How to Use Imperial Health Plan Part D Drug Coverage

The contents of the following pages describe the rules you must follow when you get Part D drugs as part of the Plan benefit.

  • How to use the Plan’s Drug Formulary to find which drugs are covered
  • Which drugs are not covered
  • What type of drugs have coverage restrictions and what the restrictions are
  • Where and how to get your drug prescriptions filled
  • The Plan’s programs for drug safety and managing medications
  • The three (3) stages of drug coverage (Initial Coverage stage, Coverage Gap stage, and Catastrophic)
  • What you pay for Prescription drugs in the different cover stages and cost tiers

To view our 2019 Provider/Pharmacy Directory – Click here
To view our 2018 Provider/Pharmacy Directory – Click here


2019 Provider/Pharmacy Directory

For an updated listing of pharmacies go to the pharmacy finder.

For an updated listing of providers go to the Provider Look Up tool.


2019 Drug Formulary

In order to help you see which drug are covered by your plan, click on one of the links below.

For an updated listing of Drug Formulary go to the Drug Formulary search tool.


Part D Utilization Management

 


Part D Appeals & Grievances

Coverage Determinations

A coverage determination means that the Plan would be making a decision about whether prescription drugs are covered.in order to be covered, the drug must be used for a medically accepted indication. If you want to find out whether our plan will cover a certain drug you can request a Coverage Determination. If your health requires a quick response, you can ask us to make a “fast coverage decision.” You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought.

Exceptions

What is a Part D/Prescription exception? If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An exception is a type of coverage decision. If we turn down your request for an exception, you can appeal our coverage decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception to be approved. We will then consider your request. Here are three examples of exceptions that you or your doctor/other prescriber can ask us to make:

  • To cover a Part D drug for you that is not on our List of Covered Drugs (Formulary).
  • To remove a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary).
  • To reassign a drug to a lower cost-sharing tier. Every drug on the plan’s Drug List is in one of the cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug.

Important things to know about asking for exceptions Your doctor or other prescriber must give us a written request for exception that explains the medical reasons for requesting the exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. Typically, our Drug List includes more than one drug for treating a certain condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

You can ask for a coverage decision and/or exception by:

  • Phone: Call Member Services at 1-800-708-8273 TTY: 711.
  • Fax: Submitting a written request or a completed Imperial Health Plan Redetermination Form by fax to 1-626-380-9049.
  • Email: appealsgrievances@www.imperialhealthplan.com with a completed Imperial Health Plan Redetermination Request Form
  • Send a letter to us. Mail your written request to:

Imperial Health Plan of California, Inc.
Attn: Appeals & Grievances
PO Box 60874
Pasadena, CA 91116

You can ask for a coverage decision and/or exception by calling us or completing our form:

If the Plan says no to your Coverage Determination or Exceptions request you have the right to request an appeal (redetermination) or a grievance.

There are two types of formal process for handling problems and concerns about prescription drugs, the Appeals Process and the Grievance Process:

You can request an Appeal (Redetermination) when a prescription drug was denied by the plan that the member believes he or she is entitled to receive. You have the right to ask us for a redetermination (appeal) of our coverage decision, this is considered a Level 1 Appeal. You or your representative must ask for an appeal in writing. If requested by a representative, there are additional steps necessary before the request can be processed (please see the AOR process below). You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. The plan will provide a response to your request no later than 7 calendar days from receipt date of your appeal request.

Expedited (Fast) Appeal

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision.  If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours.  If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision.  You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

Request For Redetermination of Medicare Prescription Drug Denial

Standard Grievance

If you are asking for a standard grievance regarding a complaint or dispute about a non-covered prescription drug or an excluded drug you can request this in any of the ways listed below. The plan will provide a response to you no later than 30 calendar days from receipt date of your grievance.

Expedited (Fast) Grievance

A fast complaint can be requested for the following reasons:

  • If we denied your request for a ‘fast coverage decision’ or a ‘fast appeal’, we will automatically give you the option to request a ‘fast complaint’.
  • If we have requested to take an additional 14 days to resolve your appeal or complaint, and you believe we should not take extra days, you can file a “fast complaint”.

If you have a “fast complaint” which meets the above criteria we will give you an answer within 24 hours.

Independent Review Organizations; also known as Independent Review Entity (IRE)

The IRE, MAXIMUS Federal Services, is an independent organization that is hired by Medicare (not the plan). If our plan denies your Level 1 Appeal, you then can choose whether to accept this decision or continue making another appeal. If you decide to go on to a Level 2 appeal, the IRE will review the plan’s decision when we said no to your first appeal. The IRE decides whether the decision we made should be changed.

Appointment of Representative Form

This form confirms your request for a person, other than yourself, to act as your representative in connection with an appeal of grievance (complaint) request and must be completed and received before the plan can process your request.

You can download the Appointment of Representative Form by clicking on your preferred language below.

