Thank you for your membership in VibrantRx (PDP). VibrantRx for the Office of Group Benefits Medicare eligible retirees provides you with access to a wide variety of prescription drugs. The service area for this plan includes all 50 states and the District of Columbia.
Our member web site provides you with tools, information and resources to help you understand your prescription drug benefits. Click on the links below to easily jump to information on these topics.
Summary of Benefits
Evidence of Coverage (EOC)
Errata Sheet (Correction Sheet)
Annual Notice of Changes (ANOC)
Formulary Information
Pharmacy Access
Transition Policy & Process
Coverage Decisions, Appeals and Grievances
Rights and Responsibilities
Medication Therapy Management & Drug Utilization Review
Extra Help
Star Ratings
Fraud, Waste and Abuse
Forms
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year. The formulary and pharmacy network may change at any time. You will receive notice when necessary. Members must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. We also list pharmacies that are in our network but are outside of our plan's service area.
Your Summary of Benefits tells you about some of the features of our plan, such as our plan's service area, as well as a list of benefits, conditions and limitations, premiums, cost-sharing (copayments, coinsurance, deductible) and more. It doesn't list every drug we cover, every limitation, nor every exclusion. To get a complete list of our benefits, please review your Evidence of Coverage.
Your Evidence of Coverage booklet explains any changes to your prescription drug coverage for the following year. First-time VibrantRx members will not receive an ANOC booklet until the following September.
We send an Errata Sheet if we need to make corrections to your Evidence of Coverage. This notice is an amendment to your original Evidence of Coverage and replaces certain sections or pages noted in the errata sheet. Please keep this updated information with your member materials for future reference. There is no action required on your part when you receive one of these documents. If you have any questions after reading an errata sheet, you may contact VibrantRx Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year. TTY users should call 711.
The Annual Notice of Changes booklet explains any changes to your prescription drug coverage for the following year.
A formulary is a list of covered drugs chosen by VibrantRx in consultation with a team of health care professionals. The VibrantRx Formulary lists the drugs believed to be necessary to meet our members' needs. You received a partial (abridged) formulary in your Welcome Kit, which covers the most commonly used drugs. This website has a full (comprehensive) list of all drugs covered by our plan. VibrantRx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a VibrantRx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not stop or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when questions about the safety or effectiveness of a drug are released. Other types of formulary changes, such as removing a drug from our formulary, will not affect most members who are taking the drug at that time. The drug will stay available at the same cost-sharing for those members taking it for the rest of the coverage year.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy limits on a drug, or if we move a drug to a higher cost-sharing tier, we must tell affected members of the change at least 60 days before the change occurs, or at the time the member requests a refill of the drug. Please review the VibrantRx Formulary Updates (Change Notices).
If the Food and Drug Administration (FDA) decides a drug on our formulary is unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and give notice of this change as soon as possible to members who take the drug. Please review Formulary Changes Due to Drug Recalls. If mid-year non-maintenance formulary changes occur, affected members will be told of formulary changes in their Monthly Prescription Drug Summary, also called the Part D Explanation of Benefits (EOB).
To get updated information about the drugs covered by VibrantRx, please call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year. TTY/TDD users should call 711.
There are two ways to find your drug:
VibrantRx covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient as a brand name drug. Generic drugs usually cost less than brand name drugs and are deemed by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
Some covered drugs may have requirements or limits on their coverage. These requirements and limits may include:
You can find out if your drug has any other requirements or limits by looking in the VibrantRx Formulary. Your provider can also review our specific clinical criteria for step therapy and quantity limits in the Utilization Management Guidelines. You can also get more information about the restrictions for specific covered drugs by calling Member Services toll-free at 1-844-826-3451, 24 hours a day/365 days a year. TTY/TDD users should call 711.
You can ask VibrantRx to make an exception to these restrictions or limits. See the question "How do I request an exception to the VibrantRx's formulary?" below for information about how to request an exception. You can also refer to Chapter 7 of your Evidence of Coverage.
If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that VibrantRx does not cover your drug, you have two options:
You can ask VibrantRx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make for a drug.
