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Member Services: 1-800-838-8271 TTY: 711

To enroll by phone call: 1-800-838-5914

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Providers: We are excited to announce the launch of our new Provider Portal. For access, please fill out our web portal application here.
CORONAVIRUS/COVID-19: Access important information and updates
Members: You can now sign up for the member portal and access your healthcare data.
Providers: We are excited to announce the launch of our new Provider Portal. For access, please fill out our web portal application here.
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CORONAVIRUS/COVID-19: Access important information and updates
Members: You can now sign up for the member portal and access your healthcare data.
Providers: We are excited to announce the launch of our new Provider Portal. For access, please fill out our web portal application here.

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Pharmacy Resources

2023

How to Use Imperial Health Plan Part D Drug Coverage

The contents of the following pages describe the rules you must follow when you get Part D drugs as part of the Plan benefit.

  • How to use the Plan’s Drug Formulary to find which drugs are covered
  • Which drugs are not covered
  • What type of drugs have coverage restrictions and what the restrictions are
  • Where and how to get your drug prescriptions filled
  • The Plan’s programs for drug safety and managing medications
  • The three (3) stages of drug coverage (Initial Coverage stage, Coverage Gap stage, and Catastrophic)
  • What you pay for Prescription drugs in the different coverage stages and cost tiers

Pharmacy Directory

For an updated listing of pharmacies go to the Pharmacy Finder.

For an updated listing of providers go to the Provider Look Up tool.

Drug Formulary

IIn order to help you see which drugs are covered by your plan, click on one of the links below

A coverage determination is an initial coverage decision made by the Plan regarding your Medicare Part D prescription drug.  You can request a coverage determination for your part D drugs when:

  • You want to find out if a certain drug is covered for and whether you meet applicable coverage rules. Certain drugs may be on the Plan’s list of covered drugs (formulary) but may require a prior authorization or approval before it is covered. 
  • You can ask us to pay for a drug you already bought.  
  • You can ask us for an exception.  If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception.” Examples include:  
    • Asking to pay for a lower cost-sharing amount for a covered non-preferred drug 
    • Asking for coverage of a drug that is not on the Plan’s list of covered drugs 
    • Asking us to remove restrictions and extra rules on the Plan’s coverage for drugs such as quantity limits, step therapy and prior authorization requirements.

Important information to know about asking for Exceptions 

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception to be approved.  Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception.  If your health requires a quick response, you can ask us to make a “fast decision.”  For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.  You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought. 

Typically, our Drug List includes more than one drug for treating a certain 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.

What to do 

You, your representative, doctor, or other prescriber may use the form below to submit your request for a Part D coverage determination:  

If you do not use this form, you will need to provide the same information indicated in the form so that we can process your request in a timely manner.   

You can ask for a coverage decision and/or exception by:  

  • Phone: Call Member Services at 1-800-838-8271, TTY: 711 
  • Fax: Submitting a written request or a completed Medicare Prescription Drug Determination Request Form by fax to 1-877-503-7231  
  • Online: covermymeds.com/main/prior-authorization-forms/elixirsolutions/ 
  • Mail your request to:  

Attn: Clinical Services 
7835 Freedom Ave NW
North Canton, OH 44720

To find out more about the Part D Coverage Determination process, please refer to your Evidence of Coverage (EOC) -- see chapter 9, Section 6: "How to ask for a coverage decision or make an appeal." Or call Member Services at the number(s) listed above.

Part D Appeals & Grievances

If the Plan says no to your Coverage Determination or Exception request, you have the right to request an appeal (redetermination) or a grievance. There are two types of formal process for handling problems and concerns about prescription drugs, the Appeals Process, and the Grievance.

Process:
You can request an Appeal (Redetermination) when a prescription drug was denied by the plan that the member believes he or she is entitled to receive. You have the right to ask us for a redetermination (appeal) of our coverage decision, this is considered a Level 1 Appeal. You or your representative must ask for an appeal in writing. If requested by a representative, there are additional steps necessary before the request can be processed (please see the AOR process below). You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. The plan will provide a response to your request no later than 7 calendar days from receipt date of your appeal request.  

Expedited (Fast) Appeal

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision.  If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours.  If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision.  You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

Request For Redetermination of Medicare Prescription Drug Denial

You can ask for a Redetermination by:  

  • Phone: Call Member Services at 1-800-838-8271, TTY: 711 
  • Fax: Submitting a written request or a completed Imperial Health Plan Redetermination Form by fax to 1-626-380-9049 
  • Email: appealsgrievances@imperialhealthplan.com with a completed Imperial Health Plan Redetermination Request Form 
  • Please complete your form and mail to: 

Imperial Health Plan of California, Inc

Attn: Appeals & Grievances  

PO Box 60874  

Pasadena, CA 91116  

Independent Review Organizations; also known as Independent Review Entity (IRE)  

The IRE, MAXIMUS Federal Services, is an independent organization that is hired by Medicare (not the plan). If our plan denies your Level 1 Appeal, you then can choose whether to accept this decision or continue making another appeal. If you decide to go on to a Level 2 appeal, the IRE will review the plan’s decision when we said no to your first appeal. The IRE decides whether the decision we made should be changed.  

Standard Grievance

If you are asking for a standard grievance regarding a complaint or dispute about a non-covered prescription drug or an excluded drug you can request this in any of the ways listed below. The plan will provide a response to you no later than 30 calendar days from receipt date of your grievance.

Expedited (Fast) Grievance

A fast complaint can be requested for the following reasons:

  • If we denied your request for a ‘fast coverage decision’ or a ‘fast appeal’, we will automatically give you the option to request a ‘fast complaint’
  • If we have requested to take an additional 14 days to resolve your appeal or complaint, and you believe we should not take extra days, you can file a “fast complaint”.

If you have a “fast complaint” which meets the above criteria we will give you an answer within 24 hours.

Appointment of Representative Form

This form confirms your request for a person, other than yourself, to act as your representative in connection with an appeal of grievance (complaint) request and must be completed and received before the plan can process your request.  

You can download the Appointment of Representative Form by clicking on your preferred language below. 

If you or your providers have any questions regarding this process, while completing this form, or would like to get the status of an open case, please call our Member Services at: 1-800-838-8271.

You can also refer to Chapter 9 What to do if you have a problem of complaint (coverage decisions, appeals, complaints) in your Evidence of Coverage for more information about appeals and grievances.

Or visit the following Medicare websites for additional information on coverage determinations, exceptions and redeterminations.

If you or your providers have any questions regarding this process, while completing this form, or would like to get the status of an open case, please call our Member Services at: 1-800-838-8271.

If you would like information on how to obtain information about the total number of grievances, appeals, and exceptions filed with our plan, contact us for more information.

You can also file a complaint about the plan by going directly to Medicare and calling 1-800-Medicare or going to https://www.Medicare.gov/MedicareComplaintForm/home.aspx

Transition Policy

Low Income Subsidy

The Low Income Subsidy (LIS) PDFs below will tell you how much help you will get next year towards your drug premium, deductible or co-payments.

Medication Therapy Management Program

To read PDFs, you will need Adobe Acrobat Reader. You can download here.

HOURS OF OPERATION

Member service hours:

April 1 – September 30 8:00 A.M. – 8:00 P.M. PST
Monday – Friday (except holidays)

October 1 – March 31 8:00 A.M. – 8:00 P.M. PST
Monday – Sunday (except holidays)

ADDRESS

Imperial Health Plan of California, Inc.
PO BOX 60874
Pasadena, CA 91116

PHONE

1-800-838-8271

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