Please complete your form and mail to:
Imperial Health Plan of California, Inc.
PO Box 60874
Pasadena, CA 91116

You may also fax your form to:
1-626-380-9049

If you or your providers have any questions regarding this process, while completing this form, or would like to get the status of an open case, please call our Member Services at: 1-800-838-8271.

You can also refer to Chapter 9 What to do if you have a problem of complaint (coverage decisions, appeals, complaints) in your Evidence of Coverage for more information about appeals and grievances.

Or visit the following Medicare websites for additional information on coverage determinations, exceptions and redeterminations.

If you or your providers have any questions regarding this process, while completing this form, or would like to get the status of an open case, please call our Member Services at: 1-800-838-8271.

If you would like information on how to obtain information about the total number of grievances, appeals, and exceptions filed with our plan, contact us for more information.

You can also file a complaint about the plan by going directly to Medicare and calling 1-800-Medicare or going to https://www.Medicare.gov/MedicareComplaintForm/home.aspx


2019 Transition Policy

 


Low Income Subsidy

The Low Income Subsidy (LIS) PDFs below will tell you how much help you will get next year towards your drug premium, deductible or co-payments.


Medication Therapy Management Program

 


2018 Pharmacy Directory

For an updated listing of pharmacies go to the pharmacy finder.

 


2018 Drug Formulary

In order to help you see which drug are covered by your plan, click on one of the links below.

English

Chinese

For an updated listing of the Drug Formulary go to the Drug Formulary search tool https://npsonline.pti-nps.com/onlinereports/cmsdforms/2018/cmsdFormularySearch.aspx?inpWebLinkKey=MTQxMw==

 


2018 Part D

Appeals and Grievances

Concerns about Prescription Drugs – Coverage Determinations

There are two types of formal process for handling problems and concerns about prescription drugs:

  1. Appeal – A prescription drug that was denied by the plan and the member believes he or she is entitled to receive. Example of prescription drugs but not limited to: Captopril, Metformin, Lipitor, Nexium, Plaix, etc. You have the right to ask us for a redetermination (appeal) of our coverage decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination by completing this form:

You may complete the Request for Redetermination of Medicare Prescription Drug Denial (Appeal).

Request for Redetermination of Medicare Prescription Drug Denial

You can also ask the plan for a Part D/Prescription exception.

What is a Part D/Prescription exception? If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” An exception is a type of coverage decision. If we turn down your request for an exception, you can appeal our coverage decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception to be approved. We will then consider your request. Here are three examples of exceptions that you or your doctor/other prescriber can ask us to make:

  • To cover a Part D drug for you that is not on our List of Covered Drugs (Formulary).
  • To remove a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary).
  • To reassign a drug to a lower cost-sharing tier. Every drug on the plan’s Drug List is in one of the cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug.

Important things to know about asking for exceptions Your doctor or other prescriber must give us a written request for exception that explains the medical reasons for requesting the exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

You can ask for a coverage decision and/or exception by calling us or by completing our form:

Learn more about coverage determinations and exceptions on the Centers for Medicaid and Medicare website.

You can also refer to Chapter 9 What to do if you have a problem of complaint (coverage decisions, appeals, complaints) of your Evidence of Coverage for more information about appeals and grievances.

Standard Appeal

If you are asking for a standard appeal, file your appeal in any of the ways listed below. You must make your appeal request within 60 calendar days from the date of the written coverage decision notice we sent denying your request for coverage. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. The plan will provide a response to you no later than 7 calendar days from receipt date of your appeal and additional information.

Expedited Appeal

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision.  If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours.  If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision.  You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

Standard Grievance
If you are asking for a standard grievance, file your grievance in any of the ways listed below. The plan will provide a response to you no later than 30 calendar days from receipt date of your grievance.

  1. Grievance – Any complaint or dispute about a non-covered prescription drug or excluded drugs.

You may request a coverage decision and/or exception and a grievance in any of the following ways:

Call us at 1-800-838-8271
Fax us at 1-626-380-9049
Email us at appealsgrievances@www.imperialhealthplan.com
Write to:

Imperial Health Plan of California, Inc.
Appeals and Grievances Dept.
PO Box 60874
Pasadena, CA 91116

Independent Review Organizations; also known as Independent Review Entity (IRE)

The IRE is an independent organization that is hired by Medicare (not the plan). If our plan denies your appeal, you then can choose whether to accept this decision or continue making another appeal. If you decide to go on to a Level 2 appeal, the IRE will review the plan’s decision when we said no to your first appeal. The IRE decides whether the decision we made should be changed.


2018 Transition Policy


2018 Low Income Subsidy

The Low Income Subsidy (LIS) PDFs below will tell you how much help you will get next year towards your drug premium, deductible or co-payments.

 


2018 Medication Therapy Management Program


2018 Part D Drug Tiers


To read PDFs, you will need Adobe Acrobat Reader. You can download here.