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Information provided for CommuniCare Advantage (HMO-SNP)
Part D Special Needs Prescription Drug program is for 2012. It is intended to be a summary
of the plan. If you need a complete explanation of benefits, services and costs associated
with this plan please refer to your 2012 Evidence of Coverage (EOC).
Best Available Evidence
To access the CMS “Best Available Evidence Policy”, please click on the following link. You will be directed to the CMS Website.
http://www.cms.hhs.gov/PrescriptionDrugCovContra/
17_Best_Available_Evidence_Policy.asp#TopOfPage
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Medicare Part D Formulary
CommuniCare Advantage (HMO-SNP) will cover the drugs listed in our formulary as long as the drug meets the following criteria:
- Medically necessary
- it is filled at a network pharmacy, or
- filled through our network mail-order-pharmacy service, and
- all coverage rules are followed.
There are additional requirements for coverage or limits on CommuniCare Advantage (HMO-SNP)
coverage for both brand-name drugs and generic drugs are included on the formulary. Please refer to your formulary
to review the requirements.
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What drugs are on the formulary?
If you need a copy of the drug formulary, please call Member Services. To find out if your drug is
on the formulary. Please click on the Formulary/Medication listing to view the additional information
regarding CommuniCare Advantage (HMO-SNP) Formulary. The first part of this formulary booklet tells you
how to find a drug on our most recent formulary list.
Click on the following link to access the most recent Formulary/Medication Listing effective
02/01/2012.
Formulary Changes
CommuniCare Advantage (HMO-SNP) may make changes to our formulary during
the year. Some of the changes may affect covered drugs and how much you will pay when filling your prescription.
The following includes
changes that may occur in CommuniCare Advantage (HMO-SNP) formulary:
- Removing or adding drugs from the formulary
- Requiring prior authorizations, changes to quantity limits, and/or step-therapy restrictions on a specific drug
- Moving a drug to a higher or lower cost-sharing tier
What if your drug isn't on the formulary?
If you cannot locate your prescription in CommuniCare Advantage (HMO-SNP)
formulary, please call Member Services to be sure it isn't covered. Once Member Services has confirmed that your
drug is not covered, you have the following options:
- You can request your doctor to change you to another drug that is covered in our formulary.
- You can request CommuniCare Advantage (HMO-SNP) to make an exception to cover your drug.
- You may chose to pay out-of-pocket for the drug and request that
CommuniCare Advantage (HMO-SNP) reimburse you by requesting an exception.
Please note that this doesn’t mean that CommuniCare Advantage (HMO-SNP) will reimburse you if the exception request isn't approved. You may
appeal the Plan’s denial, If the exception isn't granted.
Drug Transition Policy
As a new member to CommuniCare Advantage (HMO-SNP) you may be taking drugs that are not covered
by our plan or may have certain restrictions. These may require prior authorization or step
therapy. Existing members may be impacted by changes in our formulary from one year to the
next. Please review CommuniCare Advantage (HMO-SNP) Drug Transition Policy, by clicking on the
following link:
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Part D program
In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies,
these are pharmacies that contract with CommuniCare Advantage (HMO-SNP) to provide your covered prescription
drugs. There are some retail pharmacies in CommuniCare Advantage (HMO-SNP) where you can obtain an extended
supply of all medications.
To locate a retail pharmacy in CommuniCare Advantage (HMO-SNP) network,
please call Member Services or review the pharmacy listing.
(CommuniCare Advantage (HMO-SNP) Plan has contracts with 400 pharmacies that equal or exceed Medicare requirements for pharmacy
access in the Plan's approved service area).
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Filling prescriptions outside the network
In most cases CommuniCare Advantage (HMO-SNP) only covers
drugs filled
at an out-of-network pharmacy when a network pharmacy is not available or in case of an emergency.
If you fill your prescription at an out-of-network pharmacy, you may be responsible for paying the
full cost of the prescription. You may request CommuniCare Advantage (HMO-SNP) to reimburse you for your share of the cost by submitting a claim form to the following
address:
(CommuniCare Advantage (HMO-SNP)
Attention: Pharmacy & Formulary
740 Bay Boulevard
Chula Vista, CA 91910
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Mail Order Pharmacy Service
You may obtain maintenance medications through CommuniCare Advantage (HMO-SNP) mail-order-pharmacy service. These are prescription drugs that you take on a regular
basis for a chronic or long-term medical condition. Please note that these are the only drugs available
through our mail-order service.
When you order prescription drugs through CommuniCare Advantage (HMO-SNP) mail-order-pharmacy service, you must order at least a 31-day supply, and no more than a 90-day
supply of the drug. Generally, it takes the mail-order pharmacy 14 days to process your order and ship it
to you.
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Utilization Management (UM) & Quality Assurance UM
There are certain prescription drugs that CommuniCare Advantage (HMO-SNP) may have additional requirements
for coverage or limits. These requirements and limits ensure that CommuniCare Advantage (HMO-SNP)
members use these drugs in the most effective way. These requirements and limits were developed for CommuniCare Advantage (HMO-SNP) by a team of doctors and/or pharmacists. These requirements were developed to
assist us to provide quality coverage to our members.
