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Comprehensive Health & Prescription Coverage
Medicare Part D Prescription Benefits:
• No Plan Premium or Deductible
• $5 Preferred Generics
• $17.50 Non-Preferred Generics
Healthcare Highlights:
• $0 PCP Copay
• $0 Specialist
• $0 Hospital Copay
• $0 Premium for Gym, Dental, Vision and Hearing
For more information, please download the following files
(requires Adobe Acrobat Reader)
2016 Benefit Highlights
2016 Summary of Benefits
2016 Annual Drug Formulary Most Recent 2016 Drug Formulary Updates
2016 Annual Notice of Change
2016 Evidence of Coverage
2016 Star Rating
2016 Dental Upgrade
Multi Language/Alternate Formats
Download Adobe Reader at
Medicare Part D Prescription Benefit Questions
Part D Frequently Asked Questions
Plan Summary Questions
How Can I Compare My Options?
Where Is Inter Valley Health Plan Service To Seniors Available?
Who Is Eligible To Join Inter Valley Health Plan Service To Seniors (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 this 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 Available?
The service area for these plans includes: Los Angeles*, Riverside*, San Bernardino* Counties, CA. You must live in one of these areas to join the plan.
* denotes partial county
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; 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; 91701; 91708; 91709; 91710; 91729; 91730; 91737; 91739; 91743; 91758; 91759; 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)?
You can join Inter Valley Health Plan if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, people with End-Stage Renal Disease are generally not eligible to enroll in Inter Valley Health Plan. The only exception is if you have been a member since your dialysis began.
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Can I Choose My Doctors?
Yes, you can, from our network of physicians. Inter Valley Health Plan uses an established network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. Sometimes the list of doctors and healthcare providers changes. You can always ask for a current provider directory when making your choices.
For an updated list, visit us at https://www.ivhp.com/FindaDoctor.
Questions? Our customer service number is 800-251-8191.
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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’ll have to pay for the services yourself. There are a few limited exceptions (for example, emergency care). Otherwise, neither Inter Valley Health Plan 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?
Yes, Inter Valley Health Plan covers 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?
From one of our network pharmacies. As with our doctors and hospitals, we have an extensive list of pharmacies that we work with. So you must use a network pharmacy to get plan benefits. If you fill a prescription at an out-of-network pharmacy, we may not pay for it (except in certain cases). Because the pharmacies in our network can change at any time, you can ask for a pharmacy directory or visit us at https://www.ivhp.com/FindaPharmacy.
For help, our customer service number is 800-251-8191
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What Is A Prescription Drug Formulary?
A formulary is a list of drugs covered by your health plan. Like most health plans, Inter Valley Health Plan uses a formulary. 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 your ability to fill prescriptions, we’ll notify you before the change is made. We’ll also send a formulary to you. To see our complete formulary, visit: http://ivhp.com/PDF_Uploads/Service-to-Seniors/STS-OC-Formulary-Book-2016-508_Secured.pdf
If you are currently taking a drug that’s not on our formulary or has additional requirements or limits, you may be able to get a temporary supply of the drug. Contact us to request an exception. Or ask your physician to switch to an alternative drug that is on our formulary.
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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 as well as get help with other Medicare 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 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?
This section is pretty official-sounding, but we want you to understand how it all works in very clear terms.
All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. In other words, each Medicare Advantage Plan re-ups every year, even though plan benefits and cost-sharing may change from calendar year to calendar year. At the start of each new year, 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.
Part A & B Protections
Here comes some legalese. As a member of Inter Valley Health Plan, 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). Please refer to the Evidence of Coverage (EOC) for the QIO contact information.
Now Your Part D Protections
As a member of Inter Valley Health Plan, 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). 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 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.
H0545_RAY2016_69B Approved 10/19/2015 Updated 11/02/2016