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Medicare Part D Frequently Asked Questions

What Is The Inter Valley Health Plan Formulary?


Can The Formulary Change?

How DoesThe Plan Meet Access Requirements?

What Is The Out-Of-Network Coverage

What is the Prescription Drug Plan Grievance Process?

What Is The Prescription Drug Coverage Determination Process?

What happens when you request a coverage determination?

Can I Submit An Exception Request?

What Is The Prescription Drug Standard Appeals (redetermination) Process?

What is the Prescription Drug Expedited Appeals (redetermination) Process?

Quality Assurance-Drug Utilization Review

Utilization Management

Medication Therapy Management Programs

What If The Pharmacy Leaves The Plan's Network?

What Happens If I Leave Inter Valley Health Plan?

How Can I Obtain An Aggregate Number Of The Plan's Grievances, Appeals And Exceptions?

What is the Inter Valley Health Plan Formulary?
A formulary is a list of drugs that we cover. Inter Valley Health Plan will generally cover the drugs listed in our formulary as long as it is medically necessary and the prescription is filled at a network pharmacy or through our network mail-order-pharmacy service and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

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Can the formulary change?
We may make certain changes to our formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. The kind of formulary changes may include:

Adding or removing drugs from the formulary

Adding prior authorizations, quantity limits, and/or step-therapy restrictions on a drug

Moving a drug to a higher or lower cost-sharing tier

If we remove drugs from the formulary, add prior authorizations, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, and you are taking the drug affected by the change, you will be permitted to continue taking that drug at the same level of cost-sharing for the remainder of the Plan year. However, if a brand name drug is replaced with a new generic drug, or our formulary is changed as a result of new information on a drug’s safety or effectiveness, you may be affected by this change. We will notify you of the change at least 60 days before the date that the change becomes effective or provide you with a 60-day supply at the pharmacy. This will give you an opportunity to work with your physician to switch to an appropriate drug that we cover or request a formulary exception before the change to the formulary takes effect. If a drug is removed from our formulary because the drug has been recalled from the pharmacies, we will not give 60 days notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members taking the drug about the change as soon as possible.

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How does the Plan meet access requirements?

Inter Valley Health Plan has contracted pharmacy networks, which consist of retail pharmacies sufficient to ensure that for beneficiaries residing in each of our service area the following requirements are satisfied to assure pharmacy access.
At least 90% of Medicare beneficiaries, on average, in urban areas served by Inter Valley Health Plan live within 2 miles of a network retail pharmacy.
At least 90% of Medicare beneficiaries, on average, in suburban areas served by Inter Valley Health Plan live within 5 miles of a network retail pharmacy.
At least 70% of Medicare beneficiaries, on average, in rural areas served by Inter Valley Health Plan live within 15 miles of a network retail pharmacy.

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What is the out-of-network coverage?
Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill your prescription in these situations, call Pharmacy Services to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You may ask us to reimburse you for our share of the cost by submitting a claim form. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay will help you qualify for catastrophic coverage. If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

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What is the Prescription Drug Plan Grievance Process?
Inter Valley Health Plan’s grievance process is designed to address enrollee coverage issues, complaints and problems. If you have a coverage issue or other problem, please call at the toll-free number on your ID card or at 1-800-251-8191, TTY/TDD DEVICES (800) 505-7150 . If Member Services is unable to resolve your issue, complaint or problem to your satisfaction, you can request that your concern be forwarded to the Plan’s grievance department or you may write to the Grievance and Appeals address listed in the Evidence of Coverage you received.
Grievances can be filed orally or in writing P.O. Box 6002, Pomona, CA 91769-6002; Fax#: 909-620-6413 and must be filed within 60 days of the event or incident. For instructions on how to appoint a representative and a link to CMS' appointment representative form click here. A quality of care grievance can be filed with Inter Valley Health Plan or Lumetra, the Quality Improvement Organization (QIO) for California. Grievances will be resolved as expeditiously as the case requires based on the enrollee's health status, but no later than 30 days from the date of receipt. Inter Valley Health Plan or the enrollee can take up to a 14-day extension. If Inter Valley Health Plan initiates an extension, the enrollee must be notified in writing and the letter must provide the reason for the delay. Inter Valley Health Plan will track all oral and written grievances received, including the date received, type of grievance and final disposition of the grievance, and the date the enrollee was notified of the final outcome or resolution.