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The requirements for coverage or limits on certain drugs are listed as follows:
Prior Authorization: CommuniCare Advantage (HMO-SNP) requires you
to obtain prior authorization for certain drugs. Authorized providers will need to obtain approval
from CommuniCare Advantage (HMO-SNP) before filling your prescription.
Your prescription drug may not be covered if prior approval is not obtained from the plan. Please click
on the following link to access CommuniCare Advantage (HMO-SNP) Part D
Prior Authorization Criteria:
Medicare Part B or Part D may cover some prescription drugs depending on the circumstances. Before making
a determination, information may need to be submitted describing the use and setting of the prescription
drug. Please click on the following link to view a list of the drugs:
Quantity Limits: CommuniCare Advantage (HMO-SNP) has limits in the amount for prescription drugs that
we cover or a defined period of time. CommuniCare Advantage (HMO-SNP) will provide up to 31 tablets per
defined prescription period, quantity limits are noted within the formulary.
Step Therapy: In some cases, CommuniCare Advantage (HMO-SNP) requires 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, CommuniCare Advantage (HMO-SNP) 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, CommuniCare Advantage (HMO-SNP) network pharmacies will automatically give you the generic version, unless your doctor has requested the brand name drug and
we have approved this request.
Please call Member Services if you need to find out if the drug you take is subject to these additional
requirements or limits. 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, your physician, or other prescriber may request an exception (coverage determination). See
your Evidence of Coverage (EOC) for more information about how to request an exception.
Quality Assurance
CommuniCare Advantage (HMO-SNP) conducts drug utilization reviews for all of
our members to determine you are getting safe and appropriate care. These reviews are especially important
for members who have more than one doctor who prescribe their medications. These are conducted each time you
fill a prescription and on a regular basis by reviewing CommuniCare Advantage (HMO-SNP)
records. During these reviews, CommuniCare Advantage (HMO-SNP) looks for
the following medication red flags or problems:
- 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 CommuniCare Advantage (HMO-SNP) identifies a medication red
flag or problem during our drug utilization review, we will work with your doctor, or other prescriber
to correct it.
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Medication Therapy Management (MTM) Programs
CommuniCare Advantage (HMO-SNP) offers medication therapy management programs at no additional cost to members
who have multiple medical conditions and, who are taking many prescription drugs. These programs were developed for CommuniCare Advantage (HMO-SNP) by a team of pharmacists and doctors. These
medication therapy management programs assist CommuniCare Advantage (HMO-SNP)
to provide better coverage for our members.
For example, these programs help us make sure that our members are using appropriate drugs to treat their
medical conditions and help us identify possible medication errors. CommuniCare Advantage (HMO-SNP) may
contact members who qualify for these programs.
If we contact you, we hope you will join the program 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 CommuniCare Advantage (HMO-SNP) will send you information about the program
and how the program can be accessed.
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Appointment of Representative
You have the option to appoint a representative to act on your behalf and request a coverage determination,
formulary exception, grievance and/or an appeal.
You can name a relative, friend, advocate, doctor, or someone else to act for you. If you want to name someone to act on your behalf, you and the person you would like to act on your behalf must fill out the, "Appointment of Representative" form. When completed, this form allows this person legal permission to act as your authorized representative. Please click on the following link to access CMS' Appointment of Representative Form (Form CMS -1696);
The completed form should be faxed, mailed, or delivered in person to:
CommuniCare Advantage (HMO-SNP)
Attention: Pharmacy & Formulary
740 Bay Boulevard
Chula Vista, CA 91910
Or fax to (619) 425-5348
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Drug Coverage Determinations
You, your representative acting on your behalf, your prescribing physician, or other prescriber can request a standard or fast coverage determination. A written request may be made by printing one of the forms below:
The completed form should be faxed, mailed, or delivered in person to :
CommuniCare Advantage (HMO-SNP)
Attention: Pharmacy & Formulary
740 Bay Boulevard
Chula Vista, CA 91910
Or fax to (858) 621-5147
For a fast decision call our Member Services Department at 1-888-244-4430 (TTY 1-800-735-2929).
CommuniCare Advantage (HMO-SNP) Plan representatives
are available 24 hours a day, 7 days a week, including holidays.
CommuniCare Advantage (HMO-SNP) will make timely decisions when you ask us to cover a Medicare Part D
prescription drug. A decision about whether CommuniCare Advantage (HMO-SNP) will cover a Part D
prescription drug can be:
- A "standard decision" that is made with the standard time frame (typically within 72 hours)
- A "fast decision" that is made more quickly (typically within 24 hours)
You can ask for a fast decision only if you, your doctor, or other prescriber believe that waiting for a
standard decision could 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 have already received.
If we tell you about CommuniCare Advantage (HMO-SNP) decision not to
provide a "fast" review by phone, you can request an expedited grievance at that time if you disagree.
CommuniCare Advantage (HMO-SNP) will send you a letter explaining our decision within three calendar days
after we call you. The letter will also tell you how to file a "grievance" if you disagree with CommuniCare Advantage (HMO-SNP) decision to deny your request for a "fast" review, and will explain that
CommuniCare Advantage (HMO-SNP) will automatically give you a fast decision if you get a doctor's, or other prescriber's
explanation.
