Sunshine Health is committed to providing appropriate, high-quality, and cost-effective drug therapy to its members. As part of this commitment, they offer a pharmacy program for eligible members, covering prescription medications and certain over-the-counter medications with a written order from a Sunshine Health provider. This includes the potential coverage of weight loss medications, though it's essential to understand the specifics of their plan.
The Pharmacy Program: A Foundation for Coverage
Sunshine Health's pharmacy program operates with a Preferred Drug List (PDL), a list of covered medicines. This list is carefully reviewed by doctors and pharmacists regularly to ensure the safest and most effective drugs are included. When your doctor prescribes medication, they will use the PDL to choose the best treatment option for you. It's always a good idea to ask your doctor if your prescription is covered by Sunshine Health. If not, inquire about alternative covered medications.
Navigating the Preferred Drug List (PDL)
Sunshine Health follows the Agency for Health Care Administration (AHCA) Preferred Drug List (PDL) guidelines. The PDL is revised every quarter based on the recommendations of the AHCA Pharmaceutical and Therapeutics (P&T) Committee. This ensures that the list remains up-to-date with the latest medical advancements and cost-effective options.
Understanding Drug Tiers and Cost-Sharing
All covered drugs within the Sunshine Health pharmacy program are assigned a tier, which determines your cost-sharing responsibilities. Cost-sharing refers to the out-of-pocket expenses you pay, including copays, deductibles, and coinsurance. Understanding these tiers is crucial for managing your healthcare costs.
Here's a breakdown of the typical drug tiers:
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- Tier 0: No copayment for drugs used for prevention and mandated by the Affordable Care Act. Examples include select oral contraceptives, vitamin D, folic acid for women of childbearing age, over-the-counter (OTC) aspirin, and smoking cessation products. Age limits may apply.
- Tier 1A: Lowest copayment for select drugs that offer the greatest value compared to others used to treat similar conditions. Select over-the-counter (OTC) drugs may be covered.
- Tier 1B: Low copayment for drugs that offer great value compared to other drugs used to treat similar conditions. Select over-the-counter (OTC) drugs may also be covered.
- Tier 2: Medium copayment covers brand-name drugs that are generally more affordable or preferred compared to other drugs for the same conditions.
- Tier 3: High copayment covers higher-cost brand-name and non-preferred generic drugs. This tier may also cover non-specialty drugs not on the Prescription Drug List but approved for coverage.
- Tier 4: Highest copayment for "specialty" drugs used to treat complex, chronic conditions that may require special handling, storage, or clinical management.
Your physician can prescribe a product from any tier, but lower tiers often offer more cost-effective options. Discussing these options with your physician can help you find the most suitable and affordable medication.
Weight Loss Medications: Coverage Considerations
While Sunshine Health aims to provide comprehensive coverage, it's important to note that the pharmacy program does not cover all medications. Some medications, including certain weight loss drugs, may require prior authorization or have limitations.
Prior Authorization: This process requires your physician to submit information justifying the medical necessity of the requested medication. A Medical Director, pharmacist, or other healthcare professional with expertise in your condition will review the request based on accepted medical practice.
Non-Formulary Exception: If a weight loss drug is not covered by the formulary (PDL), your provider can request a non-formulary exception. They will need to provide information on previous approvals of the drug for you or the reason for requesting the exemption.
Step Therapy: Some medications on the PDL may require the use of specific medications beforehand. If Sunshine Health lacks a record of the required medication being tried, your physician may need to provide additional information.
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Quantity Limits: Sunshine Health may limit the amount of a certain medication you can receive at one time. If your physician believes you need a greater amount for medical reasons, they can request prior authorization.
Age Limits: Certain drugs on the PDL may have age limits, which could affect coverage for weight loss medications.
Healthy Behaviors Program: A Holistic Approach to Weight Management
Beyond medication coverage, Sunshine Health offers a Healthy Behaviors program that aims to improve members' health and wellness. This program can be a valuable resource for individuals seeking to manage their weight.
Weight Loss Health Coaching Sessions: This program is available for members ages 10 years and up. Participants must submit a consent form, verbally pledge to lose weight within 30 days, and complete six sessions within six months. A \$20 reward is provided upon completion of the sessions. These sessions are completed over the phone to fit your schedule, and Health Coaches can answer questions about how to improve your health.
Additional Programs and Services
Sunshine Health provides a range of additional programs and services to support its members' health:
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- Care Management: Enrollment in Care Management is required for some programs, such as the Substance Use Health Coaching program (ages 12 and up).
- Disease Management Programs: Children’s Medical Services Health Plan offers programs to improve the health of children with chronic conditions, providing education and personal help from CMS Health Plan staff. These programs may offer cash rewards for completing healthy activities to manage their disease or condition.
- Comprehensive Diabetes Care: This program for ages 13-20 years offers a \$25 reward for completing an HbA1c test and dilated eye exam once per calendar year.
- Tobacco Cessation Health Coaching Sessions: Available for ages 10 years and up, this program requires a consent form, a verbal pledge to stop tobacco use, and completion of four sessions within six months. A \$5 reward is given after each completed session.
Utilizing Pharmacy Resources
Sunshine Health provides several resources to help members manage their prescriptions:
- Network Pharmacy: You can have prescriptions filled at an Ambetter Health network pharmacy. The Find a Provider Tool can help you locate in-network pharmacies.
- Express Scripts Pharmacy Home Delivery: Eligible members may save time and money by ordering a 90-day supply of medicine through Express Scripts Pharmacy home delivery.
- AcariaHealth Specialty Pharmacy: This pharmacy offers convenient specialty prescription delivery services for those with complex conditions or chronic illnesses. Licensed pharmacists are available 24/7 to discuss prescribed therapy and answer questions.
- Sempre Health: Eligible members may have access to this program, which offers discounts on select prescription medications, including those for cardiovascular, respiratory, and diabetic conditions.
Important Considerations
- Generic Drugs: Sunshine Health covers both brand-name and generic drugs. Generic drugs have the same ingredients as brand-name drugs but are often cheaper and work the same.
- Maximum Day Supply: Medications may be dispensed up to a maximum of a 34-day supply for each new prescription refill or a 100-day supply for select medications.
- Spacers/Aerosol-Holding Chambers: Sunshine Health covers select spacers/aerosol-holding chambers for Medicaid members through the pharmacy benefit.
- Brand-Name Drug Coverage: When generic drugs are available, the brand-name drug will not be covered without Ambetter Health authorization unless there is a medical reason the member needs the brand-name drug.
Additional Covered Services
Sunshine Health covers a wide range of medical services, including:
- Medical care, tests, and treatments for the kidneys.
- Medical equipment used to manage and treat a condition, illness, or injury, including durable medical equipment like wheelchairs, braces, and crutches.
- Hearing tests, treatments, and supplies to diagnose or treat hearing problems.
- Hospice care: Medical care, treatment, and emotional support services for people with terminal illnesses.
- Hospital care: Medical care received while in the hospital.
- Transportation to and from medical appointments.
- Nursing facility care: Medical or nursing care received while living full-time in a nursing facility.
- Outpatient care: Medical care received in the hospital without staying overnight.
- Rehabilitative services: Services to assist people reentering everyday life.
- Imaging services: Including x-rays, MRIs, and CAT scans.
- Services for women who are pregnant or want to become pregnant, including medically necessary family planning services (available from any Medicaid provider without prior approval and free of charge).