Part B & D - Healthy Mississippi, Inc.

Healthy Mississippi gives you a special Medicare Advantage plan. This plan includes Medicare Part D, which helps you pay for medicine you get from the pharmacy. It also helps with vaccines and some things not covered by other parts of Medicare, like Part A or Part B.

Part D Prescription Drug Benefits

To find out more about the drug coverage in Part D, check out the Summary of Benefits (SB), or your Evidence of Coverage (EOC) for your prescription drug benefit. These show you your costs with our plan like your premium, your copays or coinsurance, any deductibles (if applicable). Your SB shows benefits at a glance. Your EOC shows you much more detail about your benefits. Your formulary (also called the “Drug list”) shows you which drugs we cover, if there are any limitations or prior authorizations, and what tier the drug is covered under.

Please visit https://healthy-ms.com/plan-documents/ for your EOC, your SB, and your Formulary.

Prescription Coverage Determination Requests

Effective 01/01/2027, please use the Coverage Determination form for SevaRx. Use this form to ask our plan for a coverage determination form for Scripius for 2026.

Coverage Determination Form for Scripius 2026

Pharmacy Authorization (Part B)

Pharmacy Authorization Part B refers to the process of obtaining approval for certain medications under Medicare Part B, which covers outpatient drugs that are not typically covered by Part D.

Pharmacy Authorization (Part B)

Mail-Order Pharmacy

Prescription drugs are available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

Mail Order Prescription Form

Prior Authorization Criteria

This document shows the criteria needed for Healthy Mississippi, Inc. coverage on prescription drugs and other forms of medical care.

Part D Prior Authorization Criteria

Part D Step Therapy

Step therapy is a type of prior authorization that requires you to try a less expensive drug on the plan’s drug list (formulary) that’s been proven to work for most people with your condition before you can move up a “step” to a more expensive drug.

Part D Step Therapy

Part D Coverage Redetermination (Appeal)

In case Healthy Mississippi, Inc. declines your request to cover or pay for a prescription drug, you have the option to request the redetermination (appeal) of their decision.

For the Part D Coverage Determination form, please visit https://healthy-ms.com/plan-documents/, under “Member Forms”.

Best Available Evidence (BAE)

Federal regulations at 42 CFR § 423.800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time.

Best Available Evidence (BAE)

Coverage Determination

A coverage decision is when Healthy Mississippi, Inc. decides what they will help pay for with your medical services or medication. When we make an initial decision about Part D drugs, it’s called a “coverage determination.”

For more information or to request a Coverage Determination, click here.

Drug Transition Policy

This policy outlines the steps taken by Healthy Mississippi, Inc. and its pharmacy benefit manager (PBM) to create and manage the Drug Transition Program.

For more information, click here.

Medication Therapy Management Program (MTMP)

Healthy Mississippi, Inc. offers a complimentary voluntary program for members dealing with multiple medical conditions, taking numerous prescription drugs, and facing high drug costs. If you meet the criteria, you can access this program at no additional cost.

For additional information, click here.

Quality Assurance Policy

We perform reviews of medication usage for our members to ensure they receive safe and suitable care. These assessments are particularly crucial for members with multiple providers prescribing their medications.

If we identify a potential issue with your medication usage, we will collaborate with your healthcare provider to address and rectify the concern.