Part D & Prescription Drugs

Formulary (Drug List)
How to Find Out If a Specific Drug Is on the Formulary
Changes to the Formulary
If Your Drug Is Not on the Formulary (Exceptions)
Drug Transition Policy
Pharmacies in the Plan's Network
Using a Pharmacy that Is Not in the Plan's Network
Mail-Order Pharmacy Services
Restrictions on Coverage for Some Drugs

Quality Assurance & Utilization Management Policies & Procedures:
Programs to Help Members Use Drugs Safely
Medication Therapy Management (MTM) Programs

Asking for a Coverage Decision, Including an Exception, or Making an Appeal:
Getting Help Asking for a Coverage Decision, Including an Exception, or Making an Appeal
Part D Coverage Decisions
Making a Level 1 Appeal
Making a Level 2 Appeal

Making a Complaint (Also Called a Grievance)
Low-Income Subsidy Information
Best Available Evidence Policy
How to Request an Aggregate Number of Complaints (Grievances), Appeals, and Exceptions
Disclaimer Information
 

Formulary (Drug List)

The Plan has a “List of Covered Drugs (Formulary).” In the Evidence of Coverage (EOC) (PDF), we call it the “Drug List” for short. 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 Plan’s Drug List.

We will generally cover a drug on the Plan’s Drug List as long as you follow the other coverage rules explained in the EOC 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.

The Drug List includes both brand-name and generic drugs. A generic drug is a prescription drug that has the same active ingredients as the brand-name drug. It works just as well as the brand-name drug, but it costs less. There are generic drug substitutes available for many brand-name drugs.

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How to Find Out If a Specific Drug Is on the Formulary

You have three ways to find out:

• Check the most recent Drug List we sent you in the mail.
• View the current Formulary (PDF). The Drug List on the website is always the most current.
• Call Member Services to find out if a particular drug is on the Plan’s Drug List or to ask for a copy of the list.

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 (for more information about restrictions to coverage, see Chapter 5, Section 5 in the Evidence of Coverage (PDF).
• Replace a brand-name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the Plan’s Drug List.

Changes to the Formulary effective 01/01/2011 (PDF)

Changes to the Formulary effective 02/01/2011 (PDF)

Changes to the Formulary effective 03/01/2011 (PDF)

Changes to the Formulary effective 04/01/2011 (PDF)

Changes to the Formulary effective 05/01/2011 (PDF)

Changes to the Formulary effective 06/01/2011 (PDF)

Changes to the Formulary effective 07/01/2011 (PDF)

Changes to the Formulary effective 08/01/2011 (PDF)

Changes to the Formulary effective 09/01/2011 (PDF)

Changes to the Formulary effective 10/01/2011 (PDF)

Changes to the Formulary effective 11/01/2011 (PDF) 

Changes to the Formulary effective 04/01/2012 (PDF)

Changes to the Formulary effective 06/01/2012 (PDF)

Changes to the Formulary effective 07/01/2012 (PDF)

Changes to the Formulary effective 08/1/2012   (PDF)

Changes to the Formulary effective 09/1/2012 (PDF)

Changes to the Formulary effective 10/1/2012 (PDF)  ***Please be advised that there were errors in the August Formulary update and that all subsequent formularies have been corrected.***

Changes to the Formulary effective 11/1/2012 (PDF)

Changes to the Formulary effective 12/1/2012 (PDF)

Changes to the Formulary effective 05/1/2013 (PDF)

Changes to the Formulary effective 06/1/2013 (PDF)

Changes to the Formulary effective 07/1/2013 (PDF)

Changes to the Formulary effective 08/1/2013 (PDF)

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If Your Drug Is Not on the Formulary (Exceptions)

If your drug is not on the Drug List or is restricted, here are things you can do:

• You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). For more information, see our Drug Transition Policy (PDF). 
• You can change to another drug.
• You can request an exception and ask the Plan to cover the drug in the way you would like it to be covered.

If your drug is in a cost-sharing tier you think is too high, here are things you can do:

• You can change to another drug.
• You can file an exception.

Important things to know about asking for exceptions:

• Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.
• Our Plan can say yes or no to your request. If we approve your request for an exception, our approval usually is valid until the end of the Plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. If we say no to your request for an exception, you can ask for a review of our decision by making an appeal.

For more information see Chapter 9, Section 6 in the Evidence of Coverage (PDF).

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Drug Transition Policy

New members in our Plan may be taking drugs that aren't in our 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 (PDF).
 

