Part D & Prescription Drugs

• Request for Medicare Prescription Drug Determination Request Form (pdf)
• Request for Medicare Redetermination Request Form 1st Level of Appeal (pdf)

The Medicare Prescription Drug Determination Request Form is not required to request a coverage decision. L.A. care 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. L.A. Care is prohibited from requiring a member, physician or other prescriber to make a written request on a specific form. You or your physician can attach any “supporting documents” to this form. The written request can be mailed, delivered in person, or faxed to:
 
L.A. Care Cal MediConnect Plan
Attn: Pharmacy & Formulary
1055 West 7th Street
Los Angeles, CA 90017
Fax: 1-213-438-5776
 
To ask for a redetermination (appeal), you can use the “Request for Medicare Redetermination Request Form – 1st Level of Appeal” form linked above.  You are not required to use this form.   For more information on L.A. Care Cal MediConnect Plan’s Coverage Determinations, Redeterminations, Appeals & Grievances process, please visit our Appeals & Grievances page.

Formulary (Drug List)

Our List of Covered Drugs (Formulary) or “Drug List” tells you:

• Which drugs we pay for
• Which of the 4 cost-sharing tiers each drug is in
• Whether there are any limits on the drugs

The drugs on this list are selected by the Plan with the help of a team of doctors and pharmacists.

If you need a copy of the Drug List, call Member Services or you can find the most current Drug List (Formulary) on the Member Materials section of this website.

Changes to the Formulary

The Drug List can change during the year. 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 Drug List. For example, the Plan might:

• Add or remove drugs from the Drug List. 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
• Replace a brand-name drug with a generic drug

Related documents:

• Preferred Diabetes Test Strip Program (pdf)
• April 2018 Formulary Updates
• March 2018 Formulary Updates
• March to November 2017 Formulary Updates (pdf)

Restrictions on Coverage for Some Drugs

For certain prescription drugs, special rules restrict how and when the Plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you get a drug that works for your medical condition and is safe. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing. L.A. Care Cal MediConnect Plan uses different types of restrictions to help our members use drugs in the most effective ways:

Using generic drugs whenever you can.
A “generic” drug works the same as a brand-name drug, but usually costs less. When a generic version of a brand-name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand-name drug when a generic version is available. However, if your doctor has told us the medical reason that the generic drug will not work for you, then we will cover the brand-name drug. (Your share of the cost may be greater for the brand-name drug than for the generic drug).

Getting L.A. Care Cal MediConnect approval in advance.
For certain drugs, you or your doctor need to get approval from us before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes our approval is required so we can be sure that your drug is covered by Medicare rules. Sometimes the requirement for getting approval in advance helps guide correct use of certain drugs. If you do not get this approval, your drug might not be covered by us.  For a list of drugs that need Prior Authorization see the document entitled Drugs Requiring Prior Authorization.

Trying a different drug first.
This requirement encourages you to try safer or more effective drugs before we cover another drug. For example, if Drug A and Drug B treat the same medical condition, we may require you to try Drug A first. If Drug A does not work for you, the we will then cover Drug B. This requirement to try a different drug first is called “Step Therapy.” For a list of drugs that need Step Therapy see the document entitled Drugs Requiring Step Therapy.

Quantity limits.
For certain drugs, we limit the amount of the drug that you can have. For example, we might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. To see the Quantity Limits for drugs, see the most current Drug List (Formulary) on the Member Materials section of this website.

Related documents:

• 2018 Drugs Requiring Prior Authorization (pdf)
• 2018 Drugs Requiring Step Therapy (pdf)
• 2017 Drugs Requiring Prior Authorization (pdf)
• 2017 Drugs Requiring Step Therapy (pdf)

Mail-Order Pharmacy Services

One of the benefits of being a member of L.A. Care Cal MediConnect is the chance to have your prescription drugs delivered through our mail-order pharmacy service. Our plan’s mail-order service allows you to get up to a 90-day supply of your prescription drugs sent directly to your home.

To get Prescription Drugs by Mail-Order

Urgent Mail Order Drug Notice

1. What should I do if I did not get my mail order drug?
   Answer: It is Kroger Mail Order Pharmacy’s goal to have your order in your hands 7 to 10 days after Kroger receives it at its facility. If you have not received your order after 10 days please contact the Kroger Mail Order Pharmacy at 1-800-552-6694.They will be able to track your order through the shipping provider. You can also visit www.ppsrx.com and select “Prescription History” to view deliver status updates and tracking information.
    
2. What should I do if I did not get my order and I am out of refills?
   Answer: Contact your doctor and have him/her call in an emergency supply to your local retail pharmacy. Also, contact the Kroger Mail Order Pharmacy at 1-800-552-6694. They will be able to track your order through the shipping provider.
    
3. What should I do if I am running out of my mail order medication(s) and I did not call Kroger Mail Order Pharmacy for a refill(s)?
   Answer: If you are low on your medication(s), please contact your doctor and have them call in a two-week supply to a local pharmacy. Kroger may also be able to transfer your prescription to a local pharmacy to be filled immediately if you need it the same day. 
    
