Drug Coverage

The drugs covered by RiverSpring MAP (HMO D-SNP), including prescription drugs and over-the-counter health items and any restrictions, are described on the List of Covered Drugs (Formulary). You generally must use pharmacies in the RiverSpring MAP (HMO D-SNP) network to obtain your medications.

List of Covered Drugs (Formulary)

The List of Covered Drugs (Formulary) and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. You can always check RiverSpring MAP’s up-to-date List of Covered Drugs (Formulary) online at www.riverspringhealthplans.org or by calling RiverSpring MAP (HMO D-SNP) Pharmacy Services toll-free at 1-855-898-1482 TTY/TTD 711. If there is a change to coverage for a drug you are taking, we will send you a notice. Normally, we will let you know at least 60 days before the change.

Restrictions and Limitations on Drug Coverage

Some drugs have coverage rules, or limits on the amount you can get. In some cases, you must do something before you can get the drug. For more information, call RiverSpring MAP (HMO D-SNP) Member Services or read the RiverSpring MAP (HMO D-SNP) Member Handbook and Evidence of Coverage.

Prior authorization: For some drugs, you or your doctor must get approval from RiverSpring MAP (HMO D-SNP) before you fill your prescription. For details, please read our

2023 Prior Authorization Criteria.

Quantity limits: The amount of a drug that you can get may be limited. Please refer to the List of Covered Drugs (Formulary) for details.

Step Therapy: Sometimes, you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. For details, please read our

2023 Step Therapy Criteria.

Prescription Drug Transitions

In some cases, the Plan can give you a temporary supply of a drug when the drug is not on the List of Covered Drugs (Formulary) or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask RiverSpring MAP (HMO D-SNP) to approve the drug.

We may cover a 30-day supply of your drug during the first 90 days you are a member of RiverSpring MAP (HMO D-SNP). If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30 days of medications.

If you have been in the plan for more than 90 days, live in a long-term care facility, we will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new RiverSpring MAP ( HMO D-SNP) member. This is in addition to the temporary supply during the first 90 days you are a member of RiverSpring MAP (HMO D-SNP). For details, please read our Drug Transition Policy.

To ask for a temporary or transitional supply of a drug, you or your appointed representative, or the prescriber may call RiverSpring MAP (HMO D-SNP) Pharmacy Services toll-free at 1-855-898-1482 TTY/TTD 711 or fax the request to 1-855-898-1483.

Opioid Drug Management Program

Monthly Plan Premium for People Who Get Extra Help from Medicare to Help Pay for Their Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. These amounts do not include any Medicare Part B Premium you may have to pay.

Last updated on January 4, 2023