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What is the Prescription Drug Coverage Determination Process?
The Prescription Drug Coverage Determination process is the starting point for dealing with requests you have about covering or paying for a Part D prescription drug. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you should contact us and ask us for a coverage determination. With this decision, we explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. If we deny your request (this is sometimes called an “adverse coverage determination”), you may “appeal” the decision by going on to Appeal Level 1. If we fail to make a timely coverage determination on your request, it will be automatically forwarded to the independent review entity for review (see Appeal Level 2).
The following are examples of coverage-determination requests:

You ask us to pay for a prescription drug you have received. This is a request for a coverage determination about payment.
 

You ask for a Part D drug that is not on your plan sponsor's list of covered drugs (called a "formulary"). This is a request for a "formulary exception."

You ask for an exception to our utilization management tools - such as prior authorization, dosage limits, quantity limits, or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception.
You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a "tiering exception."
You ask us to pay you back for the cost of a drug you bought at an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the Plan.

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What happens when you request a coverage determination?

1. For a standard coverage determination about a Part D drug that includes a request to pay you back for a Part D drug that you have already received.
Generally, we must give you our decision no later than 72 hours after we receive your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception (including a formulary exception, tiering exception, or an exception from utilization management rules – such as dosage or quantity limits or step therapy requirements), we must give you our decision no later than 72 hours after we receive your physician's "supporting statement" explaining why the drug you are asking for is medically necessary. If you have not received an answer from us within 72 hours after we receive your request, your request will automatically go to Appeal
Level 2, where an independent review organization will review your case.

2. For a fast coverage determination about a Part D drug that you have not received.
If we give you a fast review, we will give you our decision within 24 hours after you or your doctor ask for a fast review – sooner if your health requires. If your request involves a request for an exception, we will give you our decision no later than 24 hours after we have received your physician's "supporting statement," which explains why the non-formulary or non-preferred drug you are asking for is medically necessary.
If we decide you are eligible for a fast review, and you have not received an answer from us within 24 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent review organization will review your case.


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Can I submit an exception request?

An exception is a type of coverage determination. You may ask us to make an exception to our coverage rules in a number of situations.

You may ask us to cover your drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
You may ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you may ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the co-payment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.
Generally, we will only approve your request for an exception if the alternative drugs included on the Plan formulary or the drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.

If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you may appeal our decision. Note: If we approve your exception request for a non-formulary drug, you cannot request an exception to the co-payment or coinsurance amount we require you to pay for the drug.

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What is the Prescription Drug Standard Appeals (redetermination) Process

The appeals process, also referred to as a redetermination process, is used to review an adverse coverage determination made by Inter Valley Health Plan on the benefits that you believe you are entitled to receive. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage. Below is a description of the appeals process:
There are several levels of appeals that you can exercise (independent review entity, ALJ hearing, review by the Medicare Appeals Council and the Federal Court Judge).
You, your appointed representative or your prescribing physician can request an appeal (redetermination).
You must ask for an appeal by making a written request to Inter Valley Health Plan and must file their request within 60 days of the adverse coverage determination.
Upon receipt of a standard coverage redeterminations request, Inter Valley Health Plan will review the request and make the determination within the following timeframes.

