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Comprehensive Plan With Alternative Benefits
Medicare Part D Prescription Benefits:
• No Premium or Deductible
• $10 Preferred Generics
• $14 Non-Preferred Generics
Healthcare Highlights:
• $0 PCP Copayment
• Chiropractic Coverage
• Acupuncture
• No Premium Dental
• Gym Membership
Available in portions of San Bernardino, Riverside,
and Los Angeles Counties
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 Total Fit Available?
Who Is Eligible To Join Inter Valley Health Plan Total Fit?
Can I Choose My Doctors?
What Services Can You Get On Your Own, Without Getting A Referral (Approval In Advance) From Your Primary Care Physician (PCP)?
What If Your Doctor Or Other Provider Leaves Your Plan?
How Does Your Enrollment In This Plan Affect Coverage For The Drugs Covered Under Medicare Part A Or Part B?
Where Can I Get My Prescriptions If I Join This Plan?
What Is A Prescription Drug Formulary?
What Extra Help Is Available To Help Pay My Plan Costs?
How do costs change when you qualify for extra help?
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 Total Fit 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 Total Fit (HMO) Available?
The service area for this plan includes: Los Angeles*, Riverside*, San Bernardino* 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; 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; 91387; 91390; 91706; 91711; 91731; 91732; 91733; 91734; 91741; 91750; 91759; 91765; 91766; 91767; 91768; 91769; 91770; 91775; 91776; 91778; 91780; 91789; 91790; 91791; 91792; 91793; 91801; 91802; 91803; 91804; 91702; 91722; 91723; 91724; 91740; 91744; 91745; 91746; 91747; 91748; 91773
Riverside County:
91718; 91719; 91720; 91752; 91760; 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?
You can join Inter Valley Health Plan Service to Seniors or Inter Valley Health Plan Total Fit 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 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 and Inter Valley Health Plan Total Fit 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 for an up-todate list or visit us at www.ivhp.com. Our customer service number is listed at the end of this introduction.
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What Services Can You Get On Your Own, Without Getting A Referral (Approval In Advance) From Your Primary Care Physician (PCP)?
You may get the following services on your own, without a referral (approval in advance) from your PCP. You still have to pay your share of the cost, as appropriate, for these services.
• Routine women’s health care, which include breast exams, mammograms (x-rays of the breast), Pap tests, and pelvic exams. This care is covered without a referral from a plan provider. You may self-refer to any contracted provider in the provider group of which your PCP is a member.
• Flu shots and pneumonia vaccinations as long as you get them from a plan provider.
• Emergency services, whether you get these services from plan providers or
non-plan providers.
• Urgently needed care that you get from non-plan providers when you are temporarily outside the Plan’s service area. Also, urgently needed care that you get from non-plan providers when you are in the service area but, because of unusual or extraordinary circumstances, the Plan providers are temporarily unavailable or inaccessible.
• Renal Dialysis (kidney) services that you get when you are temporarily outside the Plan’s service area. If possible, please let us know before you leave the service area where you are going to be so we can help arrange for you to have maintenance dialysis while outside the service area.
If you need care when you are outside the service area, your coverage is limited. The only services we cover when you are outside our service area are care for medical emergency, urgently need care, renal dialysis and care that Inter Valley Health Plan or a Network Provider has approved in advance. If you have questions about what medical care is covered when you travel, please call Member Services. In general, if a referral (prior approval) is required for services and you go directly to a specialist without first obtaining a referral from your PCP, the Plan will not pay for that service and you will be responsible for payment of care.
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What If Your Doctor Or Other Provider Leaves Your Plan?
Sometimes a network provider you are using might leave the Plan. If this happens, you will have to switch to another provider who is part of our Plan. Member Services can assist you in finding and selecting another provider.
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How Does Your Enrollment In This Plan Affect Coverage For The Drugs Covered Under Medicare Part A Or Part B?
We cover drugs under both Parts A and B of Medicare, as well as Part D. The Part D coverage we offer doesn’t affect Medicare coverage for drugs that would normally be covered under Medicare Part A or Part B. Depending on where you may receive your drugs, for example in the doctor’s office versus from a network pharmacy, there may be a difference in your cost-sharing for those drugs. You may contact our Plan about different costs associated with drugs available in different settings and situations.
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Where Can I Get My Prescriptions If I Join This Plan?
Inter Valley Health Plan Service To Seniors and Inter Valley Health Plan Total Fit 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 visit us at 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 and Inter Valley Health Plan Total Fit 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 and 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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What Extra Help Is Available To Help Pay My Plan Costs?
Medicare provides “extra help” to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you will get help paying for any Medicare drug plan’s monthly premium, and prescription co-payments. If you qualify, this extra help will count toward your out-of-pocket costs.
Do you qualify for extra help? People with limited income and resources may qualify for extra help one of two ways. The amount of extra help you get will depend on your income and resources.
1. You automatically qualify for extra help and don’t need to apply. If you have full coverage from a state Medicaid program, get help from Medicaid paying your Medicare premiums (belong to a Medicare Savings Program), or get Supplemental Security Income benefits, you automatically qualify for extra help and do not have to apply for it. Medicare mails a letter to people who automatically qualify for extra help.
2. You apply and qualify for extra help. You may qualify if your yearly income in 2008 is less than $15,600 (single with no dependents) or $21,000 (married and living with your spouse with no dependents), and your resources are less than $11,990 (single) or $23,970 (married and living with your spouse). These resource amounts include $1,500 per person for burial expenses. Resources include your savings and stocks but not your home or car. If you think you may qualify, call Social Security at 1-800-772-1213 (TTY users should call 1-800-325-0778) or visit http://www.socialsecurity.gov/ on the Web. You may also be able to apply at your State Medical Assistance (Medicaid) office. After you apply, you will get a letter in the mail letting you know if you qualify and what you need to do next.
The above income and resource amounts are for 2008 and will change in 2009. If you live in Alaska or Hawaii, or pay at least half of the living expenses of dependent family members, income limits are higher.
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How do costs change when you qualify for extra help?
If you qualify for extra help, we will send you by mail an “Evidence of Coverage Rider for those who Receive Extra Help Paying for their Prescription Drugs” that explains your costs as a member of our Plan. If the amount of your extra help changes during the year, we will also mail you an updated “Evidence of Coverage Rider for those who Receive Extra Help Paying for their Prescription Drugs”.
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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 90 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 or Inter Valley Health Plan Total Fit, 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.
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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 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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