable to get a covered drug in a timely manner within our service area, because there is not a network pharmacy within a reasonable driving distance which provides 24-hour service.
• If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (the drugs include orphan drugs or specialty pharmaceuticals).
• Self-administered medications that you receive in an outpatient setting may be covered under Part D. For consideration, please submit a paper claim.

In these situations, please check first with Customer Care to see if there is a network pharmacy nearby. You can contact Customer Care by calling 1-800-982-3117 (TTY: 711 for hearing impaired). You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You may request reimbursement for your share of the cost by submitting a paper claim to Medical Mutual. You may, however, be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

This Prescription Drug Claim Form is offered as a tool to assist in getting your claim paid as soon as possible. Please print clearly. Use of this particular form is not required and you may submit equivalent written documentation, but it must provide all of the requested information on this form.

Please review your Evidence of Coverage for complete information about out-of-network pharmacy coverage and how to submit a paper claim for reimbursement, or call Member Services at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired).

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Medication Therapy Management

The Medication Therapy Management (MTM) Program is a service for members with multiple health conditions and who take multiple medicines. The MTM program helps you and your doctor make sure that your medicines are working to improve your health.

Eligible members will be automatically enrolled into the program and the service is provided at no additional cost to the member. Please see below for eligibility details. Participation is voluntary, but strongly encouraged. Members may choose not to participate in the program and opt out of the program on a yearly basis.

The MTM program is offered through our partnership with Clarest Health. The MTM program is not considered a part of the plan’s benefit.

Who Is Eligible for the MTM Program

You may qualify for the MTM Program if:

1. You have 3 or more chronic health problems. These may include:
   
   • Alzheimer’s Disease
   • Bone Disease (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 (High blood pressure)
   • Mental health (including depression, schizophrenia, bipolar disorder, and other chronic/disabling mental health conditions)
   • Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders)
2. You take 8 or more daily medicines covered by Medicare Part D.
3. You spend $1,623 or more per year on Part D covered medications

How the MTM Program Helps You

If you qualify for the MTM Program, you will be contacted and have the chance to speak with a highly-trained pharmacist or other qualified clinician. During that call, the pharmacist or other qualified clinician will complete a comprehensive medication review of your medicines and talk with you about:

• Any questions or concerns about your prescription or over-the-counter medicines, such as drug safety and cost
• Better understanding your medicines and how to take them
• How to get the most benefit from your medicines

Preparing for Your Medication Review

To get the most out of your free medication review, we encourage you to gather all your medications, including over the counter drugs, vitamins and supplements and have them handy prior to the review. If needed, have a family member or caregiver on hand to help you ask questions and understand answers about the drugs that you are taking.

What You Will Receive

If you qualify for the MTM Program, you will receive:

• Welcome letter by mail and/ or phone call that tells you know how to get started.
  
  • Full medication review
  • You will have the chance to review your medicines and any issues you may have with a highly-trained pharmacist or other qualified clinician.
    • This review will take about 20-30 minutes. This call can be scheduled at a convenient time for you.
• Summary letter will be mailed that contains the following:
  
  • A medication action plan which contains a list of actions that can be completed by you to help improve your health. Included in the plan is space for you to take notes or write down any follow-up questions that you can address with your doctor at your next visit.
  • A personal medication list is a record of all of the medicines, prescription and non-prescription, that you take and the reasons why you take them.
• Click here to see an example of a full medication review letter which includes the Personal Medication List.
• Ongoing targeted medication reviews
  
  • At least once every 3 months, your medicines will be reviewed, and you or your doctor may receive a letter or a phone call about any identified problems.

How to Learn More about the MTM Program

For information about the MTM Program or to see if you qualify, please contact the Medication Management Center at 1-877-205-8550 (TTY: 711 for hearing impaired).

If you are already enrolled in the MTM Program and you would like to complete your medication review, you can call Clarest Health at 1-877-205-8550 (TTY: 711 for hearing impaired), Monday through Friday, 9 a.m. to 6 p.m. EST.

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