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Latest News - Statewide Initiative Supports Behavioral Health of I.E. Youth

h Molina Healthcare, County Behavioral Health, the Offices of Education in Riverside and San Bernardino counties, and select local school districts and charter schools to implement the Student Behavioral Health Incentive Program (SBHIP).  The three-year program is in accordance with the California Department of Health Care Services’ (DHCS) goal to expand prevention and early intervention behavioral health services in schools and provides financial incentives to partnering school districts and charter schools. A total of $389 million has been allocated for California. Between both IEHP and Molina Healthcare, up to $50,845,334 can be utilized to support this program. According to the American Psychological Association, one in five young women and one in ten young men experience a major depressive episode before the age of 25. The COVID Collaborative also notes one in 330 California children have lost either a parent or caregiver in the last two years, adding significant stress and trauma to the lives of California’s youth, along with stay-at-home orders and remote learning.  “If the past few years have taught us anything, it’s that we need to be proactive in addressing mental health and wellness needs early on, before traumas have a chance to manifest later in life,” said Amrita Rai, IEHP’s clinical director of community behavioral health.  Through SBHIP efforts, existing mental health initiatives will be bolstered, and coordination between schools, managed care plans, county behavioral health and community partners aim to address the equity gap and improve access to mental health prevention and treatment for students.  Resources will be directed to fill gaps in these areas throughout the participating schools and their respective communities. Services will be limited to schools who are participating in SBHIP and who receive funding.   “We are well into a crisis when it comes to the mental health and wellness of our youth. Now is the time to be bold and work tirelessly for our children because what we do now will affect generations to come,” said Rai. “Why not focus our resources, our passion, and our commitment back into the community and schools? Our children spend most of their lives in school, which makes this multi-organizational partnership so worthwhile.” Partnerships with local education agencies and school sites include San Bernardino County Superintendent of Schools (SBCSS); Riverside County of Education; Palm Springs Unified School District; Hemet Unified School District; San Bernardino City Unified School District; Rialto Unified School District; Victor Valley Union High School; Ontario-Montclair School District; Leadership Military Academy; Nuview Union School District; Provisional Accelerated Learning Academy; and Riverside County Office of Education Alternative Education Program.  While the initiative will begin at these partner sites, it is anticipated that learnings would benefit other schools and districts interested in implementing similar programs in the future.   “San Bernardino County Superintendent of Schools recognizes the growing mental health crisis among our youth and supports this joint effort to address this critical issue,” said County Superintendent Ted Alejandre. “SBCSS seeks to build capacity within countywide systems and increase access to much needed support to ensure every child receives the services they need when they need them.”  “Educators at the Riverside County Office of Education and within all Local Educational Agencies (LEA) in Riverside County, are vitally interested in addressing the needs of the whole student beyond the classroom. Linking arms with partners across the county via the Student Behavioral Health Incentive Program (SBHIP) will equitably provide mental health services to those who might not otherwise have access to this level of support,” said Riverside County Superintendent of Schools, Dr. Edwin Gomez. Selection of school districts and charter schools was dependent on DHCS guidelines and considered specific criteria, such as the number of students who received Medi-Cal, were foster youth or English learners, received free or reduced priced meals, were interested in participating in the program and other factors.  “It’s the right thing to do. This program gives us a great opportunity to extend both heart and hand to children in our community,” said Dr. Takashi Wada, IEHP’s chief medical officer. “Working together, we can equip them with necessary skills, habits and care they can use today and through adulthood, setting them up for a healthier and happier tomorrow.”  “The COVID-19 pandemic has exacerbated and elevated behavioral health needs in our communities, including in young people. Mental and emotional wellbeing make up a significant portion of overall health and healthy youth lead to improved community wellness. We are proud to partner with IEHP, local offices of education and mental health professionals to address the youth behavioral health crisis in tangible, preventative ways.” said Dr. Sayeed Khan, chief medical officer at Molina Healthcare. Program preparation began this year and will support a January 2023 launch at all 10 participating local education agencies. Through careful planning and implementation, the program will aim to build and support a sustainable system beyond the life of the program, which will end in December 2024. alt=" "="" src="-/media/7c6d40e217094fb1be8ec6cec9473878.ashx?h=233&w=350" class="" />

Senior Health - Senior Health

This includes making a plan to improve safety and taking routine tests and health screenings to detect health problems and treat them early. Advanced Care Directive What’s an Advanced Care Directive and why do I need someone else to help me? Advanced Care Directive is a specific type of power of attorney or health care proxy, in which the person authorizes someone (an agent) to make decisions on their behalf when they are unable to do so. Decisions can be large and small.  For example, “Who will be responsible for communicating with your family?” or “In the final stages of living, do you want to be at home?” IEHP offers free Advanced Care Directive Workshops to help you. Call IEHP Health Education Department at 1-866-224-IEHP (4347) or 1-800-718-4347 for TTY users to see if a workshop is coming up near you! See also: Advanced Care Directive Guide (PDF) Advanced Care Directive Form (PDF) PREPARE: A California program to help you make medical decisions for yourself and others. National Library of Medicine: Seniors' Health You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Download Adobe Acrobat Reader.