You should contact us to ask us for an initial coverage decision for a formulary or tiering exception. You should submit a statement from your prescriber supporting your request. Generally, we must make our decision within 72 hours of getting your doctor's (or other prescriber's) supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request for a fast decision is granted, we must give you a decision no later than 24 hours after we get your doctor's (or other prescriber's) supporting statement.
For more detailed information about your VibrantRx prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about VibrantRx, please call Member Services toll-free at 1-844-826-3451, 24 hours a day/365 days a year. TTY/TDD users should call 711.
Members must use network pharmacies to access their prescription drug benefit, except in certain non-routine circumstances. Quantity limitations and restrictions may apply.
We call the pharmacies on this list our "network pharmacies" because we have made arrangements with them to provide prescription drugs to our plan members. VibrantRx (PDP) has contracts with more than 65,000 pharmacies nationwide that meet or exceed Medicare's requirements for pharmacy access in your area. This ensures easy access to a network pharmacy. As a VibrantRx member, you have access to thousands of retail pharmacy locations, as well as convenient and safe mail-order delivery through Postal Prescription Services (PPS). Long-term care and home infusion pharmacies may serve a larger area. Therefore, you may need to look outside of your local area for these types of pharmacies.
A network pharmacy is a pharmacy where members can use the prescription drug benefits provided by VibrantRx. In most cases, your prescriptions are covered by VibrantRx only if they are filled at a network pharmacy. Once you go to one pharmacy, you are not required to keep going to the same pharmacy to fill your prescription. You can go to any of our network pharmacies. We will fill prescriptions at non-network pharmacies only under certain circumstances described under the question "When can I use an out-of-network pharmacy?" below.
VibrantRx has options to match your needs. If you are looking for the local service of a neighborhood pharmacy, you can choose one of our more than 65,000 community network pharmacies. If you are looking for the ease of having your prescriptions filled and sent to you by mail, you can access our mail-order pharmacy. Or, if you need drugs of a specialty type, the support of a specialty pharmacy may be of use to you.
VibrantRx has more than 65,000 community pharmacies for your use, including most chain drug stores and many independent pharmacies. At home or on vacation, you can find a pharmacy by calling VibrantRx Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year. TTY/TDD users should call 711. You can also use our online Pharmacy Locator tool. For your convenience, you may get an extended day supply of your prescription drugs at many of our retail pharmacies under our Choice90Rx® program. See your Pharmacy Directory, use the online Pharmacy Locator tool, or call Member Services at the number above for more details about which pharmacies participate in the Choice90Rx program.
Ordering prescriptions by mail is like having a pharmacy at your door. It can save you trips to the pharmacy while giving you the added privacy of having prescription drugs shipped to your home. You may also see copayment savings. Up to a 90-day supply of your prescriptions can be delivered to your mailbox for what you would normally pay for a 60-day supply at your community pharmacy. Ordering prescriptions by mail lowers your drug cost by 33%! Postal Prescription Services (PPS) is your VibrantRx mail order pharmacy. Upon placing an order, you will receive up to a 90-day supply of your prescription(s) in your mailbox in no more than 10 to 14 calendar days. It's as simple as that! For more information, visit the Mail Order page.
If you are taking a medication that is on the Specialty tier of your prescription benefit, you may use any specialty pharmacy in the VibrantRx specialty pharmacy network.
Other pharmacies are available in our network.
Only you know what pharmacy options best suit you. VibrantRx is pleased to offer you the choice of local pharmacies, prescriptions by mail, and a preferred specialty pharmacy that supports you and your specific needs. If you have questions on any of these pharmacy options or your VibrantRx plan, or you'd like to request a hard copy pharmacy directory for your state, our Member Services staff is here to help you toll-free at 1-844-826-3451, 24 hours a day/365 days a year. TTY TTY/TDD users should call 711.