Pharmacies in the Plan's Network

In most cases, your prescriptions are covered only if they are filled at the Plan’s network pharmacies. A network pharmacy is a pharmacy that has a contract with the Plan to provide your covered prescription drugs. The term “covered drugs” means all of the Part D prescription drugs that are covered by the Plan.

L.A. Care Health Plan has contracts with 1,665 pharmacies that equal or exceed Medicare requirements for pharmacy access in the Plan's approved service area. To find a network pharmacy, see the Pharmacy Directory (PDF) or call Member Services.

Using a Pharmacy that Is Not in the Plan’s Network
Your prescription might be covered in certain situations. We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our Plan. Generally, we 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:

• If the prescriptions are related to care for a medical emergency
• If the prescriptions are related to care for urgently needed care
• Coverage is limited to no more than a 20 day supply

In these situations, please check first with Member Services to see if there is a network pharmacy nearby.

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 our share of the cost. Chapter 7, Section 2.1 in the Evidence of Coverage (PDF) explains how to ask the Plan to pay you back.

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Mail-Order Pharmacy Services

Our Plan’s mail-order service requires you to order at least a 60-day supply of the drug and no more than a 90-day supply. To get order forms and information about filling your prescriptions by mail contact Member Services. If you use a mail-order pharmacy not in the Plan’s network, your prescription will not be covered.

Usually a mail-order pharmacy order will get shipped to you in no more than 10 days. However, sometimes your mail order may be delayed. You must contact your doctor to request a short-term prescription to cover the period until the mail-order medication arrives.

Prescription Drug Mail Order Information (PDF)

Prescription Drug Mail Order Form (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. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the Plan’s rules are designed to encourage you and your doctor to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing. Our 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 Plan approval in advance. For certain drugs, you or your doctor need to get approval from the Plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes Plan 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 appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the Plan. See Drugs Requiring Prior Authorization (PDF).app
• Trying a different drug first. This requirement encourages you to try safer or more effective drugs before the Plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the Plan may require you to try Drug A first. If Drug A does not work for you, the Plan will then cover Drug B. This requirement to try a different drug first is called “Step Therapy.” See Drugs Requiring Step Therapy (PDF).
• Quantity limits. For certain drugs, we limit the amount of the drug that you can have. For example, the Plan 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. See the Formulary (PDF), which lists the Quantity Limits for drugs.

The Plan’s Drug List includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Formulary (PDF). For more information, see Chapter 5, Section 5.1 in the Evidence of Coverage (PDF).

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Quality Assurance & Utilization Management Policies & Procedures

Programs to Help Members Use Drugs Safely

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.

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 (MTM) Program

 

L.A. Care Health Plan has contracted with Outcomes Pharmaceutical Health Care® (“Outcomes®”) to offer Medication Therapy Management services to all L.A. Care Health Plan Medicare Advantage (HMO SNP) members. This medication therapy management program is offered at no additional cost to all members, to help members get the best results from their medications, while keeping out-of-pocket costs down. Through Outcomes, specially trained Personal Pharmacists throughout Los Angeles County are identified and will be available to you in your community.

Members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs will likely benefit from this program the most, but all members are eligible to participate as you do not need a specific condition to join. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.

We hope you will participate in the Medication Therapy Management program, so that we can help you manage your medications and get the best results. Remember, you don’t need to pay anything extra to participate and this is not considered a benefit. 

If you have any questions, or to begin participation by finding an Outcomes pharmacist in your area, please contact L.A. Care Health Plan Member Services at 1-888-522-1298. TTY/TDD users should call 1-866-522-2731. We are available 24 hours a day, 7 days a week, including holidays.

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Asking for a Coverage Decision, Including an Exception, or Making an Appeal

Getting Help Asking for a Coverage Decision, Including an Exception, or Making an Appeal

Here are resources you may wish to use if you decide to ask for any kind of decision or appeal a decision:

• You can call us at Member Services: 1-888-522-1298 (TTY/TDD 1-866-522-2731). LA. Care Health Plan representatives are available 24 hours a day, 7 days a week (including holidays). Fax: 213-438-5748.
  
  You may send your request in writing to:
  L.A. Care Health Plan
  Attn: Grievance and Appeals Unit
  P.O. Box 811610
  Los Angeles, CA 90081

• To get free help from an independent organization that is not connected with our Plan, contact your State Health Insurance Assistance Program:
  
  Health Insurance Counseling and Advocacy Program (HICAP)
  520 S. Lafayette Park Place, Suite 214
  Los Angeles, CA 90057
  1-800-824-0780 or 213-383-4519
  www.calmedicare.org


• Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision or a Level 1 appeal on your behalf. To request any appeal after Level 1, your doctor or other provider must be appointed as your representative.


