Once you have joined Buckeye, your prescription drug coverage is included. 

Our Prescription Drug List

Thousands of prescription drugs are covered, including most of the brand-name and generic drugs used by people with Medicare. You can print our Medicare Advantage Comprehensive Formulary or search for a particular drug within that list. Or call Member Services at (866) 389-7690 (TTY 800-750-0750), 8 a.m. to 8 p.m. seven days a week, with questions.

Quality Pharmacy Programs for You

Once you are on our plan, there are a lot of ways we work to coordinate your medical care and your prescription drug needs so that you can stay healthy and focus on other things in your life.

• Members with serious conditions (e.g., asthma, diabetes, high blood pressure, etc.) may be referred to our Care Management Program.  In this program, members have support from nurse managers, behavioral health professionals, physicians, and other program specialists that are there to make sure members have what information or services they need to meet their healthcare needs and become more independent.
• Members with serious conditions who are on a lot of medications may be referred to our Medication Therapy Management Program.  Members in this program have a team of nurses and pharmacists who are working to make sure members get the most out of their drug therapy.  Not only do we want to make sure you get the medications you need – even if it is a drug that is not on our list of covered drugs – but we also want to make sure you are protected from drug interactions that may harm you.
• Buckeye also works with your doctors and pharmacies to make sure you get the most of your drug therapy while getting medically appropriate, safe, and cost-effective care.  We rely on standards set by the U.S. Food and Drug Administration as well as other national quality organizations when setting standards of care for our members.  As a result, some covered drugs may have additional requirements or limits on coverage. These requirements and limits are listed in the 2012 Prior Authorization Guidelines.
• Prior Authorization: Buckeye requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Buckeye before you fill your prescriptions. If you don’t get approval, Buckeye may not cover the drug. To see a list of drugs that require prior authorization and the medical criteria we are looking for with the request, see our 2012 Prior Authorization Guidelines.
• Quantity Limits: For certain drugs, Buckeye limits the amount of the drug that Buckeye will cover. For example, Buckeye provides 30 tablets per prescription for Zetia. This may be in addition to a standard one month or three month supply. To see a list of drugs that have quantity limits and the details of those limits, see our 2012 Quantity Limits.

Of course, you always have the right to request an exception to our coverage rules. For more information about asking for an exception, please see our Prescription Drug List Introduction. Or, complete the Model Coverage Determination Request Form below and fax it to US Script at 866-399-0929.

Model Coverage Determination Request Form (PDF)

Initial requests can also be made using one of the following form:

Part D Coverage Request (PDF)

If you have any questions about these programs or requirements, please contact Member Services at (866) 389-7690 (TTY 800-750-0750), 8 a.m. to 8 p.m., Monday through Sunday.

How the Formulary Can Change
Generally, if you are taking a drug on our 2011 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2011 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

For more information about how a formulary can change during the year and what notification you would receive, see page 2 of either the Abridged or Comprehensive Formularies (links to the right on this page).

Buckeye Pharmacies
With Buckeye, we provide access to more than thousands of pharmacies, which are listed in the Provider Directory.

Our plan has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. We also have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. 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:
• When you are out of the area, require a prescription filled, and are unable to obtain medications at a local in-network pharmacy.
• Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available.
In these situations, please check first with Member Services to see if there is a network pharmacy nearby.

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost. See your Evidence of Coverage Reimbursement Information for instructions about how to request a reimbursement.

Mail Order

You may also obtain certain medications through mail order using the following resources:

• 2012 List of Medications Available Through Mail Order 
• Mail Order Request Form

Members New to Buckeye

Within the first 90 days of enrollment, new members will get up to a 30-day supply of any covered Medicare drug that is not on our Prescription Drug List, or that requires a prior authorization. For long-term care members (members in a nursing facility), the transition benefit provides up to a 31-day fill, with multiple refills as necessary, during the first 90 days of enrollment. Additional days may be provided while an exception request is being processed. Any member that receives a prescription as a part of this transition process, will receive a letter that outlines which medications will be transitioned, the reason for the transition fill, and the requirement for the member to contact his/her physician so that the member’s physician can switch the member to another drug that is listed on the Buckeye Prescription Drug List.

What Part D Prescription Drugs Will Cost You on Our Plan

Because our plan is a Special Needs Plan, we only enroll Medicare and Medicaid eligible consumers, or dual eligible consumers. Medicare helps pay for Part D prescription drugs for members with full Medicaid. 

Members with full Medicaid, who are not in a nursing facility, will pay the following for Part D prescription drugs:

• Monthly Plan Premium of $0 – Medicare pays for the $29.60 monthly plan premium for our members because they have full Medicaid.  If members lose their full Medicaid coverage, depending on the timing, their monthly premium may increase; to see a list of premiums for members that do not have full Medicaid, see our  Monthly Plan Premium Website Notice.
• Initial Deductible of $0 – Medicare pays for the annual deductible for our members because they have full Medicaid.
• Initial Coverage Stage – After Medicare pays the yearly deductible, members will stay in this stage until their drug costs reach $4,550.  While they are in this stage, they will pay the following:
  • $0 for generic medications*
  • $3.30 or $6.30 for all other medications*
• Coverage Gap Stage & Catastrophic Coverage Stage – After drug costs reach $4,550, members will pay nothing because Medicare covers the costs of prescription drugs while members have full Medicaid during these stages. 

*Note: Members’ costs may increase, depending on their level of Medicaid eligibility and level of Extra Help from Medicare.

Members who are institutionalized or in a nursing facility will not pay anything for their Part D prescription drugs, as long as they have full Medicaid. 

These costs are standard prescription drug costs that you would have to pay as a member of any Special Needs Plan in the country. The Centers for Medicare and Medicaid Services sets these amounts and require us to charge you for these medications.

Information for Members About Medicaid and Medicare

Low Income Subsidy and Medicare’s Extra Help Program

Maintaining Medicaid eligibility is key to keeping costs down while on our plan.  To read more about this, see our Extra Help Guide. This guide explains the help that members get by having full Medicaid, how costs get paid, how to maintain eligibility, and where to go for more information. In this guide, there is a link to CMS’ website regarding Best Available Evidence, a policy that shows you how to provide proof of evidence of Medicaid coverage.

If you don’t have full Medicaid, you still may be able to get extra help to pay for your prescription drug premium and costs. To see if you qualify for getting extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week.
• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778.
• Your State Medicaid Office
  • Ohio: 1-800-324-8680 (TTY/TDD 1-800-292-3572) from 7 a.m. to 8 p.m., Monday – Friday.

Or visit Centers for Medicare and Medicaid Services website.