2017 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 Physicians 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 sixty (60) calendar 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.
Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the Formulary. For example, the plan might:
- Add or remove drugs from the Formulary. 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, for more information about restrictions to coverage, see Chapter 5 of your IEHP DualChoice Member Handbook. 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 Formulary. If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time.
Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for other reasons. If this happens, 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 sixty (60) calendar 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 to Chapter 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. The notice must be copied for distribution to the member or posted in the pharmacy for viewing beginning January 1, 2006.
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 January 4, 2017