hat means understanding how it works and that both CCHP Senior Program (HMO), CCHP Senior Value Program (HMO), and CCHP Senior Select Program (HMO SNP) have contracts with pharmacies that equal or exceed CMS (Centers for Medicare and Medicaid Services) requirements for pharmacy access in your area.
Last Edited: 7/13/2023
What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
If you chose this plan because you were looking for insulin coverage at $35 a month or less, it is important to know that you may have other options available to you for 2023 at even lower costs because of changes to the Medicare Part D program. Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week for help comparing your options. TTY users should call 1-877-486-2048.
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year.
We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. If the Food and Drug Administration 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 and provide notice to members who take the drug.
To get updated information about the drugs covered by the Plan, contact our Member Services.
If we make any mid-year non-maintenance changes to the formulary, we will send an errata sheet to you. You can also find the changes on our Website.
If you are a new or current member, changes to the formulary may affect your drug coverage. The plan can offer a temporary supply of the drug if any of the following types of changes affect a drug you are taking:
In almost all cases, we must get approval from Medicare for changes we make to the plan’s formulary.
If any of the following types of changes affect a drug you are taking, the change will not affect you until January 1 of the next year if you stay in the plan:
If any of these changes happens for a drug you are taking, then the change won’t affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any increase in your payments or any added restriction to your use of the drug. However, on January 1 of the next year, the changes will affect you.
In some cases, you will be affected by the coverage change before January 1:
If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of our rules for coverage.
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the formulary or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
In any of these circumstances, you should talk to your doctors to decide if you should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug.
Please note that our transition policy applies only to those drugs that are “Part D drugs” and bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out of network. See Chapter 5 of your Evidence of Coverage for information about non-Part D drugs.
If your drug is not on the formulary or is restricted, here are things you can do:
A written request may be made using the Prescription Drug Prior Authorization or Step Therapy Exception Request Form.
If your drug is in a cost-sharing tier you think is too high, here are things you can do:
For more information see Chapter 9 in your Evidence of Coverage (EOC).
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D drugs.
Here are examples of coverage decisions you ask us to make about your Part D drugs. An initial coverage decision about your Part D drugs is called a “coverage determination.”
If you disagree with a coverage decision we have made, you can appeal our decision. For more information, please refer to Chapter 9 in your Evidence of Coverage (EOC).
Step-by-step: How to ask for a Coverage Decision, Including an Exception
Step 1: You ask our plan to make a coverage decision about the drug(s) or payment you need.
If your health requires a quick response, you must ask us to make a “fast decision.” You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought.
Request the type of coverage decision you want. Start by calling, writing, or faxing our plan to make your request. You, your representative, or your doctor (or other prescriber) can do this.
You can contact our Member Services.
A written request may be made using the Medicare Prescription Drug Coverage Determination Request Form.
The Medicare Part D Coverage Determination Request Form is not required to request a coverage decision. Our plan is required to accept any request that is made in writing (when made by a Member, a Member’s prescribing physician or other prescriber, or a Member’s appointed representative) and is prohibited from requiring a Member or physician, or other prescriber to make a written request on a specific form.
The written request can be mailed, delivered in person, CCHP, 445 Grant Avenue, San Francisco, CA 94108 or faxed to: 1-415-397-2129.
Step 2: Our plan considers your request and we give you our answer.
If we are using the fast deadlines, we must give you our answer within 24 hours.
If we are using the standard deadlines, we must give you our answer within 72 hours.
Deadlines for a “standard” coverage decision about payment for a drug you have already bought–We must give you our answer within 14 calendar days after we receive your request.
Step 3: If we say no to your coverage request, you decide if you want to make an appeal.
If our Plan says no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider—and possibly change—the decision we made. For more information, please refer to Chapter 9 in your Evidence of Coverage.
Drug Benefit Questions and Concerns
CCHP wants you to be satisfied with the services you receive. We can help you resolve problems or issues you may have with your Medicare drug benefits. Please contact our Member Services whenever you have questions or concerns regarding your drug benefits. If our Member Services staff cannot resolve your complaint over the phone, you may file an appeal or a grievance. If you would like to obtain an aggregate number of grievances, appeals, and exceptions that have been filed with CCHP, please contact our Member Services Center by writing or calling.
Appeals Procedure
Please call our CCHP Member Services Center if you disagree with a decision and you want to file an appeal. You have the right to appeal a decision within 60 days from the date of the denial notice (unless you show good cause for a delay past 60 days). You can file an appeal by using this Request for Redetermination of Medicare Prescription Drug Denial Form. However, the use of this form is not required. You, your appointed representative, or your physician can request a fast appeal.
You may file a “standard” appeal orally by telephone, or in writing, by fax or mail. CCHP will make a decision within 7 days after receiving your appeal.
You may ask for a “fast” appeal if waiting for a standard decision could seriously harm your health or your ability to regain maximum function. CCHP will make a decision within 72 hours.
Where to file Drug Benefit Appeals
To file an appeal, to ask questions about the process, or to check on the status of an appeal you have filed, call our Member Services Center. Our Member Services staff will answer your questions and guide you through the process. To file a fast appeal, you must call, send or fax your request to the Member Services Center. To file a standard appeal, you may fax or mail your appeal.
Where to File Drug Benefit Grievances
You may file a grievance orally by telephone or in writing by fax or mail. To file a grievance, to ask questions about the process, or to check on the status of a grievance you have filed, call our Member Services Center. Our Member Services staff will answer your questions and guide you through the process.
CCHP must notify you of the decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance. CCHP may extend the time frame by up to 14 calendar days if you request the extension, or if the Plan justifies a need for additional information and the delay is in your best interest. However, CCHP must respond to a grievance within 24 hours if: (1) the grievance involves a refusal by CCHP to grant your request for an expedited coverage determination or expedited redetermination, and (2) you have not yet purchased or received the drug that is in dispute.
Appointing A Representative
If you need assistance with these procedures, you can have someone act as your appointed representative. If you name an appointed representative, you may use the Appointment of Representative Form. Both you and that person must sign and date an appointment of representative form that gives the person legal permission to act as your appointed representative. If you need help completing the form, please call our Member Services Center. As an alternative to this form, you can also provide CCHP with other appropriate legal documents supporting his or her status as your authorized representative
CCHP has quality assurance programs that are designed to lower medication errors, harmful drug interactions, and improve medication use. These programs include reviews of past and current prescription claims to make sure our members are on the right medications and are taking them safely.
The goal of these programs is to provide you with quality prescription coverage while reducing any possible health risks to you. CCHP has the following quality assurance programs:
For some prescription medications, CCHP has particular requirements or limits on provision of coverage. These Utilization Management tools are commonly known as Prior Authorization, Step Therapy and Quantity Limits. These limits help ensure that our members utilize their medications in the most effective way according to clinical standards of care and economic concerns. A team of physicians and pharmacists developed these guidelines for our Plan, in conjunction with our Pharmacy Benefits Manager in order to provide the highest quality care to our members. Please consult your copy of the formulary or the formulary section on the website for additional information regarding these Utilization Management Tools.
Drug Benefit Questions and Concerns
The Medicare Plan Finder is a tool to compare coverage options. It includes a feature that allows prospective enrollees to view estimated drug costs across plans when a list of prescription drugs is entered. In support of this feature, drug pricing and pharmacy data are routinely submitted to CMS for integration into the Medicare Plan Finder tool. The tool can be accessed here: Medicare Plan Finder
