Member Decisions

For a full explanation of medical and prescription drug coverage decisions, formulary exceptions, medical and prescription drug appeals, and grievances, see your 2010 Evidence of Coverage (Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints):

• Chronic Condition Special Needs Plan
  • Silver Rx (Regional PPO)
  • Gold Rx (Regional PPO)
  • Gold Rx Advantage (Regional PPO)
• Medicare/Full Medicaid Special Needs Plan
• Medicare Advantage (Regional PPO)
• Arkansas – Medicare Advantage (PPO)

• Chronic Condition Special Needs Plan
  • Silver Rx (Regional PPO)
  • Gold Rx (Regional PPO)
  • Gold Rx Advantage (Regional PPO)
• Medicare Advantage (Regional PPO)

• Chronic Condition Special Needs Plan (English)
  • Silver Rx (Regional PPO)
  • Gold Rx (Regional PPO)
  • Gold Rx Advantage (Regional PPO)
• Chronic Condition Special Needs Plan (Spanish)
  • Silver Rx (Regional PPO)
  • Gold Rx (Regional PPO)
  • Gold Rx Advantage (Regional PPO)
• Medicare/Full Medicaid Special Needs Plan (English)
• Medicare/Full Medicaid Special Needs Plan (Spanish)
• Medicare Advantage (Regional PPO) (English)
• Medicare Advantage (Regional PPO) (Spanish)
• Medicare Advantage (PPO) (English)
• Medicare Advantage (PPO) (Spanish)

• Chronic Condition Special Needs Plan

Coverage decisions
Coverage decisions are "determinations" about what tests, treatment services, and prescription drugs are covered or paid for under your health plan. These decisions are guided by Medicare coverage guidelines as well as what is medically necessary, appropriate, and safe. Your physician makes most decisions about your medical care, and Care Improvement Plus works with providers to help assure that you receive the covered benefits you need.

You can read about coverage decisions regarding your prescription drugs in the section that follows.

Prescription Drug Decisions and Exceptions
A decision whether a prescription drug will be covered under the health plan is called a "coverage determination." Like most health plans, Care Improvement Plus uses a "formulary" to set out its drug coverage. A formulary is a comprehensive plan that includes a list of all the drugs covered under the benefit as well as dosage amounts and form of administration, a member cost-sharing structure known as copayment “tiers,” and, for certain drugs, pre-authorization requirements and quantity limits.

We have teamed up with pharmacy benefit experts at Medco to help make coverage determinations using the formulary and to work with your physician. We work together to ensure that prescriptions are covered under the plan, filled timely, and are safe for you.

• prior authorizations by Medco before a pharmacy may dispense certain drugs,
• limits set by Medco on the quantity or amount that can be dispensed of certain drugs,
• a decision to pay a claim for a drug you paid for,
• a decision whether a prescribed drug is medically necessary, appropriate, or used for an FDA-approved indication, and
• a request for an "exception" to the formulary as discussed below
• determinations made by Medco as to whether select prescription drugs should be covered and billed under Medicare Part B, or Medicare Part D

You, your authorized representative, or your prescribing physician may request a coverage determination. Decisions for Prior authorization coverage determinations are made within 72 hours of the request, unless your health is in jeopardy and a request is made for a fast-track decision. We verify the need for a fast-track decision and then make an expedited decision as quickly as possible - within 24 hours of the request.

If coverage is denied, you will be notified and receive a written explanation with appeal rights. If your request for a fast-track decision is denied and you disagree, you may file an expedited grievance. You are always notified of our decisions.

Prior Authorizations for Medications Under Part B
Care Improvement Plus requires you (or your physician) to get prior authorization for certain drugs that are given in the doctor's office. This means that you will need to get approval for certain medications before you can receive your medication at the doctor's office. If you don't get approval, Care Improvement Plus may not cover the drug. You or your doctor will need to call 1-800-204-1002 (TTY 1-800-713-1603) to receive authorization for your medication. The following drugs need prior authorization in 2010:

Claims -If you submit a claim for a prescription filled outside of our national network of pharmacies or at a physician's office, Care Improvement Plus will issue a written determination, including an explanation of appeal rights if any part of the claim is denied.

Exceptions - In some cases, it may be medically necessary and appropriate for you to have an "exception" to the formulary. Exceptions are requests for a non-formulary drug, a lower copayment tier, or to remove the formulary's pre-authorization requirements or quantity limits. You, your authorized representative, or your physician may request the exception by phone, fax, or mail. There is a form that you may use and another form for physicians. For all exception requests, your physician must provide information that supports the medical basis for the exception. Care Improvement Plus will issue a decision within 72 hours, or 24 hours (if expedited), of receiving complete supporting information from your physician or other prescriber. If your exception request is denied you will receive a written notice with your appeal rights

Authorized Representative - Requests may be made by a family member, friend, or other party if the individual demonstrates legal authority, such as a medical power of attorney. Another way to be delegated this authority is by submitting to the plan a signed Appointment of Representative form.

For prescription drug determinations, physicians may act on behalf of the beneficiary and do not need the authority just described.