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2015 Member Decisions

For a full explanation of medical and prescription drug coverage decisions, formulary exceptions, medical and prescription drug appeals, and grievances, see your 2015 Evidence of Coverage (Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints):

2015 Evidence of Coverage


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 OptumRx 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.

Coverage determinations include, but are not limited to:
  • prior authorizations by OptumRx before a pharmacy may dispense certain drugs,
  • limits set by OptumRx 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 OptumRx 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.

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

Appointment of Representative form - 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. A physician may request a coverage determination on a member’s behalf without appointment of representative form.

Authorization to Release Form - An authorized representative is an individual who is granted, by the member, the right to discuss and/or receive the member’s personal health information. Medicare Partners do not have the authority to make changes to the member’s account or to take action on behalf of the member. Not to be misconstrued/used as an Appointment of Representative.

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

This page was last updated on: 8/12/2014 3:44:38 PM

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Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Medicare evaluates plans based on a 5-Star rating system. Star ratings are calculated each year and may change from one year to the next.

Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity and restrictions may apply. It may cost more to get care from out–of–network providers, except in an emergency. If there isn’t a network provider available for you to see, you can go to an out–of–network provider but still pay the in–network amounts. The health providers in our network can change at any time.

To be eligible for a Care Improvement Plus Regional PPO plan you must be a Medicare beneficiary living in Arkansas, Georgia, Missouri, South Carolina, or Texas and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Local PPO plan you must be a Medicare beneficiary living in select counties of: Arkansas, Georgia, Illinois, Indiana, Iowa, Missouri, Nebraska, New Mexico, North Carolina, South Carolina, Texas or Wisconsin and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Chronic Conditions Special Needs Plan, you must have diabetes and/or heart failure and/or, cardiovascular disorder. This plan is available to anyone having a qualifying chronic care condition. Members may enroll in the plan only during specific times of the year. Contact Care Improvement Plus for more information. If you have diabetes, heart failure, cardiovascular disorder or Medicaid/Low Income Subsidy, you may qualify to enroll in a Care Improvement Plus Special Needs Plan ANYTIME of the year by exercising a “Special Election Period.

To be eligible for a Care Improvement Plus Dual Advantage Plan, you must be enrolled in state Medicaid and be a dual eligible beneficiary whom the State holds harmless for Part A and Part B cost sharing. This plan is available to anyone who has both medical assistance from the state and from Medicare. If you are a full benefit dual beneficiary and your Part B premium is paid for by the State, you will not be responsible for paying your Part B premium. Premiums, copays, co-insurance and deductibles may vary based on the level of extra help you receive. Please contact the plan for further details.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call:

  • 1–800–MEDICARE (1–800–633–4227). TTY users should call 1–877–486–2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1–800–772–1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1–800–325–0778; or
  • Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1– 800–772–1213.TTY users should call 1–800–325–0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a part of this premium, we will bill you for the amount that Medicare doesn’t cover.

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