Inter Valley Health Plan : 2012 Service To Seniors (HMO)

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Service to Seniors (HMO)

$0 PCP Copay, $4 Preferred Generic Drug Copay and Gym Membership, Dental, Vision and Chiropractic Benefit
Service To Seniors is a comprehensive plan with broad prescription benefits.
Includes: $4 preferred generic drug, low hospital and outpatient surgery copays, as well as Vision, Chiropractic, and $0 premium Comprehensive Dental and Gym Membership.

Plan available in portions of San Bernardino, Riverside and LA County

Comprehensive Health & Prescription Coverage

Medicare Part D Prescription Benefits:
• No Plan Premium or Deductible
• $4 Preferred Generics Covered in the Gap
• $12 Non-Preferred Generics
• Initial Coverage Limit Up to $3,200

Healthcare Highlights:
• $0 PCP Copayment
• Low Hospital Copay
• Chiropractic and Vision Coverage
• $0 premium Comprehensive Dental and Gym Membership

For more information, please download the following files
(requires Adobe Acrobat Reader)

2012 Summary of Benefits

2012 Drug Formulary

2012 Annual Notice of Change/Evidence of Coverage
2012 Evidence of Coverage Large Print

Alternate Formats

Download Adobe Reader at

1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week and see www.medicare.gov ‘Programs for People with Limited Income and Resources’ in the publication Medicare & You.
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 calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, 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 (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. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

As a member of Inter Valley Health Plan Service To Seniors (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. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

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What Is A Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program is a free service we 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) for more details.

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 Seniors (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 Alfa 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 administered through DME.111

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