• You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a decision or make an appeal. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and ask for the form, the Appointment of Representative Form (PDF), to give that person permission to act on your behalf. You may also send a written statement authorizing the individual to act on your behalf. The form or statement must be signed by you and by the person who you would like to act on your behalf. You must give our Plan a copy of the signed form or statement indicating that the individual accepts the appointment. Please send the completed form or statement to:
  
  L.A. Care Health Plan Medicare Advantage HMO
  Attn: Grievances & Appeals Unit
  P.O. Box 811610
  Los Angeles, CA 90081
  
  or fax to: 213-438-5748 


• You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of decision or appeal a decision.

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Part D Coverage Decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D drugs. Here are examples of coverage decisions you ask us to make about your Part D drugs. 

• You ask us to make an exception, including:
  - Asking us to cover a Part D drug that is not on the Plan’s List of Covered Drugs
  - Asking us to waive a restriction on the Plan’s coverage for a drug (such as limits on the amount of the drug you can get)
  - Asking to pay a lower cost sharing amount for a covered non-preferred drug
• You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules.
• You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.
   

Step-by-step: How to ask for a Coverage Decision, Including an Exception

Step 1: You may ask our Plan to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast decision.” You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought.

• Request the type of coverage decision you want. Start by calling, writing, or faxing our Plan to make your request. You, your representative, or your doctor (or other prescriber) can do this.
  
  You can call us at Member Services: 1-888-522-1298 (TTY/TDD 1-866-522-2731). LA. Care Health Plan representatives are available 24 hours a day, 7 days a week (including holidays).
• You can email us at medicare@lacare.org  
• A written request may be made using one of these forms:
  
  L.A. Care Health Plan Request for Medicare Prescription Drug Coverage Determination (PDF)
  L.A. Care Health Plan Request for Redetermination of Medicare Prescription Drug Denial (PDF) 
  
  The Medicare Part D Coverage 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) and is prohibited from requiring a Member or physician, or other prescriber to make a written request on a specific form. The written request can be mailed, delivered in person, or faxed to:
  
  L.A. Care Health Plan Medicare Advantage (HMO SNP)
  Attn: Pharmacy & Formulary
  1055 West 7th Street
  Los Angeles. CA. 90017
  
  Fax: 213-438-5776


• If you want to ask our Plan to pay you back for a drug, see Chapter 7 in the Evidence of Coverage (PDF).
• If you are requesting an exception, provide the “doctor’s statement,” giving us the medical reasons for the drug exception you are requesting.
• When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we will answer within 24 hours.
• To get a fast decision, you must meet two requirements: You can get a fast decision only if you are asking for a drug you have not yet received. You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought. You can get a fast 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 decision,” we will automatically agree to give you a fast decision.
• If you ask for a fast decision on your own (without your doctor’s or other prescriber’s support), our Plan will decide whether your health requires that we give you a fast decision.

Step 2: Our Plan considers your request and we give you our answer.
If we are using the fast deadlines, we must give you our answer within 24 hours.

• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request.
• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

If we are using the standard deadlines, we must give you our answer within 72 hours.

• If our answer is yes to part or all of what you requested—If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request.
• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

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 receive your request.

• If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request.
• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.  

Step 3: If we say no to your coverage request, you decide if you want to make an appeal.
If our Plan says no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider—and possibly change—the decision we made.

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How to Make a Level 1 Appeal

Step 1: You contact our Plan and make your Level 1 Appeal. If your health requires a quick response, you must ask for a “fast appeal.”

• To start your appeal, you (or your representative or your doctor or other prescriber) must contact our Plan. You can call us at Member Services: 1-888-522-1298 (TTY/TDD 1-866-522-2731). LA. Care Health Plan representatives are available 24 hours a day, 7 days a week (including holidays).
• If you are asking for a standard appeal, make your appeal by submitting a written request to:
  
  L.A. Care Health Plan Medicare Advantage HMO
  Attn: Grievances & Appeals Unit
  P.O. Box 811610
  Los Angeles, CA 90081
  
  or fax your appeal to: 213-438-5748


• If you are asking for a fast appeal, you may make your appeal in writing or you may call us at Member Services: 1-888-522-1298 (TTY/TDD 1-866-522-2731). L.A Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.
• You can fill out the electronic form by clicking on the following link: https://mp.medimpact.com/partdcoveragedetermination
• You can email us at medicare@lacare.org  
• You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.
• You can ask for a copy of the information in your appeal and add more information.
• If you are appealing a decision our Plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.”
• The requirements for getting a “fast appeal” are the same as those for getting a “fast decision.”