Plan Updates - Updates

l Notes for DY 2 to 8 (PDF) Core Quality Withhold Technical Notes for DY 2 to 10 (PDF) Riverside University Health System - Health Advisory Influenza (PDF) A Message From IEHP Medical Director, Dr. Takashi Wada The 2022-2023 influenza season continues to coincide with circulation of COVID-19 virus (SARS-CoV-2). As of August 2022, approximately 94.2 million cases of COVID-19 had been reported in the United States. Influenza vaccination remains an important tool for the prevention of potentially severe respiratory illness, which helps decrease the stress on the U.S. health care system. IEHP DualChoice members who are 18 years of age or older may obtain flu vaccines through the IEHP Pharmacy Vaccine Network. Flu Vaccine Notice: Access to Pharmacy Vaccine Network (PDF) Frequently Asked Influenza (Flu) Questions: 2022-2023 Season (CDC Recommendations) What’s New for 2022-2023  By clicking on these links, you will be leaving the IEHP website. The composition of flu vaccines has been updated. For the 2022-2023 flu season, there are three flu vaccines that are preferentially recommended for people 65 years and older. These are Fluzone High-Dose Quadrivalent vaccine, Flublok Quadrivalent recombinant flu vaccine and Fluad Quadrivalent adjuvanted flu vaccine. The recommended timing of vaccination is similar to last season. For most people who need only one dose for the season, September and October are generally good times to get vaccinated. Vaccination in July and August is not recommended for most adults but can be considered for some groups. While ideally it’s recommended to get vaccinated by the end of October, it’s important to know that vaccination after October can still provide protection during the peak of flu season. The age indication for the cell culture-based inactivated flu vaccine, Flucelvax Quadrivalent (ccIIV4), changed from 2 years and older to 6 months and older. Pre-filled Afluria Quadrivalent flu shots for children are not expected to be available this season. However, children can receive this vaccine from a multidose vial at the recommended dose. Preventive Services Immunizations  By clicking on these links, you will be leaving the IEHP website. CDC ACIP Vaccine Recommendations and Guidelines: https://www.cdc.gov/vaccines/hcp/acip-recs/index.html CDC ACIP Immunization Schedule for Children: https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html CDC ACIP Immunization Schedule for Adults: https://www.cdc.gov/vaccines/schedules/hcp/adult.html USPSTF Task Force's Immunization Recommendations: https://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=immunization California Immunization Registry Portal (CAIR): https://cair.cdph.ca.gov/CAPRD/portalInfoManager.do Immunization Timing 2022 (PDF) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Plan Updates - Coronavirus (COVID-19) Advisory

e Control and Prevention (CDC) is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus that was first detected in China and which has now been detected in almost 70 locations internationally, including in the United States. The virus has been named "SARS-CoV-2" and the disease it causes has been named "coronavirus disease 2019" (abbreviated "COVID-19"). IEHP will continually update you on the latest recommendations, news, and resources on COVID-19 as it becomes available. COVID-19 Therapeutics Available for Members In an effort to provide the most up-to-date treatments against COVID-19, IEHP continues to maintain a list of providers, including but not limited to infusion clinics, ancillary, hospital and non-hospital based infusion centers offering COVID-19 infusion therapy treatment. Under all Member coverage, outpatient COVID therapeutics will be offered immediately after a Member is determined to be clinically eligible under and Emergency Use Authorization (EUA). List of Infusion Sites COVID-19 Infusion Treatments by Organization (PDF) Test-To-Treat COVID-19 Vaccine Reimbursement for Medi-Cal Providers DHCS has carved out the COVID-19 vaccine from Medi-Cal managed care health plans and will reimburse providers under the Fee-for-Service (FFS) delivery system for both medical and pharmacy claims. Medi-Cal will reimburse the associated COVID-19 vaccine administration fee at the allowable Medicare rate for all claims (medical, outpatient, and pharmacy), based