Sentara Medicare Prescription Drugs and Pharmacies

Starting January 1, 2025, the Medicare Prescription Payment Plan is a new prescription payment option for members who have a Medicare plan, including Sentara Medicare plans. 

This payment option spreads the cost of your prescriptions across capped monthly payments over a single calendar year. This payment plan does NOT lower your drug costs, but it can help with budgeting. It may not be the best choice for you if you get help paying for your prescription drug costs through programs like Extra Help from Medicare.

For more information, view the Medicare Prescription Payment Plan fact sheet.

Medicare Prescription Payment Plan Fact Sheet English

Medicare Prescription Payment Plan Fact Sheet Spanish

Medicare Prescription Payment Plan Take Away Card English

Medicare Prescription Payment Plan Take Away Card Spanish

You can opt in to the new payment plan during the Annual Enrollment Period (AEP) from October 15 to December 7 or any month throughout the plan coverage year.

You can sign up through our partner, Express Scripts by using one of these options:

Online: Log in to the Sentara Health Plans member portal, select Doctors and Medication, then click Pharmacy Resources. Once you are redirected to Express Scripts, select Account, then click Medicare Prescription Payment Plan. There will be options for more information including frequently asked questions about the program, a calculator to estimate costs, and instructions for opting in electronically.

Phone: 1-800-927-6048 (TTY: 711), October 1 to March 31, 7 days per week, 8 a.m. to 8 p.m., and from April 1 to September 30, Monday through Friday, 8 a.m. to 8 p.m.

Mail: Download and print the Medicare Prescription Payment Plan enrollment form.

Prescription Payment Plan Enrollment Form English
Prescription Payment Plan Enrollment Form Spanish

Mail the enrollment form to:

Express Scripts MPPP 
P.O. Box 801101 
Kansas City, MO 64180-1101

If you have questions about the Medicare Prescription Payment plan, please contact Express Scripts at 1-866-845-1803 (TTY: 711), 24 hours per day, 7 days per week or email MPPPElections2@express-scripts.com.

What If My Prescription Is Not Listed on the Formulary?

If your prescription drug is not listed on the formulary, or is listed with coverage restrictions such as prior authorization, step therapy, or quantity limits, you have options available for calendar year 2026.

Option 1: Ask About Covered Alternatives

You may contact the Pharmacy Help Desk to request information about covered alternative drugs that may treat your condition.

After receiving this information, you and your provider can review whether a covered alternative may be appropriate for you.

1. Calling the Pharmacy Help Desk
   • 1-800-927-6048 (TTY: 711)

1. Hours of Operation:
   • October 1 – March 31: 7 days a week, 8 a.m. to 8 p.m. b. April 1 – September 30: Monday through Friday, 8 a.m. to 8 p.m

Option 2: Request a Coverage Determination or Exception

1. A coverage determination
2. A formulary exception
3. An exception to a utilization requirement

Requests require a supporting statement from your prescriber explaining why the requested drug is medically necessary. For more information, please see the Coverage Determinations, Exceptions, and Appeals (CY2026) section on this page.

Important Information

This information applies to calendar year 2026. Coverage determinations and exceptions are processed according to Medicare Part D requirements. Please refer to your CY2026 Evidence of Coverage (EOC) or contact Sentara Medicare Member Services for complete details.

You have the right to request an exception to Sentara Medicare’s prescription drug coverage rules for calendar year 2026. Some covered drugs may have requirements or limits, such as prior authorization, step therapy, or quantity limits. For more information, please see the Utilization and Quality Assurance Program section on this page.

When Can an Exception Be Approved?

1. Covered alternative drugs on the formulary would not be as effective in treating your condition, or
2. Covered alternative drugs or utilization requirements would cause adverse medical effects

A supporting statement from your prescriber is required to review your request.

How to Request an Exception

You or your prescriber may request an exception by asking for an initial coverage determination for:

1. A formulary exception, or
2. An exception to a utilization requirement

Decision Timeframes

After receiving your prescriber’s supporting statement, Sentara Medicare will make a decision within the following timeframes:

1. Standard Exception Request 
   •  A decision will be provided within 72 hours
2. Expedited (Fast) Exception Request:
   •  If you or your prescriber believe waiting could seriously harm your health, you may request an expedited review.

If approved, a decision will be provided within 24 hours

How to Submit a Request

You or your prescriber may initiate a coverage determination by:

1. Submitting a Sentara Medicare Prescription Drug Coverage Determination Request Form (CY2026), or
2. Calling the Pharmacy Help Desk
   1-800-927-6048 (TTY: 711)
3. Hours of Operation: 
   • October 1 – March 31: 7 days a week, 8 a.m. to 8 p.m. 
   • April 1 – September 30: Monday through Friday, 8 a.m. to 8 p.m.

Important Information

This information applies to calendar year 2026. Coverage determinations and exceptions are processed according to Medicare Part D requirements. Please refer to your CY2026 Evidence of Coverage (EOC) or contact Sentara Medicare Member Services for complete details.

The Medication Therapy Management Program (MTMP) is designed to help improve health outcomes for Sentara Medicare Part D members who have multiple medical conditions and take multiple prescription medications.

This program applies to calendar year 2026 and is offered at no cost to eligible members. Participation in MTMP does not change your prescription drug coverage, copayments, doctors, or pharmacies.

Who May Be Eligible

You may be eligible for MTMP if you meet Medicare requirements for the program, which may include:

1. Taking multiple chronic Part D medications
2. Having multiple chronic medical conditions, such as:
   • Asthma
   • Chronic obstructive pulmonary disease (COPD)
   • Congestive heart failure (CHF)
   • Depression
   • Diabetes
   • Dyslipidemia 
   • HIV/AIDS
   • Hypertension 
   • Osteoporosis
   • R Rheumatoid arthritis
3. You are likely to spend more than $1,276 in 2026 on prescription drug costs (includes what you and your plan pay).AND
4. You take eight (8) or more maintenance drugs that are covered by your Medicare Part D plan.
5. How else you may qualify: You also may qualify if you’re an at-risk beneficiary (ARB) under a drug management program (DMP).

