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2013 Pharmacy Part D Coverage Information

America’s 1st Choice Insurance Company of NC, Inc. uses a network of pharmacies that is equal to or exceeds CMS requirements for pharmacy access in your area. In the state of North Carolina, America’s 1st Choice Insurance Company of NC, Inc. has 2,060 pharmacies in their network. These pharmacies are contracted through our Pharmacy Benefit Administrator, Spectral Solutions.

We also list pharmacies that are in our network but are outside our service area . Please contact  America's 1st Choice Insurance Company of North Carolina at 1-866-321-3947 (TTY/TDD 1-800-735-2962), 8am to 8pm 7 days a week Oct. 1, 2012 to Feb 14, 2013, 8am to 8pm Mon. through Fri. from Feb. 15, 2013 to Sept.30, 2013, 8am to 8pm 7 days a week Oct. 1, 2013 to Feb 14, 2014, for additional information.

2013 Formulary

Formulary Changes

Formulary list may change during the year. Updates, if any, will be posted monthly.

Formulary FAQs

Grievances and Coverage Determinations

To make an oral request for determination (exceptions)/re-determinations (expedited appeals), call 1-888-407-9977.

What to do if you have a problem or complaint about getting a Part D drug?

Click here to learn more about how to ask for an Exception, a Coverage Determination an Appeal or to make a complaint.

Pharmacy Network Information

To search for a pharmacy, click on the Pharmacy Network Listing link below. Type your county or pharmacy name in the “FIND” box then click on the “FIND NEXT” button. 

Prior Authorization Criteria

Step Therapy Criteria

Click here to learn which drugs must meet Step Therapy Criteria.

Drugs with Quantity Limits

Click here to find out about drugs with Quantity Limits.

Generic Drugs

Click here to learn more about Generic Drugs.

Transition Policy

What can you do if your drug is not on the Drug List?

CMS Best Available Evidence

For information about the (BAE) policy please contact member services.

Learn what can you do if you believe you are eligible for Low Income Subsidy but do not have a required piece of evidence.

(You will be redirected to this site)

 

Low Income Subsidy (LIS) Information

Grievance & Appeals

Members and providers who have questions about the Grievance and Appeals processes, need the status of a coverage determination or want to receive an aggregate number of grievance, appeals, and exceptions filed with the plan sponsor please contact. Member Services.

 

Appointment of a Representative

The Appointment of Representative Form (PDF, 66 KB) is located on the CMS Web site.

Beneficiaries and providers may appoint another individual, including an attorney, as their representative in dealings with Medicare, including appeals you file. Form CMS-1696, Appointment of Representative form, must be submitted with the appeal and is valid for one year from the date. The form must be signed by both you and the appointed representative. A representative may be designated at any point in the appeals process. This representative may assist you during the processing of a claim or claims and/or any subsequent appeal. Refer to the CMS Medicare Claims Processing Manual (PDF, 605 KB) (Pub. 100-04, chapter 29, section 270.1.10) for information on disclosing information to third parties.

The following types of individuals may be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:

  • Congressional staff members
  • Family members of a beneficiary
  • Friends or neighbors of a beneficiary
  • Members of beneficiary advocacy groups
  • Members of provider or supplier advocacy groups
  • Attorneys
  • Physicians or suppliers

The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696) or use a conforming written instrument. Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04, chapter 29, section 270.1) for required elements of written instruments. You may appoint a representative at any time during the course of an appeal. The representative must sign the CMS-1696 or other conforming written instrument within 30 calendar days of the date the beneficiary or you sign an order for the appointment to be valid. By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.

The CMS-1696 is available for the convenience of the beneficiary or you to use when appointing a representative. Instructions for completing the form:

  1. The name of the party making the appointment must be clearly legible. For beneficiaries, the Medicare Health Insurance Claim (HIC) number must be provided.
  2. Completing Section I - 'Appointment of Representative' - A specific individual must be named to act as representative in the first line of this section. A party may not appoint an organization or group to act as representative. The signature, address and phone number of the party making the appointment must be completed and the date it was signed must be entered. Only the beneficiary or the beneficiary’s legal guardian may sign when a beneficiary is making the appointment. If the party making the appointment is the provider or supplier, someone working for or acting as an agent of the provider or supplier must sign and complete this section.
  3. Completing Section II - 'Acceptance of Appointment' - The name of the individual appointed as representative must always be completed and his/her relationship to the party entered. The individual being appointed must then sign and complete the rest of this section.
  4. Completing Section III - 'Waiver of Fee for Representation' - This section must be completed when the beneficiary is appointing a provider or supplier as representative and the provider or supplier actually furnished the items or services that are the subject of the appeal.
  5. Completing Section IV - 'Waiver of Payment for Items or Services at Issue' - This section must be completed when the beneficiary is appointing a provider or supplier who actually furnished the items or services that are the subject of the appeal and involve issues describe in section 1879(a)(2) of the Social Security Act.

If any one of the elements listed above is missing from the appointment, the adjudicator shall contact the party (individual attempting to act as a beneficiary’s representative) and provide a description of the missing documentation or information. Unless the missing information is provided, the prospective appointed representative lacks the authority to act on behalf of the party and is not entitled to obtain or receive any information related to the appeal, including the appeal decision. The adjudicator will not dismiss the appeal request because the appointment of representative is not valid.

Appointment of Representative Form

Mail or fax this statement to the Plan at:
Grievance Appeals Department
P.O. Box210459
Columbia, SC  29221-0459 | Fax: 1-803-748-4534

You can also call the Member Services Department at 1-866-321-3947 to learn more about how to name your appointed representative.

 

Drug Utilization Management & Quality Assurance

Disclaimer

Potential for Contract Termination:

America’s 1st Choice Health Plans, Inc. has a contract with the Centers for Medicare and Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. America’s 1st Choice Health Plans, Inc. is required to notify beneficiaries that it is authorized by law to refuse to renew its contract with the Centers for Medicare & Medicaid Services (CMS), that CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of your enrollment. In addition, the plan may reduce its service area and no longer offer services in the area where you reside. In the event this happens, you will receive advance notice.

Rights and Responsibilities upon Disenrollment

"Disenrollment" from an America’s 1st Choice Health Plans, Inc. plan means ending your membership with us. Disenrollment can be voluntary (your choice) or, in limited circumstances, involuntary (not your choice).

You might leave one of our plans because you decide that you want to leave. During specified times (October 15 – December 7), you can choose to disenroll from your current Medicare plan.

Some situations require you to leave. For example, if you move out of our geographic service area, are absent from our service area for more than six consecutive months or if we no longer offer the plan in your geographic area.  

Usually, to end your membership in our plan, you simply enroll in another health plan during one of the election periods. One exception is when you want to switch from our plan to Original Medicare without a Medicare prescription drug plan. In this situation, you must contact Member Services and ask to be disenrolled from our plan.

If you have questions about ending your membership with us, call 1-866-321-3947 (TTY/TDD 1-800-735-2962), Our hours of operation are 8am to 8pm 7 days a week Oct. 1, 2012 to Feb 14, 2013, 8am to 8pm Mon. through Fri. from Feb. 15, 2013 to Sept.30, 2013, 8am to 8pm 7 days a week Oct. 1, 2013 to Feb 14, 2014.

Information on aggregate number of grievances , appeals and exceptions

Members can obtain an aggregate number of grievances, appeals and exceptions filed with the plan by calling our customer service department at 1-866-321-3947.