Prescription Drug Coverage
To change your plan:
You can enroll in a plan or switch to a new one during the Annual Enrollment Period (AEP). The Centers for Medicare & Medicaid Services (CMS) chooses this annual time period each year. This period is the only time of year when you can make changes to your plan unless you qualify for a Special Enrollment Period (SEP).
For 2022, the AEP is from Oct. 15 through Dec. 7, 2021. If you enroll during this time, your coverage begins on Jan. 1, 2022.
Contact us if you have any questions.
What are my rights and responsibilities upon disenrollment?
If you decide to disenroll from your Align powered by Sanford Health Plan Medicare Advantage plan, you’re ending your membership. Disenrollment can be voluntary (your choice) or involuntary (not your choice). For more information on enrollment or disenrollment, refer to your Evidence of Coverage.
If you decide you want to leave your plan, you can do so for any reason. However, there are limits to when you can leave, how often you can make changes and what type of plan you can join after you leave. Call us for more information.
Sanford Health Plan may disenroll you for these reasons:
Medicare Advantage (Part C)
Appeals and Grievances:
Call (888) 278-6485, TTY (888) 279-1549.
Our hours are 8:00 a.m. to 8:00 p.m. CST, 7 days a week from October 1 - March 31; and Monday through Friday from April 1 - September 30.
Mail: Mail the form to:
Sanford Health Plan
PO Box 91110
Sioux Falls, SD 57109-1110
Fax: (605) 312-8217
Where can I find an appeal form?
Medicare Advantage Part (D)
To file an appeal or grievance related to Medicare Advantage (Part D), please see section below titled: How do I request a coverage determination or medical exception for a drug?
What is an Appointment of Representative form?
If a member wants someone who is not already authorized under state law to act for them, the member and that person must sign and date an Appointment of Representative form to give that person legal permission to be an appointed representative.
How do I file a grievance?
You or your appointed representative can call the grievances phone number to file a grievance.
For more on this process, refer to “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)” in your Evidence of Coverage.
What if I don’t want to file my complaint through Sanford Health Plan?
You can go directly to medicare.gov or call (800) MEDICARE (633-4227) to file a complaint.
You can also get help with Medicare-related complaints, grievances and information requests from the Medicare Beneficiary Ombudsman (MBO).
This form may be sent to us by mail or fax:
OptumRx Prior Authorization Dept. (844) 403-1028
P.O. Box 2975
Mission, KS 66201
You may also ask us for a coverage determination by phone at (844) 642-9090 or through our website at www.optumrx.com.
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:
Do you meet all of the criteria above? Learn more about how to manage the various medications you need to stay healthy.
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:
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.
Comprehensive Medication Review (CMR)
The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of MTMP. If you meet the criteria outlined above, you will receive an MTMP Enrollment Mailer or phone call offering our CMR services. 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. 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.
The CMR includes three components:
View or download a sample copy of our MTMP Enrollment Mailer
View or download a copy of the Recommended To-Do List
View or download a copy of the Medication List
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:
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.
To view the complete Prescription Drug Transition Policy, click here.
What is Original Medicare?
Medicare is the government-run insurance program for those 65 and older or certain people with disabilities or end-stage renal disease (permanent kidney failure).
Medicare has four different parts, which can be mixed and matched through different plans to give you the coverage that’s right for you. They include:
What is Medicare Part A?
Medicare Part A, also called hospital insurance, covers:
What is Medicare Part B?
Medicare Part B is also known as medical insurance. It covers certain services from doctors, outpatient care, medical supplies and preventive care. These services fall under Medicare Part B:
What is Medicare Advantage?
Medicare Advantage Plans, or Part C plans, are plans offered by private companies like Sanford Health Plan. These plans administer your Original Medicare.
Many plans include prescription drug coverage to combine Medicare Part A, Part B and Part D into one easy package.
What is Medicare Part D?
Medicare Part D is prescription drug coverage. You can buy Part D from insurance companies to go with your Original Medicare coverage or your Medicare Supplement coverage. You could also choose a Medicare Advantage plan that includes Part D prescription drug coverage.
You’re eligible for Original Medicare, Medicare Part A and Medicare Part B if you fit one of these criteria:
To be eligible for a Medicare Advantage plan, you must:
Sanford Health Plan offers free educational seminars and wellness events throughout the year.
You can keep the health plan you have and enroll in Medicare when you retire.
It’s important to talk to your employer or local insurance agent before choosing to stay on your group plan or enroll in Medicare.
Align powered by Sanford Health Plan options are available in select counties within Iowa, Minnesota, North Dakota and South Dakota. Your eligibility to enroll in these plans depends on the service area and county where you live.
Learn more about your plan coverage:
To view a complete summary of your plan’s pharmacy benefits, see your Summary of Benefits document.
Do you qualify for a Low-Income Subsidy (LIS)?
You may be able to get extra help paying for your prescription drug premiums and costs. For more info and to see if you qualify, contact:
Medicare at (800) MEDICARE or (800) 633-4227, TTY (877) 486-2048. Help is available 24/7.
Or the Social Security Administration at (800) 772-1213, TTY (800) 325-0778. Their hours are Monday through Friday from 7 a.m. to 7 p.m.
Align powered by Sanford Health Plan is a PPO with a Medicare contract. Enrollment in Align powered by Sanford Health Plan depends on contract renewal. Align powered by Sanford Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Every year, Medicare evaluates plans based on a 5-star rating system.
CMS ID Number: H8385_SHPMAWebsite_PY2022_ND_SD, H3186_SHPMAWebsite_PY2022_MN
Last Updated On: 10.15.22 at 10:00 AM