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What is the Prescription Drug Expedited Appeals (redetermination) Process

You may file a request for an expedited appeal for drug coverage if you believe that applying the standard appeals process could jeopardize your health. If Inter Valley Health Plan decides that the time frame for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.
You, your appointed representative or your prescribing physician can request an expedited appeal. An expedited request can be submitted orally or in writing to Inter Valley Health Plan and your prescribing physician may provide oral or written support for your request for an expedited appeal.
Inter Valley Health Plan must provide an expedited appeal if it determines that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.
A request made or supported by your prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.
To request an expedited appeal, you may call 1-800-251-8191, TTY/TDD DEVICES (800) 505-7150. Or you may fax or mail your written request to Inter Valley Health Plan. If you write, the 24-hour review timeframe will not begin until your request is received. Written requests can be faxed to 1-909-620-6413 or mailed to Inter Valley Health Plan, Attention: Appeals and Grievance Department, P.O. Box 6002, Pomona, CA 91769-6002.
A request for payment of drugs that you have already received does not qualify for expedited appeals processing.
When an appeal request meets criteria for expedited processing Inter Valley Health Plan must provide you and your prescribing physician notice of its decision as expeditiously as your health condition requires, but no later than 72 hours after receiving the request.
If additional medical information is required to process the request, Inter Valley Health Plan must request it within 24 hours of receiving the expedited appeal request. Even if additional information is required, Inter Valley Health Plan must still issue notice of the decision within the 72 hour timeframe
If Inter Valley Health Plan determines that your request is not time-sensitive, where your health is not seriously jeopardized, Inter Valley Health Plan will notify you verbally and in writing and will automatically begin processing your request under the standard appeals process. If you disagree and believe the review should be expedited, you may file an expedited grievance with Inter Valley Health Plan. The written notice will include instructions on how to file an expedited grievance.
You have the right to resubmit your request for an expedited appeal with your prescribing physicians support.
Inter Valley Health Plan will track all standard and expedited appeals received, including the date received, type of appeal and the final disposition of the appeal, and the date you were notified of the final outcome or resolution.

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Quality Assurance – Drug Utilization review

Inter Valley Health Plan conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

Possible medication errors


Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition

Drugs that are inappropriate because of your age or gender

Possible harmful interactions between drugs you are taking

Drug allergies

Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

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Utilization Management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members.

The requirements for coverage or limits on certain drugs are listed as follows:

Prior Authorization: We require you to get prior authorization (prior approval) for certain drugs. This means that authorized prescriberswill need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug.

Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 9 tablets per 31-day period for Imitrex.

Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Generic Substitution:When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug and we have approved this request.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary on our formulary Web site (www.ivhp.com/ivhp/pdfs/formulary/pdf) or by calling Pharmacy Services at 1-800-523-3142, TTY/TDD 1-800-505-7150 (this number requires special telephone equipment). If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination).

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Medication Therapy Management Programs

Inter Valley Health Plan offers a Medication Therapy Management Program (MTMP) at no additional cost to members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. A team of pharmacists and doctors developed this program for us. We use this medication therapy management program to help us provide better coverage for our members. For example, these program help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.

We may contact members who qualify for these programs. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you don’t need to pay anything extra to participate. If you are selected to join a medication therapy management program we will send you information about the specific program, including information about how to access the program.

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What if the pharmacy leaves the Plan’s network?

Sometimes a pharmacy might leave the Plan’s network. If this happens, you will have to get your prescriptions filled at another Plan network pharmacy. Please refer to your Pharmacy; Directory or call Member Services at 1-800-251-8191, TTY/TDD 1-800-505-7150 (this number requires special telephone equipment) to find another network pharmacy in your area.

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What happens if I leave Inter Valley Health Plan?

Ending your membership in our Plan may be voluntary (your own choice) or involuntary
(not your own choice):

You might leave our Plan because you have decided that you want to leave.
There are also limited situations where we are required to end your membership. For example, if you move permanently out of our geographic service area.

Voluntarily ending your membership

In general, there are only certain times during the year when you may voluntarily end your membership in our Plan.

