Pharmacy

Medicare Advantage Formulary Information

The PPO Formulary is a tiered formulary that consists of 6 tiers

Tier 1 – Preferred Generic Drugs - lowest cost generic drugs

Tier 2 – Generic Drugs - may include few preferred brand

Tier 3 – Preferred Brand Drugs - may include high-cost generic drugs

Tier 4 – Non-Preferred Brand Drugs - non-preferred brand or generic, non-formulary drugs

Tier 5 – Specialty Drugs - highest cost-sharing tier

Tier 6 – Select Care Drugs (Zero-copay)

Biosimilars

1. Biosimilars 101: A Primer for Your Practice
2. Test Your Skill: Incorporating Biosimilars Into the Management of Patients with Immunological Conditions
3. Biosimilars in the Real World: Perspectives for Staying Within the Scope of Care
4. Putting the Patient into Perspective: Strategies for Educating Patients About Biosimilars

Inflation Reduction Act

1. Insulins – Zero copay for initial coverage until the member reaches the coverage gap. When in the coverage gap, member copay will be capped at $35 for 30-day supply even if member has not met their annual deductible
2. Part D vaccines - Zero copay

• Formulary Insulins

Tools and Resources

• Medical Record Audit Response Form - Electronic Submission
• To submit claims directly to American Specialty Health please click here.
• Qualified Medicare Beneficiary (QMB) Program
• PCP Attestation Form
• Medicare Advantage Plans Benefit Information
• Medicare Advantage Provider Directory
• Notice of Medicare Non-Coverage (NOMNC)
• Notice of Medicare Non-Coverage (NOMNC) - Instructions
• Notice of Medicare Non-Coverage (NOMNC) - SNF Checklist
• Protected Health Information Disclosure Form
• Appointment of Representative Form (CMS - 1696) (For Medicare Appeals, Grievances, and Coverage Requests only)
• Provider Policy Listing

Medicare Star Rating Resources

View Saint Mary's ATRIO’s Star Ratings Program page for measure descriptions and resource materials.

For questions on the Star Ratings Program, please click here to contact ATRIO Quality Improvement.

Opioid Information for Prescribers

Opioid drugs (“opioids”) have serious risks such as addiction, overdose, and death. CMS is very concerned about the opioid epidemic and its effect on our communities, and is committed to a complete strategy to combat this public health emergency. Several drug management programs are in place to prevent and combat opioid overuse.

Click here to see the formulary-level opioid safety edits at the point of sale, as recommended by CMS.

Payer IDs

Click here for Payer IDs

VSP Information:

VSP Provider Customer Service Line:

1.800.615.1883 Monday – Saturday: 6:00 a.m. – 5:00 p.m. PST

Sunday: Closed

Additional helpful provider information can be found at the following link:

https://www.vspproviderhub.com/

To learn more about becoming an in network VSP provider please see link below:

https://www.vspproviderhub.com/working-with-vsp/be-a-vsp-doctor.html

Extra Benefits:

To see extra benefits ATRIO offers, please select the link below:

https://www.atriohp.com/extra-benefits/

Appeals and Provider Claim Dispute

Medicare Appeals

Provider Appeal Form - Electronic Submission

Provider Appeal Form - Fillable PDF

Waiver of Liability Form

Appointment of Representative Form (CMS - 1696) (For Medicare Appeals, Grievances, and Coverage Requests only)

Appeals Types

An Appeal may be filed for any of the following reasons:

Standard

1. Part C Pre-Service Appeal – appeals of an adverse decision for pre-authorization of a service
2. Part C Payment Appeal – appeal of an adverse decision of a claim
3. Part D Appeal – appeal of adverse decision regarding a part D medication

Who Can Appeal?

An Appeal may be filed by the following:

Part D Appeal

Appeal of adverse decision regarding a Part D medication -- Prescriber - MD, DO, NP, PA can file over the phone, in writing or by fax

Part C Pre-Service Appeal

Appeal of an adverse decision for pre-authorization of a service -- Physician - can file over the phone, in writing or by fax

Part C Payment Appeal

Appeal of an adverse decision of a claim must be received in writing

1. 1. Any Provider can appeal for a member with a signed Appointment of Representative (AOR-1696).
   2. Non-contracted providers may appeal on their own behalf if they sign a Waiver of Liability (WOL). Or on behalf of a member with a signed AOR (CMS 1696) When a non-contracted provider signs a Waiver of Liability, and the adverse decision is upheld, they agree not to bill the member for the services in question.

Providers can use the forms above, otherwise request for Appeal need to include the following:

1. Member name
2. Address
3. Member number
4. Reasons for appealing
5. Any evidence included for review, such as medical records, doctor’s letters, or other information that support why the service or item is necessary.

Provider Claim Disputes

Must be submitted in writing using forms below

Provider Claim Dispute Form - Electronic Submission

Provider Claim Dispute Form - Downloadable PDF (Print and Fax)

Payment Dispute – Providers disputing the manner in which a claim was paid

1. 1. Can be submitted by a Par (contracted) or Non-Par (non-contracted) provider
   2. Request payment must be submitted in writing.
   3. Request must include supporting documentation for all items dispute.

Par Provider Reconsideration – Dispute of a claim or claim line denial

1. 1. Par Provider Reconsiderations are not a CMS requirement, but instead are a service provided by ATRIO to contracted providers.
   2. Request for par provider reconsideration must be submitted in writing.
   3. Request must include supporting documentation for all items in dispute - Any evidence included for review, such as medical records, doctor’s letters, or other information that support why the service or item is necessary.