<
Adjust Page Text Size:
 

Call Center hours:

Mon through Fri - 8:00 a.m. to 8:00 p.m.

Local calls:
  • 330-363-7407
  • 1-800-577-5084
TTY / TDD users:
  • 330-363-7460
  • 1-800-617-7446

Part D

PrimeTime Health Plan provides quality service to our members. In cases of any changes to our formulary including addition of a prior authorization, adding quantity limits, step therapy, and changing cost share due to a tier level change of formulary drug, PrimeTime Health Plan will send a letter to the members that have been affected by the change.

Number of pharmacies and Out of Network plan coverage

PrimeTime Health Plan is contracted with over 300 network pharmacies. A network pharmacy is one who has the ability to process your prescription via an electronic submission. While we encourage the use of network pharmacies, you may have benefits at a non-network pharmacy. If you use a non-network pharmacy, you will be responsible for the payment of your prescription at the point of sale. You may then submit your receipt to PrimeTime Health Plan for reimbursement. The provider directory does not include all contracted pharmacies. Please contact PrimeTime Health Plan member services at 330-363-7407 or 1-800-577-5084 with any questions regarding your pharmacy benefits.

Grievance, Appeals, and Exceptions

PrimeTime Health Plan maintains information on the number of Grievances, Appeals and Exceptions that are made against us. This information can be obtained by writing to PrimeTime Health Plan and mailing to P.O. Box 6029, Canton, OH 44706.

If you need more information on Grievances, Appeals, and Exceptions you may call PrimeTime Member Services by dialing 1-800-577-5084 (toll free) or 330-363-7407 (local calls). Our TTY phone number for the hearing impaired is toll free 1-800-617-7446. Chapter 9 of your Evidence of Coverage explains these processes in more details.

Low Income Subsidy Information

As a member of our Plan, you pay a monthly premium. If you qualify for extra help from Medicare, called the Low Income Subsidy, or LIS you may not have to pay for all or part of the monthly premium. The PrimeTime Health Plan premiums that are listed are for both medical and prescription coverage.

The premiums that are listed on this website do not reflect additional premiums you may have to pay as a member of Medicare. The Part B premium is in addition to the PrimeTime Health Plan premium that is listed. You may have to pay a late enrollment penalty (LEP) if you did not meet the requirements. Please refer to any of our Evidence of Coverage's to review this information in Chapter 6.

There is also a Medicare Part A premium that may have to be paid (Generally, most people do not have to pay this premium.).

The Low Income summary Chart below will tell you by plan what your premium will generally be if you qualify for extra help from Medicare.

2011 LIS Premium Summary Chart


To inquire with the Social Security Administration on the status or level of your LIS benefits, you may contact them calling 1-800-772-1213 (TTY users should call 1-800-325-0778).


Determination Request Form
Medicare Prescription Drug Determination Request Form (for use by Enrollees)

Medicare Part D Coverage Determination Request Form
Medicare Part D Coverage Determination Request Form (for use by provider)

www.cms.hhs.gov
Best available evidence by CMS

2011 Pharmacy List
...Addresses for all non-chain pharmacies.
...Chain pharmacies, local or toll-free numbers and TTY/TDD number.
...Number of network pharmacies.

2011 Formulary
...An abridged version of our 2011 Formulary.
2011 Individual Plans Comprehensive Formulary
...For members on Plus, Premier, Basic Select, and Prime PPO groups.

2011 Employer Group Plans Comprehensive Formulary
...For members on any Employer Group Sponsored Health Plan.

Medication Pricing (RxEOB)

Coverage Determination Form
...Form for enrollee to request an exception to the limitations, drug to be covered at a lower co pay, and/or coverage of drugs not on the formulary. Please be advised that requesting a Tier 3 drug to be covered as a generic or asking for an exception on an exclusion is not permitted per Medicare.

Provider Prior Authorization/Exception Request Form
...Form for a Provider to request a prior authorization or an exception.

Transition Policy

Drug Recalls

Medication/Health Information




Last Updated: 07/13/2011 10:46:00 AM
Special Communication Needs
If you or someone you know requires the assistance of a translator, please contact our Service Center at 330-363-7460 and we will gladly provide one for you. To access our TTY phone line, please dial 330-363-7460 or toll free at 1-800-617-7446 for the hearing impaired.
PrimeTime Health Plan
P. O. Box 6905 ; Canton, Ohio 44706
Copyright ;2006 PrimeTime Heath Plan		 Web Disclaimer

Contact Us		 CMS Approved 10292010
H3620H3664_102010WEB