What Prescription Drugs Does IEHP DualChoice Cover?
IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) has a List of Covered Drugs called a Formulary. It tells which Part D prescription drugs are covered by IEHP DualChoice. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the IEHP DualChoice Formulary.
Find a covered drug below:
If your drug is not on the list, you may still be able to get it. Call IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am - 8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347.
Changes to the IEHP DualChoice Formulary
IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). IEHP DualChoice develops and maintains the Formulary continuously by reviewing the efficacy (how effective) and safety (how safe) of new drugs, compare new versus existing drugs, and develops clinical practice guidelines based on clinical evidence.
From time to time (during the benefit year), IEHP DualChoice revises (adding or removing drugs) the Formulary based on new clinical evidence and availability of products in the market. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice.
IEHP DualChoice will give notice to IEHP DualChoice Members prior to removing Part D drug from the Part D formulary. We will also give notice if there are any changes regarding prior authorizations, quantity limits, step therapy or moving a drug to a higher cost-sharing tier.
If IEHP DualChoice removes a Covered Part D drug or makes any changes in the IEHP DualChoice Formulary, we will post the formulary changes on IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. However, if the Food and Drug Administration (FDA) 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.
In some cases, you will be affected by the coverage change before January 1:
Some changes to the Drug List will happen immediately. For example:
- A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower.
When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.
- We may not tell you before we make this change, but we will send you information about the specific change or changes we made.
- You or your provider can ask for an “exception” from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]) of the Member Handbook for more information on exceptions.
- A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Your provider will also know about this change. He or she can work with you to find another drug for your condition.
We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:
- The FDA provides new guidance or there are new clinical guidelines about a drug.
- We add a generic drug that is not new to the market and
- Replace a brand name drug currently on the Drug List or
- Change the coverage rules or limits for the brand name drug.
When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:
- Get a 31-day supply of the drug before the change to the Drug List is made, or
- Ask for an exception from these changes. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]).
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 Formulary. 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.
How will you find out if your drugs coverage has been changed?
If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. However, if the Food and Drug Administration (FDA) 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.
For information on changes to the Formulary go to Pharmacy Transition Policy and Process.
Getting Plan Approval
For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. For additional information on step therapy and quantity limits, refer toChapter 5 of the IEHP DualChoice Member Handbook. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization.
These forms are also available on the CMS website:
Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). By clicking on this link, you will be leaving the IEHP DualChoice website.
Applicable Conditions and limitations
We will generally cover a drug on the plan’s Formulary as long as you follow the other coverage rules explained in Chapter 6 of the IEHP DualChoice Member Handbook and the drug is medically necessary, meaning reasonable and necessary for treatment of your injury or illness. It also needs to be an accepted treatment for your medical condition.
Here are three general rules about drugs that Medicare drug plans will not cover under Part D:
- Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.
- Our plan cannot cover a drug purchased outside the United States and its territories.
- Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.
For more information refer to Chapter 6 of your IEHP DualChoice Member Handbook.
Medicare Prescription Drug Coverage and Your Rights Notice- Posting of Member Drug Coverage Rights:
Medicare requires pharmacies to provide notice to enrollees each time a member is denied coverage or disagrees with cost-sharing information.
You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. Read your Medicare Member Drug Coverage Rights.
IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations, copays and restrictions may apply. Copays for prescription drugs may vary based on the level of Extra Help you receive. Benefits and copayments may change on January 1 of each year. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook.
Information on this page is current as of October 15, 2018.