on the number of required doses for all Medi-Cal beneficiaries. For further information: June 13, 2022 - DHCS COVID-19 Vaccine Administration Provider FAQs   How Vaccines Build Immunity While the COVID-19 vaccines are relatively new - the technology and science behind the vaccines have been in development for decades. In the video below, we demonstrate how years of vaccine research and advanced technology allowed researchers and scientists worldwide to be prepared to develop an mRNA vaccine that could help fight the spread of a global infectious disease. FIND A TESTING AND VACCINATION SITE NEAR YOU TODAY! RIVERSIDE Riverside County Public Health COVID Testing Site Vaccine Information Vaccine Locations & Registration Registrations encouraged but not required for: The CDC recommends everyone ages 6 months and older get vaccinated against COVID-19 as well as a booster for everyone 5 years and older, if eligible. For more information, visit the Riverside Country Vaccine webpage. Teenagers 5 to 17 years old must register for a vaccination clinic that offers the Pfizer vaccine and be accompanied by a parent/legal guardian or present a signed written consent from a parent/legal guardian and be accompanied by an adult. Pfizer Minor Consent Form (PDF) | Spanish  The Moderna and Johnson & Johnson vaccines can only be given to individuals age 18 years and older. Johnson & Johnson Fact Sheet (PDF) | Spanish - Published April 26, 2021  SAN BERNARDINO San Bernardino County Public Health COVID Testing Site Vaccine Locations & Registration Additional Dose and Boosters Information COVID-19 Vaccine Consent Form (PDF) | Spanish   The CDC recommends everyone ages 6 months and older get vaccinated against COVID-19 as well as a booster for everyone 5 years and older, if eligible. For more information, visit the San Bernardino County Pediatric COVID-19 Vaccination web page Walk-ins are now available at County-operated vaccination sites. Walk-in individuals will not need to bring any additional information to the site, however be prepared to register on site, which will include answering health screening questions. Walk-ins may experience longer wait times and availability may vary based on site demand.  Centers for Disease Control and Prevention (CDC) Clinical Care Guidance Vaccines Vaccination Plans January 10, 2022 - Continued Coverage of COVID-19 Diagnostic Testing (PDF) CalVax CalVax is a state-wide centralized system for health care Providers enrolled or interested in participating in the California COVID-19 Vaccination Program, developed by the California Department of Public Health (CDPH). The new CalVax platform will provide a system to manage vaccine enrollment, ordering, inventory, administration, reporting and data analytics. Training materials such as job aids, videos, and recorded demos will be available to support all system users as they navigate through the new CalVax platform (mycavax.cdph.ca.gov).  CA Notify • CA Notify Flyer in English (PDF) and Spanish(PDF) • CA Notify Shareable Tools for web and social media • CA Notify Website  Financial Assistance Resources Riverside County Medical Association - COVID-19 Financial Toolkit for Medical Practice U.S. Department of Health & Human Services (HHS) CARES Provider Relief Fund Learn more about the Provider Relief Fund (PRF) Provider Relief Fund (PRF) Portal U.S. Small Business Administration. Borrowers may be eligible for Paycheck Protection Program (PPP) loan forgiveness. See if you're eligible here. Guidance Regarding Monoclonal Antibody Treatment for COVID-19 Even with decreasing cases and hospitalizations, those with high-risk conditions who have tested positive for COVID-19 are encouraged to get monoclonal antibody treatment at Riverside University Health System (RUHS) – Medical Center. In January, the U.S. Food and Drug Administration (FDA) limited the use of certain monoclonal antibody therapies that were ineffective against the omicron variant. In response, RUHS – Medical Center is administering sotrovimab, an IV infusion shown to be effective against omicron and other variants. January 14, 2022 - RUHS-Medical Center Offers Monoclonal Antibodies Treatment Quest Diagnostic For more information, please visit Quest Diagnostics FAQs COVID-19 Specimen Collection Instructions (Watch Video Here)                        Fact Sheet for Healthcare Providers for COVID-19 Testing (View PDF Here)   LabCorp For more information, please visit LabCorp's COVID-19 page. Which COVID-19 Test is Right For You? COVID-19 FAQs If you do not have the ability to collect specimens for COVID-19, please refer to your County Public Health resources for guidance on directing Members for testing.   