Pharmacy & Part D Coverage Information

 
2017 Formulary Information Formulary FAQ Pharmacy Network Information
Appointment of a Representative Generic Drugs Prior Authorization Criteria
CMS Best Available Evidence Grievance & Appeals Step Therapy Criteria
Drug Utilization Management & Quality Assurance Low Income Subsidy Information Transition Policy
Drugs with Quantity Limits Medication Therapy Management Coverage Determination Request Form
Formulary Changes Part D Drug Problems or Complaints Redetermination Request Form

Access our Pharmacy System

Members can register and login to our Pharmacy Benefit Manager (PBM) system by going to MyCatamaranRx.com. This site allows members to search for pharmacy locations, price pharmacy claims, order mail order refills, determine generic availability for your medication, lookup drug interactions and side effects.

Pharmacy Network Information

Freedom Health uses a network of pharmacies that is equal to or exceeds CMS requirements for pharmacy access in your area. In the State of Florida, Freedom Health has 4,134 pharmacies in their network. These pharmacies are contracted through our Pharmacy Benefit Administrator, Spectral Solutions.

You can get prescription drugs shipped to your home through our network mail order delivery service. If you need your medication immediately, have your doctor write 2 prescriptions. One prescription should be written for up to a 14 day supply. This prescription should be filled at your local retail pharmacy. The second prescription for the extended day’s supply should be mailed to the mail order pharmacy. If your prescription is already at the mail order pharmacy, you can ask them to send the prescriptions for next day delivery or 2 day delivery. There may be additional charges for this service.

For refills of your mail order prescriptions, you have the option to sign up for an automatic refill service. Under this service, we will start to process your next refill automatically when our records show that you should be close to running out of your drug. We will contact you prior to shipping each refill to make sure you are in need of more medication. You can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use the auto refill service, please contact us 10 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 the automatic refill service, please contact your mail order service directly.

If you utilize AssuredRX please call 1-888-987-9977, TTY/TDD users 711, 9:00 AM to 5:00 PM Monday through Friday. Or, if you utilize OptumRx Home Delivery please call 1-800-763-0044, TTY/TDD users 711, 7:00 am to 10:00 pm, Monday through Friday, and 8:00 am to 6:30 pm Saturdays. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact us at Freedom Health’s Member Services at 1-800-401-2740 or, for TTY/TDD users 711. Hours are October 1 to February 14 from 8:00 am to 8:00 pm 7 days a week and February 15 to September 30 from 8:00 am to 8:00 pm Monday through Friday.

We also list pharmacies that are in our network but are outside our service area. Please contact Freedom Health at 1-800-401-2740 for additional information. TTY users should call 711. Hours are October 1 to February 14 from 8 a.m. to 8 p.m. 7 days a week and February 15 to September 30 from 8 a.m. to 8 p.m. Monday through Friday for additional information. Member Services also provides free language interpreter services for non-English speakers.

To search for a pharmacy, click on the "Pharmacy Network Listing" link below. Select your "County" and "Provider Type" then click on the “Search Now” button.

2017 Formulary Information (List Of Covered Drugs)

A formulary is a list of drugs covered by your plan to meet patient needs.
To search for a drug, click on the link below. Once the page is opened, select your county and plan then type in your drug name or drug category in the “Search” box. You can even download the Formulary in a PDF version.

Formulary Changes

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

Formulary FAQs

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?

English  |  Spanish

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.

Low Income Subsidy (LIS) Information

Learn how you may be able to get extra help with your prescription drug coverage.

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 »

Where to Send This Form

Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision. 

You can also call the Member Services Department to learn more about how to name your appointed representative.

Drug Utilization Management & Quality Assurance

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

To learn more about how to ask for an Exception, a Coverage Determination, Appeal or to make a complaint, click on a link below:

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Pharmacy and Part D Disclaimer

Potential for Contract Termination:

Freedom Health has a contract with the Centers for Medicare and Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. Freedom Health 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

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.

Last Updated: 07/31/2017