eternalHealth Medicare Advantage Plans include prescription drug coverage.

Remember, your eternalHealth Member ID Card has the information on it that will allow you to fill your prescriptions. To make sure you get your prescriptions, please update your information with your pharmacy by showing them your eternalHealth Member ID.

Medicare Advantage Plans
serious mature female doctor in white lab coat wor U7EJ35D 1

Mail-Order Information

Through OptumRx, eternalHealth is proud to offer our members the option to mail-order the prescription drugs that you need. See below for the mail-order form that will allow you to get the prescription drugs you need delivered right to your door!

Formulary Management

The drug list, also called a formulary, includes both brand and generic drugs. It will tell you whether any restrictions or limitations to coverage exist such as:
  • Prior authorization
  • Step therapy
  • Quantity Limits
Drugs that are subject to these rules are clearly labeled in the drug list and on our drug pricing tool. We may periodically make certain changes within our formulary, such as:
  • Adding or removing a drug from the drug list
  • Moving a drug to higher or lower tier
  • Adding or removing coverage restrictions
  • Replacing a brand name drug with a generic
  • Or if the U.S. Food and Drug Administration finds that a drug on the formulary is unsafe and the manufacturer removes it from the market, we will update our formulary accordingly.
If you happen to be taking any of the drugs that fall within these changes, we will notify you of these changes. We may have monthly changes to our formulary.  This means certain drugs may no longer be covered. Please review the link below to see the changes. If you were taking any of the medications that are no longer covered, please talk to your doctor to find an alternative drug from the 2022 Formulary that will be covered.

Network Pharmacy

You are able to find the pharmacies within our network with the Pharmacy Locator to the left.

For a PDF version of our Pharmacy Network List that you can download directly, please click here.

Drug Pricing Tool

eternalHealth offers you an easy to use drug pricing tool so that you can see what drugs are covered under your plan, as well as how much they will cost at a variety of retail locations including through our mail-order process.

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Transition Supply

In the situation that there is a prescription drug you are currently taking, or if your provider thinks you should be taking a certain drug that is either not on our formulary or has formulary restrictions, we may offer what is called a “transition supply”. This is what you can do if your drug is not on the eternalHealth drug list or if the drug is restricted in some way.

  1. You may be able to get a temporary supply of the drug (only in certain situations). This will give you and your provider time to discuss changing to another drug or to file a request to have the drug covered.
  2. You can change to another drug
  3. You can request an exception and ask the plan to cover the drug or waive formulary restrictions.

You can access the transition policy here to see if you are eligible for this program.

Prior Authorization and Step Therapy Criteria

Prior Authorization Criteria

eternalHealth requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from eternalHealth before you fill your prescriptions. If you don’t get approval, eternalHealth may not cover the drug.

Click the link below to download a PDF copy of the Prior Authorization Criteria.

Prior Authorization Criteria

Step Therapy Criteria

In some cases, eternalHealth requires you to first try certain drugs to treat your medical condition before we can cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, eternalHealth may not cover Drug B unless you try Drug A first. If Drug A does not work for you, eternalHealth will then cover Drug B.

Click the link below to download a PDF copy of the Step Therapy Criteria.

Step Therapy Criteria

Coverage Determination Request Form

What is a Coverage Determination?
A coverage determination is any decision made by a health plan regarding coverage benefits to which a plan enrollee believes he or she is entitled. In this case, the decision would be made regarding coverage of a specific prescription drug regimen.
If you would like to request a coverage determination, make an exception to the rules or restrictions on our plan’s coverage of a drug that you are currently taking, or if your provider is planning for you to take a drug restricted by our plan, you may download the Coverage Determination Request Form below and submit it to us via mail or fax. If you need assistance, you can always contact the Pharmacy Technical Help Desk at +1 (800) 797-9791 (TTY 711)

Click the link below to download the Coverage Determination Request Form.

Coverage Determination Request Form

You can mail the form to:
6860 W 115th St. Overland Park, KS 66211
Or call directly at: +1 (800) 891-6989

Redetermination of a Medicare Prescription Drug Denial

If you or your provider disagree with a coverage decision made by the plan, you can download and submit the following Request for Redetermination of Medicare Prescription Drug Denial Form. This is considered an appeal of a coverage determination.