Step 2: Our Plan considers your appeal and we give you our answer.
If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.

• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.  
• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.

If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.

• If our answer is yes to part or all of what you requested—If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal. If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.

Step 3: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal.

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How to Make a Level 2 Appeal

If our Plan says no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision our Plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed.

Step 1: To make a Level 2 Appeal, you must contact the Independent Review Organization and ask for a review of your case.

• If our Plan says no to your Level 1 Appeal, the written notice we send you will include instructions on how to continue on to the next step and make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.

Step 2: The Independent Review Organization does a review of your appeal and gives you an answer.

• If your health requires it, ask the Independent Review Organization for a "fast appeal."
• If the review organization agrees to give you a “fast appeal,” the review organization must give you an answer to your Level 2 Appeal within 72 hours after it receives your appeal request.
• If the Independent Review Organization says yes to part or all of what you requested, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization.

If you have a standard appeal at Level 2, the review organization must give you an answer to your Level 2 Appeal within 7 calendar days after it receives your appeal.

• If the Independent Review Organization says yes to part or all of what you requested—If the Independent Review Organization approves a request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization.
• If the Independent Review Organization approves a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization.

If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request.

To continue and make another appeal at Level 3, the dollar value of the drug coverage you are requesting must meet a minimum amount. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get from the Independent Review Organization will tell you if the dollar value of the coverage you are requesting is high enough to continue with the appeals process.

Step 3: If the dollar value of the coverage you are requesting meets the requirement, you choose whether you want to take your appeal further.

• If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal.
• The Level 3 Appeal is handled by an administrative law judge. Chapter 9, Section 10 in the Evidence of Coverage (PDF) tells more about Levels 3, 4, and 5 of the appeals process.

For more information about coverage decisions and appeals about your Part D prescription drugs, see Chapter 9, Section 6 in the Evidence of Coverage (PDF).

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Making a Complaint (Also Called a Grievance)

The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

•    Quality of your medical care
•    Respecting your privacy
•    Disrespect, poor customer service, or other negative behaviors
•    Waiting times
•    Cleanliness
•    Information you get from our Plan
•    Complaints related to the timeliness of our actions related to coverage decisions and appeals

Step 1: Contact us promptly—either by phone or in writing.

You can call us at Member Services: 1-888-522-1298 (TTY/TDD 1-866-522-2731). LA. Care Health Plan representatives are available 24 hours a day, 7 days a week (including holidays).

You may fax your request to: 213-438-5748


You may send your request in writing to:

      L.A. Care Health Plan
      Attn: Grievance and Appeals Unit
      P.O. Box 811610
      Los Angeles, CA 90081

Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know.

• If you do not wish to call (or called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here’s how it works: We will send you an answer as quickly as your case requires based on your health status, but no later than 30 calendar days from the date your complaint was received. We may extend the time frame by up to 14 calendar days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.
• Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 days after you had the problem you want to complain about.
• If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

You may submit feedback about your Medicare Advantage health plan directly to Medicare. By clicking on this link you will be leaving L.A. Care Health Plan website and will de directed to the CMS Model Electronic Complaint Form. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-(800)-MEDICARE (1-800-633-42273). TTY users can call 1-877-486-2048, 24 hours a day/7 days a week. You may also visit the Medicare website at http://www.medicare.gov.

You may also visit the Office of the Medicare Ombudsman (OMO): The Medicare Beneficiary Ombudsman can help you with complaints, grievances, and requests for information. To be directed to the Office of the Medicare Ombudsman, please click on the following link: Office of the Medicare Ombudsman.

Since some of your benefits are covered by Medi-Cal, you may also file a grievance with Medi-Cal. For help with your grievance or to complain about your health plan, you may contact the Ombudsman Office of the California Department of Health Care Services at 1-888-452-8609. The Ombudsman Office was created to help Medi-Cal beneficiaries to fully use their rights and responsibilities as a member of a managed care plan. Please refer to your health Plan’s Medi-Cal Evidence of Coverage for more information about how to file a Medi-Cal grievance.

