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Coverage decisions & exceptions

We will usually cover your prescription drugs if they appear on the Drug List. See the section of our website about the Drug List for more information. For certain prescription drugs, special rules limit how and when the plan covers them. In general, our rules encourage you to get a drug that works for your medical condition and is safe.

​If there is a special rule for your drug, it usually means that you or your provider will have to take extra steps for us to cover the drug. For example, your provider may have to tell us why you are using the drug or provide results of blood tests first. If you or your provider thinks our rule should not apply to your situation, you should ask us to make an exception. To ask for an exception, see the section below on “How to ask for a coverage decision or exception.”​

​Once you or your provider have completed the extra steps, we will make a decision about covering the drug, also called a coverage determination. We may or may not agree to let you use the drug without taking the extra steps.​

Frequently asked questions

What are the rules?

  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 more 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 before you fill your prescription. This is called prior authorization (also called a coverage determination). 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 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 are equally 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. 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.

Do any of these rules apply to your drugs?

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 Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

What if you paid for a drug and want us to pay you back?

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."

What if the drug you want to take is not on the Drug List?

See the section of our website on the Drug List for more information about drugs not on the Drug List.

How to ask for a coverage decision or exception

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 Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
  • Ask your doctor to fill out and mail 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.

How to ask for a fast coverage decision

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

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

  • 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 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 a fast coverage decision.
    • If you ask for a fast coverage decision on your own (without the support of your doctor or other prescriber), we will decide whether you get a fast coverage decision.
    • If we decide to give you a standard decision, 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.

Deadlines for coverage decisions

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.
  • 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 72 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 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.” This statement 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.

How can I find out the status of my coverage decision?

You can call us at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

What if you do not agree with our decision not to cover a drug?

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.

How to get the aggregate number of all grievances, appeals and exceptions filed with SCFHP Cal MediConnect

You can get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect by contacting the SCFHP 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

Accessibility

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

If you speak a language other than English, language assistance services, free of charge, are available to you. Call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. The call is free.

Santa Clara Family Health Plan 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.

Enrollment in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect) depends on contract renewal.

Last updated 01/08/2020

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