Drug Benefit Information - CCHP Senior Program
For Members with Medicare
CCHP wants you to be satisfied with your Medicare Part D drug benefit. That means understanding how it works. Please review the following information.
- List of Covered Drugs (Formulary) (PDF)
- Pharmacy Directory (PDF)
- Member Satisfaction Procedures
- Requesting Coverage Determinations
- Requesting Exceptions to the Formulary
- Appeals Procedure
- Where to File Drug Benefit Appeals
- Grievance Procedure
- Where to File Drug Benefit Grievances
Member Satisfaction Procedures
CCHP wants you to be satisfied with the services you receive. For this reason, we have appointed Express Scripts, our pharmacy management company, to resolve any problems or issues with your Medicare drug benefits. Please call CCHP Member Services whenever you have questions or concerns regarding your drug benefits. We will answer your questions and, if necessary, we will help you contact Express Scripts. You may also contact Express Scripts directly at the telephone numbers and addresses listed below.
| Who to Contact: | CCHP Member Services |
| Telephone: | 415-834-2118 |
| TDD/TTY: | 1-877-681-8888 |
We will attempt to resolve any concerns or complaints over the phone. If you request a written response to your phone complaint, Express Scripts will respond to you in writing. If Express Scripts cannot resolve your complaint over the phone, they will begin a formal review of your complaint. Depending on the type of complaint, it will be handled by Express Scripts as a coverage determination, a grievance, or an appeal in accordance with CMS guidelines and CCHP procedures as summarized below.
If you need assistance with these procedures, you can have someone act as your appointed representative. If you name an appointed representative, both you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. Click here to download an appointment of representative form (PDF). If you need help completing the form, please call CCHP Member Services.
For more detail about coverage determinations, grievances and appeals procedures, please read Section 12 of your CCHP Senior Program Evidence of Coverage (PDF).
Requesting Coverage Determinations
A coverage determination is the process by which CCHP decides to provide or pay for a Medicare Part D drug. You should use this process for requesting an exception to the Formulary.
We will make timely decisions when you ask us to cover a Medicare Part D prescription drug. A coverage determination is handled according to your health status.
A decision about whether we will cover a Part D prescription drug can be:
- A "standard decision" made within the standard time frame (typically within 72 hours), or
- A "fast decision" made more quickly (typically within 24 hours).
You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to regain maximum function.
To request a standard or fast coverage determination, call CCHP Member Services. We can help you contact Express Scripts, or you may contact Express Scripts directly at the telephone numbers and addresses listed below. You may also complete a Coverage Determination Request Form and give it to your doctor. Your doctor will complete the remainder of the form and submit it to Express Scripts by fax. The telephone number for oral requests is 1-800-417-8164, option 2 for CCHP Members.
| Who to Contact: | CCHP Member Services or Express Scripts |
| Telephone: | 1-800-417-8164, Option 2 |
| TDD/TTY: | 1-800-899-2114 |
| Fax: | 1-877-837-5922 |
| Mail: | Express Scripts, Inc Attention: Prior Authorization - Part D Mail Route: BL0345 6625 West 78th Street Bloomington, MN 55439 |
Requesting an Exception to the Formulary
You can ask us to do any of the following:
- Make an exception to our coverage rules.
- Cover your drug even if it is not on our formulary.
- Waive coverage restrictions or limits on your drug.
- Provide a medication at a lower copayment level.
Please refer to Section 6 of your Evidence of Coverage for detailed information regarding exceptions.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary, the generic drugs, or additional utilization restrictions would not be as effective in treating your condition and/or would cause adverse medical effects.
To request an exception, call CCHP Member Services. We will answer your questions, guide you through the process, and, if necessary, help you contact Express Scripts. The coverage determination process includes requests for exceptions.
Appeals Procedure
An appeal is the type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered or what we will pay for a service.
Please call CCHP Member Services or Express Scripts if you disagree with a decision and you want to file an appeal. You have the right to appeal a decision within 60 days from the date of the denial notice (unless you show good cause for a delay past 60 days).
You may file a "standard" appeal orally by telephone, or in writing, by fax or mail.
Express Scripts will make a decision within 7 days after receiving your appeal. You may ask for a "fast" appeal if waiting for a standard decision could seriously harm your health or your ability to regain maximum function. Express Scripts will make a decision within 72 hours. You, your appointed representative, or your physician can request a fast appeal.
Where to file Drug Benefit Appeals
To file an appeal, ask questions about the process, or to check on the status of an appeal you have filed, call CCHP Member Services. We will answer your questions, guide you through the process, and, if necessary, help you contact Express Scripts. You may also contact Express Scripts directly at the telephone numbers and addresses listed below. To file a fast appeal, you must call or fax your request to Express Scripts using the phone numbers provided below. To file a standard appeal, you may call, fax or mail your appeal.
| Who to Contact: | CCHP Member Services or Express Scripts |
| Telephone: | 1-800-344-3405 |
| TDD/TTY: | 1-877-486-2048 |
| Fax: | 1-877-852-4070 |
| Mail: | Express Scripts, Inc Attention: Pharmacy Appeals-Part D Mail Route: BL0390 6625 West 78th Street Bloomington, MN 55439 |
Grievances
A grievance is any complaint that expresses dissatisfaction with the care or service you receive from CCHP, a CCHP provider, one of our network pharmacies, or Express Scripts.
Where to File Drug Benefit Grievances
You may file a grievance orally by telephone, or in writing by fax or mail. To file a grievance, ask questions about the process, or to check on the status of a grievance you have filed, call CCHP Member Services. We will answer your questions, guide you through the process, and, if necessary, help you contact Express Scripts. You may also contact Express Scripts directly at the telephone numbers and addresses listed below.
We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
| Who to Contact: | CCHP Member Services or Express Scripts |
| Telephone: | 1-866-533-8512 |
| TDD/TTY: | 1-800-899-2114 |
| Fax: | 1-877-305-1686 |
| Mail: | Express Scripts, Inc Attention: Director of Grievances PO Box 66517 Saint Louis, MO 63166-6517 |
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