4. What if Kroger Mail Order Pharmacy made a mistake and I did not get my mail order medication(s)? 
   Answer: Kroger Mail Order Pharmacy is committed to ensure each member receives the correct medication. If you have a concern, please contact the Kroger Mail Order Pharmacy at 1-800-552-6694. From time to time, we find members who are unable to wait for their first order to arrive and in these cases, Kroger Mail Order Pharmacy is prepared to use an expedited shipping provider at the member's cost.

Quality Assurance & Utilization Management Policies & Procedures

Programs to Help Members Use Drugs Safely

L.A. Care Cal MediConnect conducts drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

• Possible medication errors.
• Drugs that may not be necessary because you are taking another drug to treat the same medical condition.
• Drugs that may not be safe or appropriate because of your age or gender.
• Certain combinations of drugs that could harm you if taken at the same time.
• Prescriptions written for drugs that have ingredients you are allergic to.
• Possible errors in the amount (dosage) of a drug you are taking.
• If we see a possible problem in your use of medications, we will work with your doctor to correct the problem.

Medication Therapy Management

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program. MTM is a service offered by LA Care Cal MediConnect at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit. This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.
 
To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program. Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.
 
To qualify for LA Care Cal MediConnect’s MTM program, you must meet ALL of the following criteria:

1. Have at least 3 of the following conditions or diseases:
   • Bone Disease-Arthritis-Osteoporosis 
   • Chronic Heart Failure (CHF)
   • Diabetes
   • Dyslipidemia
   • Hypertension
   • Mental Health-Depression
   • Respiratory Disease-Asthma
   • Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD)
   • Hepatitis C
2. Take at least 8 covered Part D medications 
    
3. Are likely to have medication costs of covered Part D medications greater than $3,967 per year.
    

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications: 

• Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, by phone or mail, and/or your doctor if we detect a potential problem.
   
• Comprehensive medication review: at least once a year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely. This review, or CMR, is provided to you confidentially via telephone by SinfoníaRx through their licensed pharmacies operated by the University of Arizona Medication Management Center and The Ohio State University College of Pharmacy Medication Management Program. These services are provided on behalf of LA Care Cal MediConnect. This review requires about 30 minutes of your time. Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors. This summary includes:
  • Medication Action Plan (MAP): The action plan has steps you should take to help you get the best results from your medications.
  • Personal Medication List (PML): The medication list will help you keep track of your medications and how to use them the right way.

To obtain a blank copy of the Personal Medication List (PML) that can help you and your health care providers keep track of the medications you are taking, use the following sample list: Sample Personal Medication List (pdf).

If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please call L.A. Care Cal Mediconnect Plan Member Services at 1-888-522-1298 (TTY: 711) 24 hours a day, 7 days a week, including holidays. 

Drug Transition Policy

New members in L.A. Care Cal MediConnect may be taking drugs that aren't in our Drug List (Formulary) or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. For more information, see our Drug Transition Policy.

Drug Transition Policy

In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

To get a temporary supply of a drug, you must meet the two rules below:

1. The drug you have been taking:

• Is no longer on our Drug List, or
• Was never on our Drug List, or
• Is now limited in some way.

2. You must be in one of these situations:

You are new to our plan and do not live in a long-term care facility.

• We will cover a supply of your drug one time only during the first 90 days of your membership in the plan. This supply will be for up to 30-day supply, or less if your prescription is written for fewer days. You must fill the prescription at a network pharmacy.

You are new to the plan and live in a long-term care facility.

• We will cover a supply of your drug during the first 90 days of your membership in the plan, until we have given you a 91 and up to a 98-day supply consistent with the dispensing increment, or less if your prescription is written for fewer days.
• You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away.
• We will cover one 31-day supply, or less if your prescription is written for fewer days.
• You may experience a change in the level of care received and/or may be required to transition (move) from one facility or treatment site to another. Exceptions (special cases) are available to you if you experience a change in the level of care being received. If you experience a change in level of care, L.A. Care Cal MediConnect Plan will cover a temporary 31-day supply (unless you have a prescription written for fewer days).
• To ask for a temporary supply of a drug, call Member Services at 1-855-522-8243 (TTY: 711), 24 hours a day, 7 days a week, including holidays..
• When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:

You can change to another drug.

• There may be a different drug covered by our plan that works for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. The list can help your provider find a covered drug that might work for you.

OR

You can ask for an exception.

• You and your provider can ask us to make an exception. For example, you can ask us to cover a drug even though it is not on the Drug List. Or you can ask us to cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.
• To learn more about asking for an exception, see Chapter 9, Section 6.3 of the Member Handbook.
• If you need help asking for an exception, you can contact Member Services at 1-855-522-8243 (TTY: 711), 24 hours a day, 7 days a week, including holidays.

You can access the Appeals & Grievances page using this link: http://www.calmediconnectla.org/members/appeals-grievances

Best Available Evidence Policy

To learn more about how we must establish cost-sharing for low-income subsidy beneficiaries, see the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence policy.

Related documents:

• Drug Transition Policy (pdf)