Part D: Coverage Determination and Appeals

This page provides you information on what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug.

Your benefits as a member of our plan include coverage for many prescription drugs. Most of these drugs are “Part D drugs.” There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover.

Can I ask for a coverage determination or make an appeal about Part D prescription drugs?

Yes. Here are examples of coverage determination you can ask us to make about your Part D drugs:

  • You ask us to make an exception such as:
    • Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary)
    • 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)
  • You ask us if a drug is covered for you (for example, when your drug is on the plan’s Formulary but we require you to get approval from us before we will cover it for you).
    • Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination.
  • You ask us to pay for a prescription drug you already bought. This is asking for a coverage determination about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.

What is an exception?
An exception is permission to get coverage for a drug that is not normally on our List of Covered Drugs, or to use the drug without certain rules and limitations. If a drug is not on our List of Covered Drugs, or is not covered in the way you would like, you can ask us to make an “exception.”

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception.

Here are examples of exceptions that you or your doctor or another prescriber can ask us to make:

  1. Covering a Part D drug that is not on our List of Covered Drugs (Formulary).
  2. Removing a restriction on our coverage. There are extra rules or restrictions that apply to certain drugs on our Formulary.
  • If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drugs in Tier 2 for brand name drugs or Tier 1 for generic drugs. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.
  • The extra rules and restrictions on coverage for certain drugs include:
  • Being required to use the generic version of a drug instead of the brand name drug.
  • Getting plan approval before we will agree to cover the drug for you. (This is sometimes called “prior authorization.”)
  • Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”)
  • Quantity limits. For some drugs, the plan limits the amount of the drug you can have.
  • If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug.

Important things to know about asking for exceptions
Your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception. Our decision about the exception will be faster if you include this information from your doctor or other prescriber when you ask for the exception.

Typically, our Formulary 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 asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception.

We will say Yes or No to your request for an exception

  • If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar 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.

Coverage Determination

What to do

  • Ask for the type of coverage determination you want. Call, write, or fax us to make your request. You, your representative, or your doctor (or other prescriber) can do this.  
    • You can call us at: 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY: 1-800-718-4347. 
    • You can fax us at: 1-909-890-5877 
    • You can to write us at: IEHP DualChoice, P.O. Box 1800, Rancho Cucamonga, CA 91729-1800.
  • You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage determination. You can also have a lawyer act on your behalf.
  • You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf.
  • If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the “supporting statement.”

Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement.

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.

Deadlines for a “standard coverage decision” about a drug you have not yet received

  • If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctor’s or prescriber’s supporting statement. We will give you our answer sooner if your health requires it.
  • If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review the decision.

If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctor’s or prescriber’s supporting statement. 

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision.

Deadlines for a “standard coverage determination” about payment for a drug you have already bought

  • We must give you our answer within 14 calendar days after we get your request.
  • If we do not meet this deadline, we will send your request to Level 2 of the appeals process. At level 2, an Independent Review Entity will review the decision.

If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. This statement will also explain how you can appeal our decision.

If your health requires it, ask us to give you a “fast coverage decision”
We will use the “standard deadlines” unless we have agreed to use the “fast deadlines.”

  • A standard coverage decision means we will give you an answer within 72 hours after we get your doctor’s statement.
  • A fast coverage decision means we will give you an answer within 24 hours after we get your doctor’s statement.
  • You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
  • You can get a fast coverage 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 coverage decision,” we will automatically agree to give you an fast coverage decision, and the letter will tell you that.

If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether you get a fast coverage decision.

If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. We will send you a letter telling you that. The letter will tell you how to make a complaint about our decision to give you a standard decision. You can file a “fast complaint” and get a response to your complaint within 24 hours. If we decide that your medical condition does not meet the requirements for an fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).

Deadlines for an “fast coverage decision”

  • If we are using the fast deadlines, we must give you our answer within 24 hours. This means within 24 hours after we get your request. Or, if you are asking for an exception, 24 hours after we get your doctor’s or prescriber’s statement supporting your request. We will give you our answer sooner if your health requires us to.
  • If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an outside independent organization will review your request and our decision.

If our answer is Yes to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctor’s or prescriber’s statement supporting your request.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision.

Level 1 Appeal for Part D drugs

To start your appeal, you, your doctor or other prescriber, or your representative must contact us.

  • If you are asking for a standard appeal, you can make your appeal by sending a request in writing. You may also ask for an appeal by calling 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.
  • If you want a fast appeal, you may make your appeal in writing or you may call us.
  • Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal.  For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal.
  • You can ask for a copy of the information in your appeal and add more information.
  • You have the right to ask us for a copy of the information about your appeal. 
  • If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

You may use the following form to submit an appeal:

Can someone else make the appeal for me?
Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The form gives the other person permission to act for you.

  • If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. 

 

Deadlines for a “standard appeal”

  • If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. If you think your health requires it, you should ask for a “fast appeal.”
  • If we do not give you a decision within 7 calendar days, we will send your request to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review our decision.

If your health requires it, ask for an “fast appeal”

  • If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.”
  • The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision.” 

Our plan will review your appeal and give you our decision

  • We take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said No to your request. We may contact you or your doctor or other prescriber to get more information.

Deadlines for an “fast appeal”

  • If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it.

If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No.

If our answer is Yes to part or all of what you asked for:

  • If we approve a request for coverage, we must give you the coverage as quickly as your health requires, but no later than 7 calendar days after we get your appeal.
  • If we approve a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get your appeal request.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No and tells how to appeal our decision.

Level 2 Appeal for Part D drugs

If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision.

If you want the Independent Review Organization to review your case, your appeal request must be in writing.  

  • Ask within 60 days of the decision you are appealing. If you miss the deadline for a good reason, you may still appeal.
  • You, your doctor or other prescriber, or your representative can request the Level 2 Appeal.

When you make an appeal to the Independent Review Entity, we will send them your case file. You have the right to ask us for a copy of your case file. You have a right to give the Independent Review Entity other information to support your appeal. The Independent Review Entity is an independent organization that is hired by Medicare. It is not connected with this plan and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. The organization will send you a letter explaining its decision.

If we uphold the denial after Redetermination, you have the right to request a Reconsideration. See form below:

Deadlines for a “fast appeal” at Level 2
If your health requires it, ask the Independent Review Entity for a “fast appeal.”

  • If the review organization agrees to give you a “fast appeal,” it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request.
  • If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 24 hours after we get the decision.

Deadlines for “standard appeal” at Level 2
If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal.

  • If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision.  
  • If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision.

What if the Independent Review Entity says No to your Level 2 Appeal?
No means the Independent Review Entity agrees with our decision not to approve your request. This is called “upholding the decision.” It is also called “turning down your appeal.”

If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. The Level 3 Appeal is handled by an administrative law judge.

For more information see Chapter 9 of your IEHP DualChoice Member Handbook.

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.

Information on this page is current as of September 30, 2017
H5355_CMC_18_668327 Approved