Please refer to Section 5 of CommuniCare Advantage (HMO-SNP) 2010
Evidence of Coverage Booklet for more details about this process
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Grievances and Appeals
CommuniCare Advantage (HMO-SNP) Plan provides an appeals
and grievance process for our members to ensure you get answers to any concerns or problems
you may encounter. You may also reference the "Complaints and Appeals" Section of the
Evidence of Coverage (EOC) 2012
for additional detail regarding Grievances and Appeals.
GRIEVANCES
A grievance is a type of complaint you make if you are dissatisfied with CommuniCare Advantage (HMO-SNP) or our
contracted providers for reasons other than a coverage decision. Grievances do not involve problems related
to approving or paying for Part D drugs. You or your appointed representative may file a grievance within
60 days of the event or incident. You may file a grievance by contacting the CommuniCare Advantage (HMO-SNP)
Member Services Department toll free at 1-888-244-4430 (TTY 1-800-735-2929). CommuniCare Advantage (HMO-SNP)
Plan representatives are available 24 hours a day, 7 days a week, including holidays. You may opt to submit
your Grievance in a letter and send it directly to CommuniCare Advantage (HMO-SNP) Plan at the following address:
CommuniCare Advantage (HMO-SNP)
Attention: Grievance & Appeals Coordinator
740 Bay Boulevard
Chula Vista, CA 91910
Or fax to (619) 425-5348
You will receive a written letter telling you that CommuniCare Advantage (HMO-SNP) Plan received your
grievance, and the estimated time for a written response. A written resolution letter will be mailed to you within
thirty (30) days of CommuniCare Advantage (HMO-SNP) Plan receiving your grievance.
For questions about the status of your grievance, call Member Services Department at
1-888-244-4430 (TTY 1-800-735-2929). CommuniCare Advantage (HMO-SNP) Plan representatives are available
24 hours a day, 7 days a week, including holidays.
For additional information regarding CommuniCare Advantage (HMO-SNP)
grievance process, please see Section 4 of your EOC
APPEALS
As a member, you can file an appeal if CommuniCare Advantage (HMO-SNP)
Plan made a decision to not pay for,
not approve, or stop a service you think should be covered or provided to you. This could include denials
for drugs or involving payment for services (including co-payments and billing issues or reimbursement)
you received or believe you should receive under the CommuniCare Advantage (HMO-SNP)
pharmacy program. You,
your prescribing physician or other prescriber acting on your behalf and upon providing notice to you,
or your appointed representative must file a written request for appeal within sixty (60) calendar days
from the date of the notice of the coverage determination (i.e., the date printed or written on the
notice).
You must send your appeal in writing to:
CommuniCare Advantage (HMO-SNP)
Attention: Grievance & Appeals Coordinator
740 Bay Boulevard
Chula Vista, CA 91910
CommuniCare Advantage (HMO-SNP) will review your appeal and respond to you in writing advising you of our decision
within seven (7) days of receiving your appeal request. If you think your health could be seriously harmed
by waiting for a decision about the drug, you, your prescribing physician or other prescriber can request
a faster decision which is issued within 72 hours of receiving your appeal.
In both cases, you will receive a written notice of the outcome of your appeal, which will include any
additional appeal rights which include an independent review entity; hearings before an Administrative Law
Judge, review by the Medicare Appeals Council, and Judicial Review.
For questions about the status of your appeal, or to obtain an aggregate number of grievances,
appeals and exceptions filed with CommuniCare Advantage (HMO-SNP) Plan for our Medicare Advantage
Special Needs Plan, contact the Member Services Department at 1-888-244-4430 (TTY 1-800-735-2929).
CommuniCare Advantage (HMO-SNP) Plan representatives are available 24 hours a day, 7 days a week,
including holidays.
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Low Income Subsidy Information
Members who qualify for CommuniCare Advantage (HMO-SNP)
Special Needs Plan have
Medicare and Full-Scope Medi-Cal. By qualifying for Medi-Cal, you also qualify
for "Extra Help" with your Prescription Drug Coverage through Medicare Part D. This
"Extra Help" is also called the Low Income Subsidy. Qualifying for this subsidy
means you have no Part D premium under CommuniCare Advantage (HMO-SNP)
Special Needs Plan. For more information, please click on the following link:
In addition, you typically pay the following co-pays for drugs:
- If the amounts paid by you and or others on your behalf are less than $2,930, you pay:
- $0 for Generic Drugs and $3.30/$6.50 for Single Source and Multi-Source Brand Drugs.
OOnce the amounts paid by you and/or others on your behalf reach $2,930, you will continue paying
$1.10 or $2.60 for generic drugs. Once the amounts paid by you and/or others on your
behalf reach $4,700 in a year, your co-payment amount(s) will go down to $0 for all drugs.
Members of CommuniCare Advantage (HMO-SNP) Medicare Advantage Special Needs Plan receive
the Low Income Subsidy information in an attachment to their Evidence of Coverage,
called the Low Income Subsidy Rider, upon enrollment and each following year.
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