Request For Redetermination Of Medicare Prescription Drug Denial

You can mail the form to:
6860 W 115th St. Overland Park, KS 66211
Or call directly at: +1 (800) 891-6989

Low Income Subsidy

For more information on receiving extra help from Medicare for your prescription drug coverage, please see the chart here. If you have any questions don’t hesitate to contact eternalHealth.

Low Income Subsidy for Medicare Prescription Drug Coverage

You can mail the form to:
6860 W 115th St. Overland Park, KS 66211
Or call directly at: 1 (800) 680-4568 (TTY 711)

October 1 – March 31, 8am – 8pm, 7 days a week
April 1 – September 30, 8am – 8pm, Monday – Friday
10am – 2pm, Saturdays

Medication Therapy Management (MTM)

Better therapeutic outcomes for members with multiple conditions

Our Medication Therapy Management Program (MTMP) is focused on improving therapeutic outcomes for Medicare Part D members. To qualify for MTMP, a member must meet all of the following criteria:

  • Members must have filled eight or more chronic Part D medications; and
  • Members must have at least three of the following ten chronic conditions
    • High Blood Pressure
    • High Cholesterol
    • Congestive Heart Failure (CHF)
    • Diabetes
    • Depression
    • Osteoporosis
    • Rheumatoid Arthritis
    • Asthma
    • COPD
    • HIV
  • Members must be likely to incur annual costs of $4,696 for all covered chronic Part D medications.

OR

  • Are in a Drug Management Program to help better manage and safely use medications such as opioids and benzodiazepines

The success of our MTMP is built upon our proven experience using a wide range of services designed to help members with multiple conditions by:

  • Ensuring they take their medications correctly
  • Improving medication adherence
  • Detecting potentially harmful medication uses or combinations of medications
  • Educating members and health care providers

Our programs are evidence-based and can integrate both pharmacy and medical data, when available, and are built upon multiple measures that demonstrate positive clinical outcomes for members like you. Pharmacists, physicians and PhDs develop, manage and evaluate the programs for effectiveness.

One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their health care provider.

To obtain a blank copy of the Personal Medication List (PML) that can help you and your health care providers keep track of the medications you are taking, you can click the link below:
ENGLISH

Comprehensive Medication Review (CMR)

A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. eternalHealth members may have these conducted through a variety of ways, including receiving a phone call from an OptumRx pharmacist and having it conducted in-person during a visit to your local network pharmacy. It is expected that it may take 30 – 60 minutes to complete these reviews.  The materials you can expect to receive in your individualized summary will typically consist of a medication list, a reconciled medication list, as well as a recommended to-do list to help you with self-managing your medications.  Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members’ prescribers may receive a member-specific report.  

Safe Drug Disposal

Do you have unused expired medications and are looking for a safe way to dispose of them? Before you throw them away, here are some things you should know. 

Here is how to safely dispose of unused or expired medications before they do harm.

For safety reasons, dispose of unused medications as soon as possible. Here are a few tips for safe disposal: 

  • Find a nearby pharmacy or other local resource with a medication take back service. 
  • If you cannot get to a drug take back location promptly, or there is none near you 
    • Mix the unused supply with an undesirable substance such as dirt or coffee grounds. 
    • Put the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag, then place the sealed container in your trash. 
    • Make sure to conceal or remove any personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off to protect your privacy. 
    • Place both the sealed container with the mixture and the empty drug containers in the trash.
    • Only flush approved unused or expired medications down the toilet only if indicated on the label, patient information, or no other disposal options are available. 

More information on the safe disposal of medications can be found on the United States Department of Health and Human Services website: https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html 

Contact OptumRx or your health plan at the number listed on the back of your ID card for more information about our MTMP. If you have any questions about the MTM program, please call the MTM Department at 1-866-352-5305. (TTY users dial 711), Monday – Friday, 8 am to 8 pm CST. These programs are provided at no additional cost as part of your coverage and are not considered a benefit.

Member Reimbursement Form (Prescription Drugs)

If you were billed for a covered prescription, complete this form, and attach the prescription labels to get paid back for your covered prescription.

Mail the completed form to:

OptumRx
P.O. Box 29044
Hot Springs, AR 71903

Want your COVID-19 test kit reimbursed?

eternalHealth members are able to get up to 8 over the counter COVID home tests per calendar month at no additional cost to them ($0).

Mail the signed & completed forms with receipts to :

OptumRx Claims Department,
PO Box 650334,
Dallas, TX 75265-0334

This page is also available in: Español (Spanish)

Page Last Updated On: August 23, 2022