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Prescription Drug/Part D Information

Part D Prescription Drug Program 
We know that getting the medications you need is very important, having the right guidance and information can help you and your healthcare provider make the right decisions. Our Part D Prescription Drug Program is designed to provide you with the prescription drug and pharmacy information that other participants have found helpful as they plan for years of healthy living. At Centers Plan for Healthy Living (CPHL), we want to make your healthcare experience as easy as possible. We are available to help if you should have any questions or feedback on ways to enhance your membership. Please call or send us any comments you may have, so that we can continue to make CPHL one of the best programs available.

Coverage Determination & Redetermination

What is a coverage determination?
Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests.  You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal (an appeal is a formal way of asking us to review a decision made by your Interdisciplinary Team/IDT, Centers Plan for FIDA Care Complete, or an authorized specialist, and change it if you think a mistake was made) if we have not issued a coverage determination.  If you have problems getting the prescription drugs you believe we should provide, you can request a coverage determination. We use the word “provide” in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been getting.  If your doctor or pharmacist tells you that Centers Plan for FIDA Care Complete will not cover a prescription drug, you should contact us and ask for a coverage determination.

The following are examples of when you may want to ask us for a coverage determination:

  • If you are not getting a prescription drug that you believe may be covered by Centers Plan for FIDA Care Complete.
  • If you have received a Part D prescription drug you believe may be covered by Centers Plan for FIDA Care Complete while you were a Participant, but we have refused to pay for the drug.
  • If we will not provide or pay for a Part D prescription drug that your doctor has prescribed for you because it is not on our list of preferred drugs (also called a formulary). You can request an exception to our formulary.
  • If you disagree with the amount that we require you to pay for a Part D prescription drug that your doctor has prescribed for you. You can request an exception to the co-payment we require you to pay for a drug.
  • If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
  • If there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation.
  • If there is a requirement that you try another drug before we will pay for the drug you are requesting.
  • You bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense.


Who may ask for a coverage determination? 

You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement, Appointment of Representative, must be sent to our Pharmacy Benefit Manager (MedImpact) at:

 

MedImpact Healthcare Systems, Inc
Attention: Appeals/Grievance Department
10181 Scripps Gateway Ct
San Diego, CA 92131

Or you may fax it to them : 1- 858-790-6060
You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

 

Standard vs. Fast Coverage Determination 
Do you have a request for a Part D prescription drug that needs to be decided more quickly than the standard time frame? 
A decision about whether we will cover a Part D prescription drug can be a “standard” coverage determination that is made within the standard time frame (typically within 72 hours), or it can be a “fast” coverage determination that is made more quickly (typically within 24 hours). A fast decision is sometimes called an “expedited coverage determination.”  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 function. Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.

Standard Coverage Determination
To ask for a standard decision, you, your doctor or your appointed representative should call us at 1-888-266-7460, 7 days a week, from 8 am to 8 pm (for TTY, call 711 or 1-800-421-1220). Or, you can mail a written request, or completed Request for Coverage Determination Form to:

MedImpact Healthcare Systems, Inc
Attention: Appeals/Grievance Department
10181 Scripps Gateway Ct
San Diego, CA 92131

Or you may fax it to: 1- 858-790-6060

Fast Coverage Determination
You, your doctor or your appointed representative can ask us to give a fast decision (rather than a standard decision) by calling us at 1-888-266-7460, 7 days a week, from 8 am to 8 pm (for TTY, call 711 or 1-800-421-1220).  Or, you can mail a written request or completed Request for Coverage Determination Form to:

MedImpact Healthcare Systems, Inc
Attention: Appeals/Grievance Department
10181 Scripps Gateway Ct
San Diego, CA 92131

Or you may fax it to: 1- 858-790-6060

Be sure to ask for a “fast,” “expedited,” or “24-hour” review.
If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.
If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a grievance if you disagree with our decision to deny your request for a fast review.
If we deny your request for a fast coverage determination, we will give you our decision within the 72-hour standard time frame.
Certain drugs require supporting documentation from your physician (non-formulary and tiering exceptions, prior authorizations, step therapies, quantity limits). Your physician may use the available forms (or ANY other written forms) to assist in this process.

 

Forms
Centers Plan for FIDA Care Complete Coverage Determination Request Form – Last updated 3/8/2019

Centers Plan for FIDA Care Complete Coverage Redetermination Request Form – Last updated 3/8/2019

Medicare Prescription Drug Determination Request Form for Participants and Providers – Last updated 11/05/2014

Request for Prescription Information or Change – Provider Communication Form – Last updated 10/3/2016

Additional Medicare Appeals Forms are available on Medicare.gov, please visit:http://www.medicare.gov

For additional information on Coverage Determinations, Appeals and Grievances please see your Centers Plan for FIDA Care Complete Participant Handbook or call Participant Services a 1-800-466-2745. TTY users please call 1-800-421-1220.

Quality Assurance & Utilization Management Policies & Procedures

Programs to Help Participants use Drugs Safely
We conduct drug use reviews for our participants to help make sure that they are getting safe and appropriate care. These reviews are especially important for participants who have more than one provider who prescribes their drugs.  We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

  • Possible medication errors.
  • Drugs that may not be necessary because you are taking another drug to treat the same medical condition.
  • Drugs that may not be safe or appropriate because of your age or gender.
  • Certain combinations of drugs that could harm you if taken at the same time.
  • Prescriptions written for drugs that have ingredients you are allergic to.
  • Possible errors in the amount (dosage) of a drug you are taking.

If we see a possible problem in your use of medications, we will work with your doctor to correct the problem.

Centers Plan for FIDA Care Complete Disclaimers

Centers Plan FIDA Care Complete (Medicare-Medicaid Plan) is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

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Last modified: Nov 21, 2019