To find a participating pharmacy in your area, click on the online Pharmacy Locator link located on the home page and enter your information. Pharmacy Locator was designed to help you find participating network pharmacies in your area. At a minimum, you will need to enter the city and state or ZIP code of the area you are searching, and select the distance you are willing to travel to a participating pharmacy (from 1 to 20 miles). Pharmacy Locator will display up to 20 participating pharmacies within your area. Pharmacy Locator will show which pharmacies are 24-hour pharmacies, Indian/Tribal/Urban Clinics, Long-Term Care pharmacies, Home Infusion pharmacies, and Military Treatment Facilities. Pharmacy Locator will also show you participating pharmacies for Choice90Rx® where you can fill an extended days' supply of certain medications.
You may also refer to the pharmacy directory in your Welcome Kit. To request a printed copy of a pharmacy directory for your area or another ZIP code, call Member Services or fill out our Pharmacy Directory Request Form.
The pharmacies listed in our directory are current as of date the directory was last updated, but this does not guarantee that a pharmacy continues to participate in your plan's network.
Pharmacy Locator provides a list of VibrantRx network pharmacies and includes some basic information about how to fill your prescriptions. To get a complete description of your prescription drug coverage, including how to fill your prescriptions, please review your Evidence of Coverage. VibrantRx may add or remove pharmacies from our pharmacy network. To get current information about VibrantRx network pharmacies in your area, visit the Pharmacy Locator link on our website or call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year. TTY/TDD users should dial 711.
You may also write to:
VibrantRx
PO Box 509097
San Diego, CA 92150
In most cases, your prescriptions are covered under this plan only if they are filled at a network pharmacy. Covered Part D drugs are available at out-of-network pharmacies in special situations, including illness while traveling outside the plan's service area where there is no retail network pharmacy. You may be charged an additional cost for prescriptions filled at an out-of-network pharmacy. Please note that the pharmacies in our network may change. For the most up-to-date information, select Pharmacy Locator from the home page or call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year. TDD/TTY users should call 711.
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
For more information about submitting these claims, call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year. TDD/TTY users should call 711. Or, you may refer to the process described in the next question labeled "How do I ask for reimbursement from the plan?".
If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our network mail-order pharmacy service or through a retail network pharmacy that offers an extended supply. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. We will not reimburse members for Part D medications obtained from an Excluded Provider. We will not routinely allow more than a month's supply of medication to be dispensed at the out-of-network pharmacy. We may require members receiving Part D drugs and services from an out-of-network pharmacy to assume financial responsibility for any difference between the out-of-network pharmacy's usual and customary price and the negotiated in-network pharmacy charge. All requests for reimbursement must be made to us in writing. (See the table entitled Payment Requests in Chapter 2, Section 1, of your Evidence of Coverage for the address where you may send reimbursement requests.)
Before you fill your prescription in any of these situations, call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year (TDD/TTY users should call 711) to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your coinsurance or co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. For more information on how to submit a paper claim, please refer to the next question labeled "How do I ask for reimbursement from the plan?" or refer to Chapter 5 of your Evidence of Coverage in the section labeled "How to ask us to pay you back".
If you use an out-of-network pharmacy or if you use an in-network pharmacy but for some reason you pay out of pocket (for example, you forget your member ID card and the pharmacy is unable to confirm your information), you will generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 5, Section 2 of your Evidence of Coverage explains how to ask the plan to pay you back.) Network pharmacies automatically submit your claim electronically to us. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to verify your benefits and submit the claim directly to us, so you will have to pay the full cost of your prescription and request reimbursement. Call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year (TTY/TDD users should dial 711) to request a claim form. Simply submit your claim form and your receipt to the address provided on the form. Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Evidence of Coverage or call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year (TTY/TDD users should dial 711) for more information on initial coverage determinations.
Under certain circumstances, VibrantRx (PDP) 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:
To ask for a temporary supply, please call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year. TTY/TDD users should call 711.
During the time when you are getting a temporary supply of a drug, you should talk with your prescriber to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. (See the question in the next section below labeled "How do I request an exception to the VibrantRx's formulary?" for more information about these options.)
The process for coverage decisions and appeals is for problems related to your benefits and coverage for prescription drugs, including problems about payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered. The process for complaints, also called grievances, deals with problems about quality of care, waiting times, and customer service. For more information about coverage decisions, appeals and complaints/grievances, see Chapter 7 of your Evidence of Coverage.
