Pharmacy Network Information
America’s 1st Choice Health Plans, Inc. uses a network of pharmacies that is equal to or exceeds CMS requirements for pharmacy access in your area. In the state of South Carolina, America’s 1st Choice Health Plans, Inc. has 911 pharmacies in their network. These pharmacies are contracted through our Pharmacy Benefit Administrator, Spectral Solutions.
You can get prescription drugs shipped to your home through our network mail order delivery service. For refills of your mail order prescriptions, you have the option to sign up for an automatic refill service. Under this service, we will start to process your next refill automatically when our records show that you should be close to running out of your drug. We will contact you prior to shipping each refill to make sure you are in need of more medication. You can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use the auto refill service, please contact us 10 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time. To opt out of the automatic refill service, please contact your mail order service directly. If you utilize AssuredRX please call 1-888-987-9977, TTY/TDD users 711, 9:00 AM to 5:00 PM Monday through Friday. Or, if you utilize Catamaran Home Delivery please call 1-800-763-0044, TTY/TDD users 711, 7:00AM to 10:00PM, Monday through Friday, and 8:00AM to 6:30PM Saturdays. Typically, you should expect to receive your prescription drugs within 7 days from the time that the mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact us at America’s 1st Choice Health Plans, Inc.’s Member Services at 1-866-321-3947, or for TTY/TDD users 711. Hours are October 1 to February 14 from 8:00 am to 8:00 pm 7 days a week and February 15 to September 30 from 8:00 am to 8:00 pm Monday through Friday.
We also list pharmacies that are in our network but are outside our service area. Please contact America's 1st Choice Health Plans at 1-866-321-3947 (TTY/TDD 711), our hours are October 1 to February 14 from 8:00 am to 8:00 pm 7 days a week and February 15 to September 30 from 8:00 am to 8:00 pm Monday through Friday
To search for a pharmacy, click on the Pharmacy Network Listing link below. Type your county or pharmacy name in the “FIND” box then click on the “FIND NEXT” button.
- 2016 Formulary Search (Covered Drug List)
Formulary list may change during the year. Updates, if any, will be posted monthly. Click here
- What is a formulary?
- Can the formulary change?
- What about generic drugs?
- What if my drug isn't in the formulary?
Grievances and Coverage Determinations
What to do if you have a problem or complaint about getting a Part D drug?
Click here to learn more about how to ask for an Exception, a Coverage Determination an Appeal or to make a complaint.
- Coverage Determinations & Appeals, Grievances & Exceptions
- Coverage Determination Request Form
- Redetermination Request Form
- To go to Covergae Determination Form in CMS Website , please click here
- To go to Redetermination Form in CMS Website, please click here
Prior Authorization Criteria
- Click here to learn which drugs require Prior Authorization.
- Click here to find the Prior Authorization and Exception Request form for Provider.
Step Therapy Criteria
Drugs with Quantity Limits
What can you do if your drug is not on the Drug List?
CMS Best Available Evidence
For information about the (BAE) policy please contact member services.
Low Income Subsidy (LIS) Information
- Learn how you may be able to get extra help with your prescription drug coverage.
- Website Premium Summary Table for Those Receiving Extra Help
Grievance & Appeals
Members and providers who have questions about the Grievance and Appeals processes, need the status of a coverage determination or want to receive an aggregate number of grievance, appeals, and exceptions filed with the plan sponsor please contact. Member Services.
- Click here to make a complaint or request an appeal about a Part D drug.
- Request For Medicare Prescription Drug Coverage Determination
Appointment of a Representative
The Appointment of Representative Form is located on the CMS Web site.
Beneficiaries and providers may appoint another individual, including an attorney, as their representative in dealings with Medicare, including appeals you file. Form CMS-1696, Appointment of Representative form, must be submitted with the appeal and is valid for one year from the date. The form must be signed by both you and the appointed representative. A representative may be designated at any point in the appeals process. This representative may assist you during the processing of a claim or claims and/or any subsequent appeal. Refer to the CMS Medicare Claims Processing Manual (PDF, 605 KB) (Pub. 100-04, chapter 29, section 270.1.10) for information on disclosing information to third parties.
The following types of individuals may be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
- Congressional staff members
- Family members of a beneficiary
- Friends or neighbors of a beneficiary
- Members of beneficiary advocacy groups
- Members of provider or supplier advocacy groups
- Physicians or suppliers
The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696) or use a conforming written instrument. Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04, chapter 29, section 270.1) for required elements of written instruments. You may appoint a representative at any time during the course of an appeal. The representative must sign the CMS-1696 or other conforming written instrument within 30 calendar days of the date the beneficiary or you sign an order for the appointment to be valid. By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.
The CMS-1696 is available for the convenience of the beneficiary or you to use when appointing a representative. Instructions for completing the form:
- The name of the party making the appointment must be clearly legible. For beneficiaries, the Medicare Health Insurance Claim (HIC) number must be provided.
- Completing Section I - 'Appointment of Representative' - A specific individual must be named to act as representative in the first line of this section. A party may not appoint an organization or group to act as representative. The signature, address and phone number of the party making the appointment must be completed and the date it was signed must be entered. Only the beneficiary or the beneficiary’s legal guardian may sign when a beneficiary is making the appointment. If the party making the appointment is the provider or supplier, someone working for or acting as an agent of the provider or supplier must sign and complete this section.
- Completing Section II - 'Acceptance of Appointment' - The name of the individual appointed as representative must always be completed and his/her relationship to the party entered. The individual being appointed must then sign and complete the rest of this section.
- Completing Section III - 'Waiver of Fee for Representation' - This section must be completed when the beneficiary is appointing a provider or supplier as representative and the provider or supplier actually furnished the items or services that are the subject of the appeal.
- Completing Section IV - 'Waiver of Payment for Items or Services at Issue' - This section must be completed when the beneficiary is appointing a provider or supplier who actually furnished the items or services that are the subject of the appeal and involve issues describe in section 1879(a)(2) of the Social Security Act.
If any one of the elements listed above is missing from the appointment, the adjudicator shall contact the party (individual attempting to act as a beneficiary’s representative) and provide a description of the missing documentation or information. Unless the missing information is provided, the prospective appointed representative lacks the authority to act on behalf of the party and is not entitled to obtain or receive any information related to the appeal, including the appeal decision. The adjudicator will not dismiss the appeal request because the appointment of representative is not valid.
Where to Send This Form
Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision.
You can also call the Member Services Department at 1-866-321-3947 to learn more about how to name your appointed representative.
Drug Utilization Management & Quality Assurance
Potential for Contract Termination:
America’s 1st Choice Health Plans, Inc. has a contract with the Centers for Medicare and Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. America’s 1st Choice Health Plans, Inc. is required to notify beneficiaries that it is authorized by law to refuse to renew its contract with the Centers for Medicare & Medicaid Services (CMS), that CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of your enrollment. In addition, the plan may reduce its service area and no longer offer services in the area where you reside. In the event this happens, you will receive advance notice.
Information on aggregate number of grievances , appeals and exceptions
Members can obtain an aggregate number of grievances, appeals and exceptions filed with the plan by calling our customer service department.