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Medicare Rx Benefit Information, including Part D

CCHP wants you to be satisfied with your Medicare Part D drug benefit. That means understanding how it works. Please review the following information.

• CCHP Senior Program (HMO)
• CCHP Senior Select Program (HMO SNP)
• Can the Formulary Change?
• Pharmacy Transition Policy and Process
• Drug Exceptions
• Part D Coverage Decisions
• Part D Appeal and Grievance
  
• Utilization Management Tools

CCHP Senior Program (HMO)

For Members with Medicare

Please click on the plan year tabs (2012) below for downloadable PDFs.

 

CCHP Senior Select Program (HMO SNP)

For Members with both Medi-Cal and Medicare

Please click on the plan year tabs (2012) below for downloadable PDFs.

 

The Formulary contains information on how it might be changed during the year

Can the Formulary change? Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a dug to a higher cost sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by the Plan call Member Services at 1-888-775-7888, 7 days a week from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call (877) 681-8898. In the event of a mid-year non-maintenance formulary change you can find the changes on our Web site at www.cchphmo.com.

Pharmacy Transition Policy and Process

If you are a new or current member, changes to the Drug List may affect your drug coverage. The plan can offer a temporary supply of the drug if any of the following types of changes affect a drug you are taking:

• Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.

• Move a drug to a higher or lower cost-sharing tier.

• Add or remove a restriction on coverage for a drug.

• Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the plan's Drug List.

If any of the following types of changes affect a drug you are taking, the change will not affect you until January 1 of the next year if you stay in the plan:

• If we move your drug into a higher cost-sharing tier.

• If we put a new restriction on your use of the drug.

• If we remove your drug from the Drug List, but not because of a sudden recall or because a new generic drug has replaced it.
  

If any of these changes happens for a drug you are taking, then the change won't affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won't see any increase in your payments or any added restriction to your use of the drug. However, on January 1 of the next year, the changes will affect you.

In some cases, you will be affected by the coverage change before January 1:

• If a brand name drug you are taking is replaced by a new generic drug, the plan must give you at least 60 days' notice or give you a 60-day refill of your brand name drug at a network pharmacy.

  - During this 60-day period, you should be working with your doctor to switch to the generic or to a different drug that we cover. - Or you and your doctor or other prescriber can ask the plan to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 9 of the Evidence of Coverage (EOC)

• Again, if a drug is suddenly recalled because it's been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away.

  - Your doctor will also know about this change, and can work with you to find another drug for your condition

If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of our rules for coverage.

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do. To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:

• The drug you have been taking is no longer on the plan's Drug List.
- or -
• the drug you have been taking is now restricted in some way.

2. You must be in one of the situations described below:

• For those members who were in the plan last year and aren't in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.

• For those members who are new to the plan and aren't in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.

• For those members who are new to the plan and reside in a long-term care facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.

• For those members who have been in the plan for more than 90 days and reside in a long-term care facility and need a supply right away: We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

In any of these circumstances, you should talk to your doctors to decide if you should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out of network. See Chapter 5 of your EOC for information about non-Part D drugs.

If Your Drug Is Not on the Drug List or Is Restricted (Exceptions)

If your drug is not on the Drug List or is restricted, here are things you can do:

• You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). For more information, see our Pharmacy Transition policy.

• You can change to another drug.

• You can request an exception and ask the Plan to cover the drug in the way you would like it to be covered.

If your drug is in a cost-sharing tier you think is too high, here are things you can do:

• You can change to another drug.

• You can file an exception.

Important things to know about asking for exceptions:

• Your doctor must tell us the medical reasons. Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an 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.

• Our Plan can say yes or no to your request. If we approve your request for an exception, our approval usually is valid until the end of the Plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. If we say no to your request for an exception, you can ask for a review of our decision by making an appeal.

For more information see Chapter 9, Section 6 in your Evidence of Coverage (EOC).

Part D Coverage Decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D drugs. Here are examples of coverage decisions you ask us to make about your Part D drugs. An initial coverage decision about your Part D drugs is called a "coverage determination."

• You ask us to make an exception, including:

  - Asking us to cover a Part D drug that is not on the Plan's List of Covered Drugs - Asking us to waive a restriction on the Plan's coverage for a drug (such as limits on the amount of the drug you can get)

  - Asking to pay a lower cost sharing amount for a covered non-preferred drug

• You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules.

• You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision. For more information, please refer to Chapter 9 in your Evidence of Coverage (EOC).

Step-by-step: How to ask for a Coverage Decision, Including an Exception

Step 1: You ask our plan to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a "fast decision." You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought.

Request the type of coverage decision you want. Start by calling, writing, or faxing our plan to make your request. You, your representative, or your doctor (or other prescriber) can do this.

You can call us at Member Services: 1-888-775-7888 (TTY/TDD 1-877-681-8898) 8:00 a.m. to 8:00 p.m., 7 days a week.

A written request may be made using this form.

