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 contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

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. We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• If the prescriptions area related to care for a medical emergency or urgently needed care they will be covered. In this situation you will have to pay the full cost (rather than paying just the co-payment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary, and reasonable (UCR) or the contracted rate, whichever is less. Any amount you pay over the UCR will be applied to your TrOOP (True Out Of Pocket cost). Please refer to the paper claims process described below.
• If you are traveling within the United States, but outside the Plan’s service, and you become ill or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy (if you follow all other pay the full cost (rather than paying just the co-payment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary, and reasonable (UCR) or the contracted rate, whichever is less. Any amount you pay over the UCR will be applied to your TrOOP.
• If you are unable to get a covered drug in a timely manner within our service area because there is not a network pharmacy within a reasonable driving distance which provide 24 hour service
• If you are trying to fill a covered prescription that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or specialty pharmaceuticals).
• Self-administered medications that you receive in an outpatient setting may be covered under Part D. For consideration, please submit a paper claim.

In these situations, please check first with Member Services to see if there is a network pharmacy nearby. 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.