Prescription Drugs

IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. There are over 700 pharmacies in the IEHP DualChoice network. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California.

IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. It tells which Part D prescription drugs are covered by IEHP DualChoice. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the IEHP DualChoice Formulary. 

• Formulary
  
• Formulary Change
• Drugs Requiring Prior Authorization
  
• Step Therapy
  
• Drug Price Search Tool - This tool is an estimate of costs only. Please refer to the IEHP DualChoice Member Handbook for confirmation of the prescription benefits.

A drug recall or withdrawal occurs when a medication is removed from the market because it is found to be potentially harmful.  The important new safety information regarding drug recalls is updated on the following link: IEHP - Safety Resources : Safety Practices

If you are taking a medication that has been recalled, please talk to your health care providers about the best course of action.

Our IEHP DualChoice (HMO D-SNP) Provider and Pharmacy Directory gives you a complete list of our network pharmacies – that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members.

Generally, you must receive all routine care from plan providers and network pharmacies to access their prescription drug benefits, except in non-routine circumstances, quantity limitations and restrictions may apply. 

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. Limitations, copays, and restrictions may apply. Copays for prescription drugs may vary based on the level of Extra Help you receive. Benefits and copayments may change on January 1 of each year. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook

• IEHP DualChoice Provider and Pharmacy Directory Riverside County
  
• IEHP DualChoice Provider and Pharmacy Directory San Bernardino County

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP DualChoice website. 

If you don’t have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8 a.m.-8 p.m. (PST), 7 days a week, including holidays. TTY users should call 1-800-718-IEHP (4347).

If you would like to use Mail Order Pharmacy for no-cost home delivery, please call SortPak. With Mail Order Pharmacy, you can enjoy:

• Refill reminders to make sure you have the right amount of medication on hand.
• Up to a 100-day supply of your medication to make things easy.

Hours: 24 hours a day / 7 days a week

Mailing address: SortPak Pharmacy, 124 South Glendale Ave., Glendale, CA 91205

Call Now: 1-877-570-7787

Prescriber Fax Number: 1-877-475-2382

Generally, IEHP DualChoice (HMO D-SNP) will cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• What if I need a prescription because of a medical emergency?

  We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.
  

   

• Getting coverage when you travel or are away from the Plan’s service area

  If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply.
  

   

  If you are traveling within the US, but outside of the Plan’s service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.

   

  Prior to filling your prescription at an out-of-network pharmacy, call IEHP DualChoice Member Services to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, IEHP DualChoice Member Services may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

   

  We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.
   

• What if you are outside the plan’s service area when you have an urgent need for care?

  When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States.
   

• Other times you can get your prescription covered if you go to an out-of-network pharmacy

  We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

  • If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
  • If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. 
• How do you ask for reimbursement from the plan? 

  If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for IEHP DualChoice's share of the cost. Send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records. Mail your request for payment together with any bills or receipts to us at this address: 
  

   

  IEHP DualChoice
  P.O. Box 4259
  Rancho Cucamonga, CA 91729-4259 

   

  You must submit your claim to us within 1 year of the date you received the service, item, or drug. Please be sure to contact IEHP DualChoice Member Services if you have any questions. If you don’t know what you should have paid, or you receive bills and you don’t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us. See Chapters 7 and 9 of the IEHP DualChoice Member Handbook to learn how to ask the plan to pay you back.

IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). IEHP DualChoice develops and maintains the Formulary continuously by reviewing the efficacy (how effective) and safety (how safe) of new drugs, compare new versus existing drugs, and develops clinical practice guidelines based on clinical evidence.

From time to time (during the benefit year), IEHP DualChoice revises (adding or removing drugs) the Formulary based on new clinical evidence and availability of products in the market.  All the changes are reviewed and approved by a selected group of providers and pharmacists that are currently in practice.

IEHP DualChoice will give notice to IEHP DualChoice Members prior to removing Part D drug from the Part D formulary. We will also give notice if there are any changes regarding prior authorizations, quantity limits, step therapy or moving a drug to a higher cost-sharing tier.

If IEHP DualChoice removes a Covered Part D drug or makes any changes in the IEHP DualChoice Formulary, we will post the formulary changes on IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market we will immediately remove the drug from our formulary.

Some changes to the Drug List will happen immediately. For example:

• A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.
  • We may not tell you before we make this change, but we will send you information about the specific change or changes we made.
  • You or your provider can ask for an “exception” from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]) of the Member Handbook for more information on exceptions.
• A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Your provider will also know about this change. He or she can work with you to find another drug for your condition.

We will tell you in advance about these other changes to the Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.
• We add a generic drug that is not new to the market and:
  • Replace a brand name drug currently on the Drug List or
  • Change the coverage rules or limits for the brand name drug.

When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:

• Get a 31-day supply of the drug before the change to the Drug List is made, or
• Ask for an exception from these changes. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]).

Again, if a drug is suddenly recalled because it’s been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Formulary. We will let you know of this change right away.

Your doctor will also know about this change and can work with you to find another drug for your condition.

If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market we will immediately remove the drug from our formulary.

For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. For additional information on step therapy and quantity limits, refer to Chapter 5 of the IEHP DualChoice Member Handbook. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization.

• Request for MedImpact Medicare Part D Coverage Determination Request Form (PDF), updated 10/14/24
• Model Form Instructions, updated 02/19. By clicking on this link, you will be leaving the IEHP DualChoice website.
  

These forms are also available on the CMS website: 
Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). 

By clicking on this link, you will be leaving the IEHP DualChoice website.

We will generally cover a drug on the plan’s Formulary as long as you follow the other coverage rules explained in Chapter 6 of the IEHP DualChoice Member Handbook and the drug is medically necessary, meaning reasonable and necessary for treatment of your injury or illness. It also needs to be an accepted treatment for your medical condition.

Here are three general rules about drugs that Medicare drug plans will not cover under Part D:

• Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.
• Our plan cannot cover a drug purchased outside the United States and its territories.
• Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.

For more information refer to Chapter 6 of your IEHP DualChoice Member Handbook

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.

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 were in the plan last year.
   • You are new to our plan.
   • 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.

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.

• 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.

If a drug you are taking will be taken off the Drug List or limited in some way for next year, we will allow you to ask for an exception before next year.

• We will tell you about any change in the coverage for your drug for next year. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year.
• We will answer your request for an exception within 72 hours after we get your request (or your prescriber’s supporting statement).

Medicare requires pharmacies to provide notice to enrollees each time a member is denied coverage or disagrees with cost-sharing information.

You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist.  Read your Medicare Member Drug Coverage Rights. By clicking on this link, you will be leaving the IEHP DualChoice website.

We conduct 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.

IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. 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) or duration of a drug you are taking.
• Over-utilization and under-utilization.
• Clinical abuse/misuse.

If we see a possible problem in your use of medications, we will work with your doctor to correct the problem. IEHP DualChoice also provides information to the Centers for Medicare and Medicaid Services (CMS) regarding its quality assurance measures according to the guidelines specified by CMS.

IEHP DualChoice (HMP D-SNP) is an HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal.

Information on this page is current as of October 15, 2024.
H8894_DSNP_4892019_M_2025