If you have additional questions about this process, about the status of your coverage decision, appeal or grievance, or to get a summary of the grievances, appeals and exceptions filed with our plan, see the contact information listed at the bottom of this section.
A coverage decision is a decision we make about the coverage of or the amount we will pay for your prescription drugs. This includes asking our plan to make an exception to how we cover a drug.
Start by calling, writing, or faxing us to make your request. (Scroll to the bottom of this section for contact information.) If you would like to submit a request in writing, you may download the Coverage Decision Request Form.
You can also submit a coverage decision request online. Include your name, address, Member ID Number, the reason for your request, and any additional information/evidence you wish to provide. You, your representative, or your doctor (or other prescriber) can do this. For the form to be completed by your doctor (or other prescriber), download the Coverage Decision Request Form for Prescribers. If your health requires a quick response, you must ask us to make a "fast decision" when you call. When a "fast decision" is requested, you will get an answer within 24 hours (or less if your health requires us to do so). To ask for a "fast decision", you must be asking for coverage for a drug you have not yet received and using the standard timeline for a decision could cause serious harm to your health or hurt your ability to function. If your doctor or prescriber tells us your health requires a "fast decision", we will automatically give you a fast decision.
If you do not ask for a "fast decision", we will use the standard decision timeline. With a standard decision, we will give you an answer within 72 hours if your request is about a drug you have not yet bought and within 14 calendar days if it is about a drug you have already bought. If you made a payment request and we agree with your request, we must make payment to you within 14 calendar days.
In some cases, we might decide a 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.
If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception." An exception is a type of coverage decision and the above timelines apply. Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception before we will consider your request.
You or your doctor or other prescriber can ask us to make any of the following exceptions:
Our plan is not required to grant any of these exception requests.
If you disagree with a coverage decision we make, you can appeal our decision. There are several levels of appeal, described below. You can also find this information in Chapter 7 of your Evidence of Coverage.
Member Services is open 24 hours a day, 365 days a year.
| Call: | 1-844-826-3451. TTY/TDD users should call 711. |
| TTY/TDD: | 711 |
| Fax: | 1-858-790-7100 |
| Write: |
Attn: Prior Authorization Department
VibrantRx 10181 Scripps Gateway Court San Diego, CA 92131 |
If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision (also known as asking for a redetermination). An appeal is a formal way of asking us to review and change a coverage decision we made. This includes a decision to deny coverage or payment for prescription drugs you have already received and paid for.
You have up to 60 calendar days to file your appeal, but it is best to file your appeal as soon as you decide you disagree with the decision our plan has made. We may give you more time if you have a good reason for missing this deadline. Start by calling, writing, or faxing us to make your request. (Scroll to the bottom of this section for contact information.)
You may download the Redetermination Request Form or you may submit your request online.
Include your name, address, Member ID Number, the reason for your request, and any additional information/evidence you wish to provide. You, your representative, or your doctor (or other prescriber) can do this.
You may request a "fast appeal" in writing or over the phone if you are appealing a decision we made about a drug you have not yet received and using the standard timeline for an appeal could cause serious harm to your health or hurt your ability to function. If you request a "fast appeal", you will receive a decision from us within 72 hours of receipt of the appeal.
If you do not request a "fast appeal", we will use the standard appeal timeline and you will receive a response from us within 7 calendar days. We do not accept standard appeals by phone.
When you make an appeal, we review the coverage decision we made to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision in writing.
If our plan says no to your appeal, we will send you a written explanation of our Level 1 decision along with instructions on how to make a Level 2 Appeal. You choose whether to accept our Level 1 decision or continue by making another appeal. If you decide to make another appeal, your appeal will go on to Level 2 of the appeals process where our decision will be reviewed by the Independent Review Organization. This organization is not connected with us in any way and decides whether our decision should be changed or not. To make a Level 2 Appeal, you must contact the Independent Review Organization and ask for a review of your case. When you make a Level 2 Appeal, we will send the information we have to the Independent Review Organization.
