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Comprehensive Health & Prescription Coverage
Medicare Part D Prescription Benefits:
• No Premium or Deductible
• $2 Preferred Generics Covered in the Gap
• $12 Non-Preferred Generics
• Initial Coverage Limit Up to $3,400
Healthcare Highlights:
• $0 PCP Copayment
• Low Hospital Copay
• Chiropractic and Vision Coverage
• Dental Option
Plan available in portions of San Bernardino, Riverside and Los Angeles County
For more information, please download the following files
(requires Adobe Acrobat Reader)
2010 Enrollment Instructions
2010 Summary of Benefits
2010 Drug Formulary
2010 Evidence of Coverage
Part D Questions
Part D Frequently Asked Questions
Plan Summary Questions
How Can I Compare My Options?
Where Is Inter Valley Health Plan Service To Seniors (HMO) And Inter Valley Health Plan Total Fit (HMO) Available?
Who Is Eligible To Join Inter Valley Health Plan Service To Seniors (HMO) Or Inter Valley Health Plan Total Fit (HMO)?
Can I Choose My Doctors?
What Happens If I Go To A Doctor Who’s Not In Your Network?
Does My Plan Cover Medicare Part B Or Part D Drugs?
Where Can I Get My Prescriptions If I Join This Plan?
What Is A Prescription Drug Formulary?
How Can I Get Extra Help With Prescription Drug Plan Costs?
What Are My Protections In This Plan?
What Is A Medication Therapy Management (MTM) Program?
What Types Of Drugs May Be Covered Under Medicare Part B?
How Can I Compare My Options?
You can compare Inter Valley Health Plan Service To Seniors (HMO) and the Original Medicare Plan using the Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers.
Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.
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Where Is Inter Valley Health Plan Service To Seniors (HMO) And Inter Valley Health Plan Total Fit (HMO) Available?
There is more than one plan listed in this Summary of Benefits. If you are enrolled in one plan and wish to switch to another plan, you may do so only during certain times of the year. Please call Customer Service for more information.
The service area for this plan includes: Los Angeles*, Riverside*, San Bernardino* Riverside Counties, CA. You must live in one of these areas to join this plan.
*The asterisk indicates a partially covered county. The zip codes below identify portions of the county that are inside the service area.
Los Angeles County:
90605; 90670; 90671; 91001; 91003; 91006; 91007; 91008; 91009; 91010; 91016; 91017; 91024; 91025; 91030; 91031; 91101; 91102; 91103; 91104; 91105; 91106; 91107; 91108; 91109; 91114; 91115; 91116; 91117; 91118; 91124; 91125; 91126; 91702; 91706; 91711; 91722; 91723; 91724; 91731; 91732; 91733; 91734; 91740; 91741; 91744; 91745; 91746; 91747; 91748; 91750; 91759; 91765; 91766; 91767; 91768; 91769; 91770; 91773; 91775; 91776; 91778; 91780; 91789; 91790; 91791; 91792; 91793; 91801; 91802; 91803; 91804
Riverside County:
91752; 92028; 92201; 92202; 92203; 92210; 92211; 92220; 92223; 92230; 92234; 92235; 92236; 92240; 92241; 92247; 92248; 92253; 92255; 92258; 92260; 92261; 92262; 92263; 92264; 92270; 92276; 92282; 92292; 92320; 92324; 92373; 92399; 92501; 92502; 92503; 92504; 92505; 92506; 92507; 92508; 92509; 92513; 92514; 92515; 92516; 92517; 92518; 92519; 92521; 92522; 92530; 92531; 92532; 92536; 92539; 92543; 92544; 92545; 92546; 92548; 92549; 92551; 92552; 92553; 92554; 92555; 92556; 92557; 92561; 92562; 92563; 92564; 92567; 92570; 92571; 92572; 92581; 92582; 92583; 92584; 92585; 92586; 92587; 92589; 92590; 92591; 92592; 92593; 92595; 92596; 92599; 92860; 92877; 92878; 92879; 92880; 92881; 92882; 92883
San Bernardino County:
91701; 91708; 91709; 91710; 91729; 91730; 91737; 91739; 91743; 91758; 91761; 91762; 91763; 91764; 91784; 91785; 91786; 92301; 92307; 92308; 92310; 92311; 92312; 92313; 92316; 92318; 92324; 92327; 92329; 92335; 92336; 92337; 92338; 92340; 92342; 92344; 92345; 92346; 92354; 92356; 92358; 92359; 92365; 92368; 92371; 92372; 92373; 92374; 92376; 92377; 92392; 92393; 92394; 92395; 92397; 92398; 92399; 92401; 92403; 92404; 92405; 92407; 92408; 92410; 92411
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Who Is Eligible To Join Inter Valley Health Plan Service To Seniors (HMO) Or Inter Valley Health Plan Total Fit (HMO)?
You can join Inter Valley Health Plan Service To Seniors (HMO) or Inter Valley Health Plan Total Fit (HMO) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Inter Valley Health Plan Service To Seniors (HMO) or Inter Valley Health Plan Total Fit (HMO), unless they are members of our organization and have been since their dialysis began.
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Can I Choose My Doctors?
Inter Valley Health Plan Service To Seniors (HMO) and Inter Valley Health Plan Total Fit (HMO) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory or for an up-to-date list visit us at www.ivhp.com. Our customer service number is listed at the end of this introduction.
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What Happens If I Go To A Doctor Who’s Not In Your Network?
If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither Inter Valley Health Plan Service To Seniors (HMO), Inter Valley Health Plan Total Fit (HMO), nor the Original Medicare Plan will pay for these services.
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Does My Plan Cover Medicare Part B Or Part D Drugs?
Inter Valley Health Plan Service To Seniors (HMO) and Inter Valley Health Plan Total Fit (HMO) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs.
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Where Can I Get My Prescriptions If I Join This Plan?
Inter Valley Health Plan Service To Seniors (HMO) and Inter Valley Health Plan Total Fit (HMO) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or view the plan formulary here. Our customer service number is listed at the end of this introduction.
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What Is A Prescription Drug Formulary?
Inter Valley Health Plan Service To Seniors (HMO) and Inter Valley Health Plan Total Fit (HMO) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you or you can see our complete formulary here.
If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.
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How Can I Get Extra Help With Prescription Drug Plan Costs?
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or
- Your State Medicaid Office.
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What Are My Protections In This Plan?
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
As a member of Inter Valley Health Plan Service To Seniors (HMO) or Inter Valley Health Plan Total Fit (HMO), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state, Health Services Advisory Group, Inc. (HSAG) 1-800-841-1602. Seven days a week. 24 hours a day. The TTY/TDD number is 1-800- 881-5980.
As a member of Inter Valley Health Plan Service To Seniors (HMO) or Inter Valley Health Plan Total Fit (HMO), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state, Health Services Advisory Group, Inc. (HSAG) 1-800-841-1602. Seven days a week. 24 hours a day. The TTY/TDD number is 1-800-881-5980.
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What Is A Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Inter Valley Health Plan Service To Seniors (HMO) or Inter Valley Health Plan Total Fit (HMO) for more details.
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What Types Of Drugs May Be Covered Under Medicare Part B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Inter Valley Health Plan Service To Senior or Inter Valley Health Plan Total Fit (HMO) for more details.
— Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.
— Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.
— Erythropoietin (Epoetin alpha or Epogen®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.
— Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.
— Injectable Drugs: Most injectable drugs administered incident to a physician’s service.
— Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.
— Some Oral Cancer Drugs: If the same drug is available in injectable form.
— Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.
— Inhalation and infusion drugs provided through DME.
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