Every year, from November 15 through December 31, during the Annual Coordinated Election Period (AEP), anyone with Medicare may switch from one way of getting Medicare to another for the following year. Your change will take effect on January 1.

Between January 1 and March 31 of every year, individuals who are enrolled in (or eligible for) Medicare Advantage Plans have one opportunity to make (1) change to their Medicare Advantage coverage. This period may not be used to add or drop Medicare prescription drug coverage.

After March 31, you generally cannot change plans or discontinue your membership.
If plans are available in your area, and if they are accepting new members, you can make one of the following changes:

As a member of a Medicare Advantage Plan with prescription drug coverage (MA-PD), between January 1 and March 31, changes you can make include:
Switch to another Medicare Advantage Plan with prescription drug coverage (MA-PD) by enrolling in the new MA-PD plan; or
Switch to Original Medicare and a Prescription Drug Plan (PDP) by enrolling in the PDP.
There may be other limited times during which you may make changes. For more information about these times and the options available to you, please refer to the “Medicare & You” handbook you receive each fall. You may also call 1-800-MEDICARE (1-800-633-4227), TTY/TDD DEVICES (800) 505-7150, or visit www.medicare.gov to learn more about your options.


Until your membership ends, you must keep getting your medicare services through our plan or you will have to pay for them yourself.

If you leave our Plan, it may take some time for your membership to end and your new way of getting Medicare to take effect (we discuss when the change takes effect later in this section). While you are waiting for your membership to end, you are still a member and must continue to get your care as usual through our Plan.

If you must get services from plan providers and doctors or other medical providers who are not plan providers before your membership in our Plan ends, neither we nor the Medicare program will pay for these services, with just a few exceptions. The exceptions are urgently needed care, care for a medical emergency, out-of-area renal (kidney) dialysis services, and care that have been approved by us. There is another possible exception, if you happen to be hospitalized on the day your membership ends. If this happens to you, call Member Services at 1-800-251-8191, TTY/TDD 1-800-505-7150 (this number requires special telephone equipment) to find out if your hospital care will be covered by our Plan. If you have any questions about leaving our Plan, please call us at Member Services.
We cannot ask you to leave the Plan because of your health.

We cannot ask you to leave your health plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave Inter Valley Health Plan Service To Seniors because of your health, you should call 1-800-MEDICARE (1-800-633-4227), TTY/TDD DEVICES (800) 505-7150, which is the national Medicare help line. TTY users should call 1-877-486-2048, TTY/TDD DEVICES (800) 505-7150. You may call 24 hours a day, 7 days a week.
Involuntarily ending your membership

If any of the following situations occur, we will end your membership in our Plan.

If you move out of the service area or are away from the service area for more than 6 months in a row. If you plan to move or take a long trip, please call Member Services at 1-800-251-8191, TTY/TDD 1-800-505-7150 (this number requires special telephone equipment) to find out if the place you are moving to or traveling to is in our Plan’s service area. If you move permanently out of our geographic service area, or if you are away from our service area for more than six months in a row, you cannot remain a member of our Plan. In these situations, if you do not leave on your own, we must end your membership (“disenroll” you).
If you do not stay continuously enrolled in Medicare A and B.
If you give usinformation on your enrollment request that you know is false or deliberately misleading, and it affects whether or not you can enroll in our Plan.
If you behave in a way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you or for others who are members of our Plan. We cannot make you leave our Plan for this reason unless we get permission first from Medicare.
If you let someone else use your plan membership card to get medical care. If you are disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation.
You have the right to make a complaint if we end your membership in your plan

If we end your membership in our Plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.

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How can I obtain an aggregate number of the Plan’s grievances, appeals and exceptions?

You may obtain a summary of information about the appeals and grievances that members have filed in the past. To get this information, please call our Member Service at 1-800-251-8191 (toll free), TTY/TDD DEVICES (800) 505-7150.

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