The Medicare Part D Coverage Determination Request Form is not required to request a coverage decision. Our plan is required to accept any request that is made in writing (when made by a Member, a Member's prescribing physician or other prescriber, or a Member's appointed representative) and is prohibited from requiring a Member or physician, or other prescriber to make a written request on a specific form. The written request can be mailed, delivered in person, or faxed to:

Chinese Community Health Plan
445 Grant Ave., Suite 700
San Francisco, CA 94108

Fax: 415-397-2129

• If you want to ask our Plan to pay you back for a drug, see Chapter 7 in the EOC.

• If you are requesting an exception, provide the "doctor's statement," giving us the medical reasons for the drug exception you are requesting.

• When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard decision means we will give you an answer within 72 hours after we receive your doctor's statement. A fast decision means we will answer within 24 hours.

• To get a fast decision, you must meet two requirements: You can get a fast decision only if you are asking for a drug you have not yet received. You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought. You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

• If your doctor or other prescriber tells us that your health requires a "fast decision," we will automatically agree to give you a fast decision.

• If you ask for a fast decision on your own (without your doctor's or other prescriber's support), our Plan will decide whether your health requires that we give you a fast decision.

Step 2: Our plan considers your request and we give you our answer.

If we are using the fast deadlines, we must give you our answer within 24 hours.

• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor's statement supporting your request.

• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

If we are using the standard deadlines, we must give you our answer within 72 hours.

• If our answer is yes to part or all of what you requested—If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor's statement supporting your request.

• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Deadlines for a "standard" coverage decision about payment for a drug you have already bought, we must give you our answer within 14 calendar days after we receive your request.

• If our answer is yes to part or all of what you requested, we are aslo required to make payment to you within 14 calendar days after we receive your request.

• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 3: If we say no to your coverage request, you decide if you want to make an appeal.

If our Plan says no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider—and possibly change—the decision we made. For more information, please refer to Chapter 9 in your EOC.

Part D Appeal and Grievance

Drug Benefit Questions and Concerns

CCHP wants you to be satisfied with the services you receive. CCHP Member Services can help you resolve problems or issues you may have with your Medicare drug benefits. Please call CCHP Member Services at 415-834-2118 or 888-775-7888 (TTY/TDD users should call 877-681-8898) from 8:00 a.m. to 8:00 p.m., seven days a week whenever you have questions or concerns regarding your drug benefits. If Member Services cannot resolve your complaint over the phone, you may file an appeal or grievance.

Appeals Procedure

Please call CCHP Member Services 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 can file an appeal by using this form. You, your appointed representative, or your physician can request a fast appeal.

You may file a "standard" appeal orally by telephone, or in writing, by fax or mail. CCHP 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. CCHP will make a decision within 72 hours.

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. Member Services will answer your questions and guide you through the process. To file a fast appeal, you must call or fax your request to Member Services. To file a standard appeal, you may fax or mail your appeal.

You can visit us in person at:

Member Services
835 Jackson Street
San Francisco, CA 94133
Monday - Friday: 8:30 AM to 5:00 PM
Saturday: 9:00 AM to 5:00 PM

You can also call Member Services from 8:00 AM to 8:00 PM, 7 days a week.
Telephone: 1-415-834-2118
Toll-free Number: 1-888-775-7888
TTY: 1-877-681-8898
Fax: 415-397-2129

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. Member Services will answer your questions and guide you through the process.

CCHP must notify you of the 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. CCHP may extend the time frame by up to 14 calendar days if you request the extension, or if the Plan justifies a need for additional information and the delay is in your best interest. However, CCHP must respond to a grievance within 24 hours if: (1) the grievance involves a refusal by CCHP to grant your request for an expedited coverage determination or expedited redetermination, and (2) you have not yet purchased or received the drug that is in dispute.

Appointing A Representative

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 an appointment of representative form that gives the person legal permission to act as your appointed representative. If you need help completing the form, please call CCHP Member Services. In the alternative to this form, you can also provide CCHP with other appropriate legal documents supporting his or her status as your authorized representative.

Utilization Management Tools

For some prescription medications, Chinese Community Health Plan has particular requirements or limits on provision of coverage. These Utilization Management tools are commonly known as Prior Authorization, Step Therapy and Quantity Limits. These limits help ensure that our members utilize their medications in the most effective way according to clinical standards of care and economic concerns. A team of physicians and pharmacists developed these guidelines for our Plan, in conjunction with our Pharmacy Benefits Manager in order to provide the highest quality care to our members. Please consult your copy of the formulary or the formulary section on the website for additional information regarding these Utilization Management Tools.

Member Services Department

You can visit us in person at:

Member Services
835 Jackson Street
San Francisco, CA 94133
Monday - Friday: 8:30 AM to 5:00 PM
Saturday: 9:00 AM to 5:00 PM

You can also call Member Services from 8:00 AM to 8:00 PM, 7 days a week.
Telephone: 1-415-834-2118
Toll-free Number: 1-888-775-7888
TTY: 1-877-681-8898
Fax: 415-397-2129

CMS Website Best Available Evidence Policy Page