If your health requires it, you can ask the Independent Review Organization for a "fast appeal". If the organization agrees to a "fast appeal", they must give you an answer within 72 hours after they receive your appeal. If the organization says yes to all or part of what you requested in your appeal, we must provide the drug coverage that was approved within 24 hours. If you have a standard appeal, the organization must give you an answer within 7 calendar days after they receive it. If the organization says yes to all or part of what you requested in your appeal, we must provide the drug coverage within 72 hours. If a payment request for a drug you have already paid for is approved by the organization, we must send you payment within 14 calendar days.
If you disagree with the Level 2 Appeal decision you can continue to Level 3, but the dollar value of the drug coverage you are requesting must meet a minimum amount. The notice you get following your Level 2 Appeal will tell you if your appeal meets that dollar amount. If the dollar amount of the coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final.
If your appeal qualifies for Level 3, an Administrative Law Judge will review your appeal and give you an answer. If the judge says no to your appeal, the notice you will get tells you what to do next if you choose to continue with your appeal. At Level 4, the Medicare Appeals Council, who works for the federal government, will review your appeal and give you an answer. If you disagree with the Level 4 decision, you may be able to continue to the next level of appeal. At Level 5, a judge at the Federal District Court will review your appeal. This is the last step of the appeals process.
Member Services is open 24 hours a day, 365 days a year.
| Call: | 1-844-826-3451. TTY/TDD users should call 711.* |
| TTY/TDD: | 711 |
| Fax: | 1-858-790-6060 |
| Write: |
Attn: Appeals Department
VibrantRx PO Box 509097 San Diego, CA 92150 |
*We do not accept standard appeals by telephone call. Standard appeals must be submitted in writing.
The formal name for making a complaint is "filing a grievance". The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times (including those for coverage decision or appeals responses), and the customer service you receive. We encourage you to let us know right away if you have questions, concerns or problems related to your prescription drug coverage. You cannot be disenrolled or penalized for making a complaint.
Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. (Scroll to the bottom of this section for contact information.)
Whether you choose to call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If you are making a complaint because we denied your request for a "fast decision" about a coverage decision or appeal, we will automatically give you a "fast complaint" and give you an answer within 24 hours. Whenever possible, we will answer you right away. Most complaints are answered within 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 days total) to answer your complaint. If we do not agree with all or part of your complaint or don't take responsibility for the problem you are complaining about, our response will include our reasons. Our plan must respond whether we agree with your complaint or not.
When your complaint is about quality of care, you can make your complaint by using the process outlined above. You also have two extra options.
To find the name and contact information for the Quality Improvement Organization for your state, see Exhibit B of your Evidence of Coverage.
Member Services is open 24 hours a day, 365 days a year.
| Call: | 1-844-826-3451. TTY/TDD users should call 711. |
| TTY/TDD: | 711 |
| Fax: | 1-858-790-6000 |
| Write: |
Attn: Grievance Department
VibrantRx PO Box 509097 San Diego, CA 92150 |
You, your prescribing physician, or someone you name may act for you to request a coverage determination or file a grievance or appeal. The person you name would be your "appointed representative." You may name a relative, friend, lawyer, doctor, or anyone else to act on your behalf. 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.
You may use CMS' Appointment of Representative form (Form CMS-1696) which can be obtained by contacting Member Services or you may download Form CMS-1696 from CMS' website. You may also use an equivalent notice that satisfies the requirements of Form CMS-1696.
By signing the form, the representative shows his/her acceptance of being appointed as your representative. If any information is missing from the form, we will contact the individual attempting to act as your representative and provide a description of the missing information. Unless the missing information is provided, the representative does not have the authority to act on your behalf and is not allowed to receive any information related to your coverage determination, grievance or appeal, including the decision.
As a member of VibrantRx, you have certain Rights and Responsibilities. Our plan must honor your rights as a member of the plan. You also have some responsibilities as a member of our plan. The document above is also part of your Evidence of Coverage.
