All drugs in our Drug List or Formulary have been evaluated by a group of health care professionals. Check the drugs you are taking on our list in our Medicare Advantage and Part D plans. (HTML version)
This information contains changes eliminating one or more drugs or changing specifications.
Triple-S Salud will require that you or your physician obtain a precertification (prior authorization) for certain medications. This means that you need the approval of Triple-S Salud before you obtain these medications. If you do not obtain the approval from Triple-S Salud, Triple-S Salud will not cover the medication.
In some cases, Triple-S Salud requires that you try certain medications first to treat your medical condition before other medications for the same medical conditions are covered. For example, if medication A and medication B both treat your medical condition, Triple-S Salud may not cover medication B unless you have used medication A first. If medication A does not work for you, then Triple-S Salud will cover medication B.
For certain medications, Triple-S Salud limits the amount of the medication to be covered. For example, Triple-S Salud provides 18 tablets per prescription of sumatriptan 25mg or 50 mg (Imitrex®) for a 30 day period.
Drugs that Require Precertification
We require you to get precertification (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don’t get the necessary information to satisfy the precertification, we will not cover the drug. Our Drug List or Formulary identifies these drugs with the letters PA.
Frequently asked questions list
Can the Drug List or Formulary change?
We are allowed to make certain changes to our Drug List or Formulary during the year. Changes in the Drug List or Formulary may affect which drugs are covered and how much you will pay when filling your prescription. The kinds of Drug List or Formulary changes we may make include:
- Adding or removing drugs from the Drug List or Formulary.
- Adding precertification, quantity limits, and/or step-therapy restrictions on a drug.
- Moving a drug to a higher or lower cost-sharing tier
If we remove drugs from the Drug List or Formulary, we will notify you of the change at least 60 days before the date that the change becomes effective or provide you with a 60-day supply at the pharmacy. If a drug is removed from our Drug List or Formulary because the drug has been recalled from the pharmacies, we will not give 60 days' notice before removing the drug from the Drug List or Formulary.
Frequently asked questions list
What if your drug isn’t on the Drug List or Formulary?
If your prescription isn’t listed on your copy of our Drug List or Formulary, check the Drug List or Formulary on our website, which we update at least monthly. In addition, you may contact Member Services. If Member Services confirms that we don’t cover your drug, you have two options:
- Ask your doctor if you can switch to another drug that is covered by us.
- You or your doctor may ask us to make an exception a type of coverage determination to cover your drug. See Section Evidence of Coverage for more information on how to request an exception or appeal.
Frequently asked questions list
How do you request an exception?
You may request an exception in our coverage. There are different types of exceptions you can request.
- You may ask us to cover your Part D drug even if it is not on our Drug List or Formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
- You may ask us to waive coverage restrictions or limits on your Part D drug. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to provide a higher level of coverage for your Part D drug. This would lower the coinsurance/copayment amount you must pay for your Part D drug.
Generally, we will only approve your request for an exception if the alternative Part D drugs included on the Plan Drug List or Formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and would cause you to have adverse medical effects.
If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision. See your Evidence of Coverage for more information about how request an appeal.
Frequently asked questions list
How do you request an appeal or initial determination?
A coverage determination or an appeals decision happens when Triple-S Salud does not cover all or part of a vaccine or other drug benefit covered under Medicare Part D.
When we make an initial determination, we are giving our interpretation of how the benefits of prescription drugs in Part D are covered, and how they apply to your specific situation.
You, your prescribing physician, or someone you name to act on your behalf may ask us for an initial determination. The person you name would be your “Appointed Representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your Appointed Representative.
Frequently asked questions list
When can you request a refund for your medications?
You may submit a paper claim for reimbursement of your drug expenses in the situations described below:
- Drugs purchased out-of-network - when you go to a network pharmacy and use our membership card, your claim is automatically submitted to us by the pharmacy.