Eligibility criteria are established by Medicare and may change from year to year.

How the Program Helps

MTMP services are designed to help:

1. Ensure medications are taken safely and correctly
2. Improve medication adherence
3. Identify potential drug interactions or duplicate therapies
4. Support better coordination between you and your health care providers

Comprehensive Medication Review (CMR)

As required by the Centers for Medicare & Medicaid Services (CMS), eligible members are offered an interactive, person-to-person Comprehensive Medication Review (CMR) at least once each year.

 A CMR includes:

1. A review of all medications you take, including:
   • Prescription drugs
   • Over-the-counter (OTC) medications
   • Herbal products and dietary supplements
2. A one-on-one consultation with a qualified clinician
3. A written summary for you, which may include:
   •  A Personal Medication List (PML)
   • An action plan or recommendations to support safe medication use

In addition, eligible members may receive Targeted Medication Reviews (TMRs) during the year to help identify potential medication-related concerns.

Program Administration

1. Express Scripts MTM Department
2. 1-855-723-7009 (TTY: 711)
3. Monday–Friday, 8 a.m. to 6 p.m. Central Time

Important Information

The Medication Therapy Management Program is provided in accordance with Medicare Part D requirements and applies to calendar year 2026.
Eligibility criteria and services may change. Please refer to your CY2026 Evidence of Coverage (EOC) or contact Sentara Medicare Member Services for complete details.

Sentara Medicare works with physicians to make sure members get the most appropriate, safe and cost-effective drugs. The plan's Utilization Management and Quality Assurance program is designed to assure adverse drug events and drug interactions are avoided and ensure optimum medication use. The Utilization Management and Quality Assurance program is provided at no additional cost to members or providers.

Utilization Management and Quality Assurance programs incorporate tools to encourage appropriate and cost-effective use of Part D drugs. These tools include prior authorization, quantity limits, additional charges and clinical interventions. Other tools may be used if necessary.

• PA = Prior Authorization. Sentara Medicare requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from Sentara Medicare before you fill your prescriptions. If you don’t get approval, Sentara Medicare may not cover the drug.
• ST = Step Therapy. In some cases, Sentara Medicare requires you to first try certain drugs to treat your medical condition. For example, if Drug A and Drug B both treat your medical condition, Sentara Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Sentara Medicare will then cover Drug B.
• QL = Quantity Limits. For certain drugs, Sentara Medicare limits the amount of the drug that it will cover. This may be in addition to a standard one-month or three-month supply.
• AN = Additional Charge. If you obtain a brand name drug when a generic equivalent is available, you will be required to pay the difference between the cost of the generic drug (which is paid by Sentara Medicare) and the cost of the brand name drug in addition to the appropriate brand copay.

See Sentara Medicare's formulary for drugs that have prior authorization requirements, step therapy, quantity limits or where additional charges may apply.

As part of the Utilization Management and Quality Assurance program, all prescriptions are screened by systems to detect and address the following:

• drug-drug interactions that are clinically significant
• duplication of drugs (taking more than one drug in the same drug class)
• inappropriate drugs
• incorrect drug
• patient-specific drug contraindications
• over-utilization of drugs
• under-utilization of drugs
• abuse or misuse of drugs.

A review of prescriptions is performed before the drug is dispensed. These are concurrent drug reviews and are clinical edits at the point-of-sale (at the pharmacy counter).

Retrospective drug utilization reviews identify inappropriate or medically unnecessary care. Sentara Medicare performs periodic reviews of claims data to evaluate prescribing patterns and drug use that may indicate inappropriate use.

Physicians treating patients who are receiving potentially inappropriate drug therapy will receive provider-specific reports detailing the patient's drug utilization. The providers receive educational materials explaining the report and the intervention it addresses. The reports identify individual patients who may require evaluation, the reason for the report and options for the provider to consider.

If you are new to a Sentara Medicare plan or experience a change in coverage during calendar year 2026, you may be eligible for a temporary supply of prescription drugs while working with your provider to transition to medications covered under your plan.

Who is Eligible:

You may qualify for a transition supply if you:

1. Are newly enrolled in a Sentara Medicare plan for CY2026
2. Switch plans during the year
3. Move between care settings, such as:
   • Home
   • Hospital
   • Skilled Nursing Facility
   • Long-term care (LTC) facility
4. This applies to members enrolled in D-SNP and FIDE D-SNP plans.

During the transition period, you may receive a temporary supply of a drug that is:

1. Not on the formulary, or
2. Subject to utilization management requirements such as:
   • Prior Authorization 
   • Step Therapy 
   • Quantity Limits
3. This temporary supply allows time for you and your provider to:
   • Change to a covered alternative, or
   • Request a coverage determination or formulary exception

Important Transition Details

1. Transition supplies are provided according to Medicare rules
2. You will receive a written notice explaining:
   • Your Transition Supply
   • Your options for continued coverage
3. Long-term care residents may receive transition supplies consistent with LTC pharmacy requirements

What You Should Do Next

1. Review your CY2026 Formulary 
2. Talk with your provider about covered alternatives
3. Submit a Coverage Determination or Exception request, if needed
4. Contact Sentara Medicare Member services for assistance

Important Information

Transition of Care coverage is provided in accordance with Medicare Part D requirements and applies to calendar year 2026. Transition supplies are temporary and subject to plan rules. Please refer to your CY2026 Evidence of Coverage (EOC) for complete details.