A Medication Therapy Management (MTM) Program is a free service offered by all Medicare Prescription Drug (Part D) plans. You may be invited to take part in a program designed for your specific health and pharmacy needs if you have certain medical conditions or chronic illnesses, take many prescription drugs, and have high drug costs. Our program was created for VibrantRx by a team of pharmacists and doctors to help members make better use of their drug coverage and to improve their understanding and use of medications. You automatically qualify to take part in this program if you meet the following three required criteria:
If you are chosen to take part in this program, you will receive:
As a member of our plan, you will receive a letter from VibrantRx if you qualify for this program. This program is not considered a benefit. You may decide not to take part in the program, but it is recommended that you take full advantage of this covered service if you are chosen. Contact Member Services toll-free for more details at 1-844-826-3451, 24 hours a day, 365 days a year. TTY/TDD users should dial 711.
You may download a form to track your Personal Medication List.
VibrantRx (PDP) conducts drug utilization reviews for all of our members to make sure they are prescription drugs they need and that those drugs are safe for them. These reviews are most important for members who have more than one health care provider prescribing their medications.
We conduct drug utilization reviews each time you fill a prescription and on a regular basis following a review of our records. During these reviews, we look for medication problems such as:
If we identify a medication problem during our drug utilization review, we will work with your health care provider to correct the problem. We also look for opportunities to lower your drug costs and will consult with your health care provider to decide if less expensive alternatives are right for you. Should you have questions about drug utilization review or any other questions about our plan, please call Member Services toll-free at 1-844-826-3451, 24 hours a day, 365 days a year. TTY/TDD users should dial 711.
Medicare provides "Extra Help" to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan's monthly premium and prescription copayments or coinsurance. This Extra Help also counts toward your out-of-pocket costs. People with limited income and resources may qualify for Extra Help. Some people automatically qualify for Extra Help and don't need to apply. Medicare mails a letter to people who automatically qualify for Extra Help.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help or to check the status of your application, call:
If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us.
Please call 1-844-826-3451, 24 hours a day, 365 days a year. TTY please dial 711.
There are several different documents that Medicare allows as Best Available Evidence to show you qualify for LIS. The document must show you were eligible for Medicaid during a month after June of the previous calendar year. These documents include:
You, your pharmacist, advocate, representative, family member or other individual acting on your behalf may provide one of these documents to us by mail (PO BOX 3835, SCRANTON, PA 18505) or fax (1-855-297-4241) as evidence showing your copayment level. When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn't collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state.
For more information about Best Available Evidence (BAE), see Chapter 2 of your Evidence of Coverage, call Member Services or visit CMS' website BAE page.
The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients, and customer service). If you have access to the web, you may use the web tools on www.medicare.gov and select "Find Health and Drug Plans" and then follow the online instructions to compare the Star Ratings for Medicare plans in your area. You currently have access to a group plan, which is not available on www.medicare.gov. Because Medicare releases Star Ratings based on prior data, new plans do not have a Star Rating. Please note the Star Ratings document may not reflect specific costs or benefits available to you through your Employer Group Waiver Plan.
To learn more, view our Star Ratings document.
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
Millions of dollars are lost every year because of Medicare fraud, waste and abuse. You can make a difference. To learn more, view the Preventing Fraud, Waste and Abuse notice.
If you have experienced or suspect fraud, waste, and/or abuse, you can contact us anonymously by clicking on the "Fraud, Waste and Abuse" link in the left-hand navigation on the home page, or you can call our Anonymous Fraud, Waste & Abuse Hotline: 1-888-274-1370.
Here are links to some commonly used forms:
Coverage Decision Request Form for Members
Coverage Decision Request Form for Prescribers
Redetermination (Appeal) Request Form
CMS' Appointment of Representative Form (Form CMS-1696)
Direct Member Reimbursement (DMR) Form
Many of the links on this page open documents produced in Adobe Portable Document Format (PDF) and require you to have Adobe Reader installed on your computer in order to view them.
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VibrantRx is a Prescription Drug Plan with a Medicare contract offered by MG Insurance Company. Enrollment in VibrantRx depends on contract renewal.
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VibrantRx complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. VibrantRx does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Website content was last updated on 01/01/2021.
