Coverage decisions & exceptions

1. Limiting use of a brand name drug when a generic version is available
   Generally, a generic drug works the same as a brand name drug and usually costs less. In most cases, if there is a generic version of a brand name drug, our network pharmacies will give you the generic version.
   • We usually will not pay for the brand name drug when there is a generic version.
   • If your provider has told us the medical reason why the generic drug and other covered drugs that treat the same condition will not work for you, we may cover the brand name drug. This is a type of exception request.
   • Your copay may be greater for the brand name drug than for the generic drug.
2. Prior Authorization – Getting plan approval in advance
   For some drugs, you or your doctor must get approval from SCFHP DualConnect before you fill your prescription. If you do not get approval, we may not cover the drug.
   
   To find out if a drug needs prior authorization, see the Drug List. Items marked with “PA”, “PA BvD”, “PA-HRM”, or “PA NSO” will need prior approval. A list of drugs requiring prior authorization can also be found in Member Materials. If you need a drug that requires prior authorization, talk to your provider or contact SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
   
   
3. Step Therapy – Trying a different drug first
   In general, we want you to try lower-cost drugs (that often are as effective ) before we cover drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, we may require you to try Drug A first. If Drug A does not work for you, we will then cover Drug B. This is called step therapy.
   
   To find out if a drug needs step therapy, see the Drug List. Drugs marked with "ST" may need prior approval if you have not tried the preferred drug. This is a type of exception request. A list of drugs requiring step therapy can also be found in Member Materials. Scroll down to the section on "How to ask for a coverage decision or exception" for more information.
   
   
4. Quantity limits
   For some drugs, we limit the amount of that drug you can have. This is called quantity limit. For example, we might limit how much of a drug you can get each time you fill your prescription.
   
   To find out if a drug has quantity limit, see the Drug List. Drugs marked with “QL” may need a prior approval if you are requesting more than what we cover. This is a type of exception request. Scroll down to the section on "How to ask for a coverage decision or exception" for more information.
   

To find out if any of the rules above apply to a drug you take or want to take, check the Drug List. For the most up-to-date information, call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m. Or you can use the online formulary search tool to find a drug and see what rules apply to it. The online formulary search tool is updated every month.

You can ask us to pay you back. This is a type of coverage decision. Follow the steps below in "How to ask for a coverage decision or exception."

If it is not on the Drug List, we may be able to cover it by giving you an exception. Follow the steps below in “How to ask for a coverage decision or exception.” Some drugs are not on the Drug List because the law does not allow us to cover those drugs. See the section of our website on the Drug List for more information about drugs not on the Drug List.

You can ask for a coverage decision or exception to the rules for us to cover or pay you back for a drug. You, your appointed representative, or your doctor (or other prescriber) can do this.

How you can ask for a coverage decision or exception:

• Call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
• Log on to the mySCFHP member portal and click on the Pharmacy tab to submit the Medicare Part D Coverage Determination Request form online.
• Ask your doctor to fill out and mail or fax the Part D Coverage Determination Request form to:

Attn: Medicare Part D Coverage Determination
MedImpact
10181 Scripps Gateway Court
San Diego, CA 92131

Or fax the completed form to: 1-858-790-7100

If you are requesting an exception, your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception. We call this the “supporting statement.” Our decision about the exception will be faster if your doctor or other prescriber gives us this information when you ask for the exception.

• Your doctor or other prescriber can fax or mail the statement to us.
• If we do not receive the supporting statement at the time of your request, we will reach out to your prescriber for it.

If your health requires it, ask us to give you a “fast coverage decision”

A “fast coverage decision” is known as an “expedited determination .” Unless we have agreed to a fast deadline, we will use the standard deadline.

• A standard coverage decision means we will give you an answer within 72 hours after receiving your request for payment for a drug you have not yet received. We will give you an answer on reimbursing you for a Part D drug you already paid for within 14 calendar days.
• A fast coverage decision means we will give you an answer within 24 hours.

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 deadline 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 a fast coverage decision.

• If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether a fast coverage decision is appropriate.
• 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 we will use the standard timeframe to process your request. 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. For more information about the process for making complaints, including fast complaints, refer to Section J of the SCFHP DualConnect Member Handbook in Member Materials.

Deadlines for a “fast coverage decision”

• If we are using the fast deadlines, we must give you our answer within 24 hours. If you are asking for an exception, we must give you our answer within 24 hours after we get your doctor’s or prescriber’s statement supporting your request.
• 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.
• 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 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 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. If you are asking for an exception, we must give you our answer within 72 hours 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 outside independent organization will review your request.
• If our answer is Yes to part or all of what you asked for, we must approve or give you the coverage within 72 hours after we get your request or, if you are asking for an exception, your 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 decision” 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 your request.
• 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. The letter will also explain how you can appeal our decision.

Visit the section of our website on Complaints, Grievances & Appeals - Pharmacy (Part D) for more information about making an appeal for a Part D drug.

You can call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

If you disagree with a coverage decision we have made, you can appeal our decision. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. See the section of our website on Complaints, Appeals & Grievances - Pharmacy (Part D) for more information about appealing a decision.

You can get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP DualConnect by contacting our Grievance and Appeals Department:

Call toll-free: 1-877-723-4795 (TTY: 711)

Fax: 1-408-874-1962

Write:

Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

You can ask for published materials for free in other formats, such as large print, Braille, or audio. Call SCFHP DualConnect Customer Service for help.

If you are more comfortable speaking a language other than English, Santa Clara Family Health Plan can help you. Whether you are contacting SCFHP or visiting a doctor, we have interpreters available. Tell your doctor you would like an interpreter for your visit.

Know your rights

• You can get an in-person or telephone interpreter at no cost to you. This includes American Sign Language.
• When you go to the doctor, interpreters are available 24-hours a day.
• You can ask for SCFHP DualConnect materials written in other languages.

How can you get an interpreter?

Tell your doctor’s office you would like one. You can do this when you call to set up your next visit. You can also ask us for an interpreter or for translated materials.