Step 2: We look into your complaint and give you our answer.

• If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
• Most complaints are answered in 30 days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.
• If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

When your complaint is about quality of care, you also have two extra options:

• You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our Plan). To find the name, address, and phone number of the Quality Improvement Organization in your state look in Chapter 2, Section 4 in the Evidence of Coverage (PDF). If you make a complaint to this organization, we will work together with them to resolve your complaint. Or you can make your complaint to both at the same time.
• If you wish, you can make your complaint about quality of care to our Plan and also to the Quality Improvement Organization.

You can make your complaint about the quality of care you received to our Plan by using the step-by-step process outlined above.

For more information about decisions, appeals or complaints, see Chapter 9 in the Evidence of Coverage (PDF) or call Member Services.  You may also get help and information from Medicare: 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048. www.medicare.gov

For questions about the status of your appeal, or to obtain an aggregate number of grievances, appeals and exceptions filed with L.A. Care Health Plan for L.A. Care Health Plan Medicare Advantage (HMO SNP), contact the Member Services department at 1-888-522-1298 (TTY/TDD 1-866-522-2731). L.A. Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.

 

Low-Income Subsidy Information

Members who qualify for L.A. Care Health Plan Medicare Advantage have Medicare and Full-Scope Medi-Cal. By qualifying for Medi-Cal, you also qualify for Extra Help with your prescription drug coverage through Medicare Part D.

This Extra Help is also called the Low-Income Subsidy. Qualifying for this subsidy means you have no Part D premium under L.A. Care Health Plan Medicare Advantage. For more information, see Low Income Subsidy Premium Table (PDF).

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

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD 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/TDD users should call 1-800-325-0778; or
• Your State Medicaid Office.

In addition, you typically pay the following copays for drugs:

• Before your total yearly drug costs reach the $4,750 Initial Coverage Limit, you pay $1.15 for generic drugs and $3.50 for brand-name drugs. 
• Once the amount paid by you and/or others on your behalf reaches $4,750 in yearly out-of-pocket drug costs, you pay $0 for covered drugs.
• Co-pays may vary based on the level of Extra Help you receive.  Please contact the plan for further details.

Members of L.A. Care Health Plan Medicare Advantage receive the Low-Income Subsidy information in a separate insert to their Evidence of Coverage, called the Low-Income Subsidy Rider, upon enrollment and each following year.

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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. The link will direct you to the CMS website.
 

 How to Request an Aggregate Number of Complaints (Grievances), Appeals, and Exceptions

You can request an aggregate number of complaints (grievances), appeals, and exceptions filed with L.A. Care Health Plan Medicare Advantage by contacting us. If you request that the information be sent to you in writing, the information will be mailed to you within seven (7) to ten (10) business days.

You can call us at Member Services: 1-888-522-1298 (TTY/TDD 1-866-522-2731). LA. Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.

You may fax your request to: 213-438-5748

You may send your request in writing to:
L.A. Care Health Plan
Attn: Grievance and Appeals Unit
P.O. Box 811610
Los Angeles, CA 90081
 

Disclaimer Information

L.A. Care Health Plan is a Coordinated Care Plan with a Medicare contract and a contract with the California Medicaid program. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medi-Cal or by another third party. Individuals must have both Part A and Part B to enroll. If you are eligible for Medicare and have a zero share-of-cost Medi-cal, you can enroll in L.A. Care Health Plan Medicare Advantage at any time. You must use network pharmacies to fill your prescriptions, except under non-routine circumstances when you cannot reasonably use network pharmacies. Limitations, copayments, and restrictions may apply.

This information is available for free in other languages. Please contact our customer service number at 1-888-522-1298 for additional information. TTY/TDD users should call 1-866-522-2731. We are available 24 hours a day, 7 days a week (including holidays).

Esta información está disponible de forma gratuita en otros idiomas. Por favor, comuníquese con el departamento de servicios para los miembros al 1-888-522-1298 para obtener información adicional. Los usuarios de TTY deben llamar al 1-866-522-2731. Estamos disponibles las 24 horas del día, los 7 días a la semana, (incluso los días festivos). 

Plan member materials are available in a different language or format, including large print, audio, and Braille or upon request.

Los materiales para miembros del plan están disponibles en otros idiomas o formatos como letra grande, audio, y braille a su solicitud

For more information about the Plan's coverage for your Part D prescription drugs, see Chapter 5 in the Evidence of Coverage (PDF).

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