- Drugs paid for in full when you don’t have your membership card with you - if you pay the full cost of the prescription rather than paying just your coinsurance or copayment because you don’t have your membership card with you when you fill your prescription, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us.
- Drugs paid for in full in other situations - if you pay the full cost of the prescription rather than paying just your coinsurance or copayment because it is not covered for some reason (for example, the drug is not on the Drug List or Formulary or is subject to coverage requirements or limits) and you need the prescription immediately, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us. In these situations, your doctor may need to submit additional documentation supporting your request.
- Drugs purchased at a lower price - in rare circumstances when you are in a coverage gap or deductible period and have bought a covered Part D drug at a network pharmacy under a special price or discount card that is outside the Plan’s benefit, you may submit a paper claim to have your out-of-pocket expense count towards qualifying you for catastrophic coverage.
- Copayments for drugs provided under a drug manufacturer patient assistance program - if you get help from, and pay copayments under, a drug manufacturer patient assistance program outside our Plan’s benefit, you may submit a paper claim to have your out-of-pocket expense count towards qualifying you for catastrophic coverage.
Frequently asked questions list
How do you submit a paper claim?
Please send your written reimbursement request to the following address:
Triple-S Salud Reimbursement Department
PO Box 363628
San Juan, PR 00936-3628
You request must include the following:
- Name and contract number of the plan member who received the service.
- Date of service
- Diagnosis
- Stamp or letterhead of provider’s name, address and specialty
- National Provider Identifier (NPI) of the physician
- Amount and description of medication received
- Amount paid
- Reason for requesting reimbursement
- For services that require a precertification, include a copy of the precertification.
- Drug name
- Daily dose
- Prescription number
- Dispensed quantity
- National Drug Code (NDC)
- NPI of the Pharmacy and of the prescribe physician, for drugs claims.
Frequently asked questions list
How to obtain a temporary supply of your medication?
You may be able to get a temporary supply of your medication
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 to your doctor 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:
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 (Section 4 chapter 5 in the Evidence of Coverage tells about restrictions).
You must be in one of the situations described below:
- For those members who were in the plan last year:
We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
- For those members who are new to the plan and aren’t in a long-term care facility:
We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of 30-day supply, or less if your prescription is written for fewer days.
- For those who are new members, and are residents in a long-term care facility:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
- For those who have been a member of the plan for more than 90 days, and are a resident of a long-term care facility and need a supply right away:
We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
To ask for a temporary supply, call Member Services.
During the time when you are getting a temporary supply of a drug, you should talk to your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered.
You can change to another drug
Start by talking to your doctor. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor to find a covered drug that might work for you.
Frequently asked questions list
Which programs help people with limited resources pay for their prescription drugs?
Extra Help - is a Medicare program to help people with limited income and resources pay for their Medicare prescription drug costs and coverage such as premiums, deductibles and coinsurances. Read Section III of your Medicare and You 2012 Handbook or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, free of charge, 24 hours a day, 7 days a week.
State Pharmaceutical Assistance Programs - These programs provide financial help for prescription drugs to medically needy seniors and individuals with disabilities and a limited income. For more information about the programs available in Puerto Rico, please contact the Oficina del Procurador del Ciudadano.
Programs for people who live in United States’ territories - There are programs in Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa to help people with limited income and resources pay for their Medicare costs. Call your local Medical Assistance (Medicaid) office to find out more about their rules. You can also visit http://www.medicare.gov for more information. Or call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week and say “Medicaid” for more information. TTY users should call 1-877-486-2048.
Frequently asked questions list
Updated on: December 5, 2011
Triple-S FarmaMed ELA (PDP) is a prescription drug plan with a Medicare contract. The plan is available to all Medicare beneficiaries with Parts A, B or both that reside in the service area. Beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Limitations and restrictions may apply. Benefits, formulary, pharmacy network, premium, copayments and/or coinsurances may change on January 1, 2013.
Y0082_WEB2012 CMS Approved 12142011