Telehealth IEHP is strongly encouraging the utilization of telehealth for visits that can be conducted over the phone or via other audiovisual telecommunications.  IEHP has published a telehealth FAQ which is available here: Telehealth Services Due to Limiting Exposure to COVID-19 (PDF)- October 17, 2022 Remember: IEHP Provider Telehealth Information (PDF) IEHP expects that Providers will offer telehealth services and support to their Members during their published business hours.  Existing authorizations are valid and do not need to be changed even if services are being provided via telehealth You can request a POS 02 or POS 10 on your authorization however if you do not, you can still utilize the authorization for telehealth services even if a different POS was approved. When billing the claim for the service, you will utilize a POS 02 or POS 10. ONLY Services that are deemed clinically appropriate to provide via telehealth should be provided via telehealth. If there are treatments, exams, procedures or other services that cannot be provided via telehealth, those are not eligible to be provided via telehealth.  Provider Resources for Combatting COVID-19 Fatigue ACEs Aware - Support for those on the front lines as California addresses stress and anxiety related to COVID-19   Department of Health Care Services (DHCS) and California Department of Public Health (CDPH) COVID 19 Response Department of Health Care Services (DHCS) California Department of Public Health (CDPH)   The California Department of HealthCare Services (DHCS) has published a COVID-19 response page with guidance for Providers and Partners, Home and Community Based Services and Behavioral Health. Found Here: DHCS COVID‑19 Response | DHCS COVID-19 Medi-Cal FAQs The California Department of Public Health (CDPH) also has a page with new guidance documents and additional resources and news releases. Found Here: CDHP COVID-19 Updates Centers for Medicare & Medicaid Services (CMS) CMS Health Care Provider Toolkit - Help link to COVID-19 related questions   San Bernardino Medical Society The San Bernardino County Medical Society promotes the science and art of medicine, the care and well-being of patients, the protection of the public health and to promote the betterment of the medical profession. The latest news, research and developments on the COVID-19 outbreak for physicians can be found here: SBCMS COVID-19. January 07, 2021 - COVID-19 Vaccines For All Practicing Physicians and Staff – San Bernardino County (PDF) 2-1-1 San Bernardino County Resource & Information Guide   2-1-1 San Bernardino County has curated a COVID-19 Resource & Information Guide and will update this page regularly as the situation changes. For more information, please click here.   Correspondences May 2, 2022 - Webinar - IWIN COVID and the Community April 13, 2022 - COVID-19 “Test to Treat” Initiative April 8, 2022 - 2nd Round of Free At-Home COVID-19 Test Kits Available February 23, 2022 - COVID-19 Oral Antiviral Drugs – Coverage and Dispensing Pharmacies  January 28, 2022 - Free OTC COVID-19 Antigen Kits Available January 26, 2022 - Free At-Home COVID-19 Tests Available by Request January 5, 2022 - Extending SNF COVID-19 Per Diem Rate December 22, 2021 - COVID-19 Vaccine Billing for Medicare Advantage Enrollees Effective DOS January 1, 2022 December 16, 2021- COVID-19 Vaccine Incentive Program – Program Guide December 16, 2021 - REMINDER: COVID Vaccine Enrollment Survey - Your Response is Requested December 10, 2021 - REMINDER: COVID Vaccine Enrollment Survey - Your Response is Requested December 10, 2021 - COVID-19 Vaccine Billing for Medicare Advantage Enrollees December 3, 2021- COVID-19 Vaccine Enrollment Survey December 1, 2021- CDC Encourages COVID Booster Due to Omicron Variant November 17, 2021- UPDATE! COVID-19 Vaccine FQHC, RHC and IHF Incentive Program November 9, 2021- Three Upcoming Webinars on Building COVID-19 Vaccine Trust October 22, 2021- 2021 COVID-19 Vaccination Member Incentive October 22, 2021- NEW!!! COVID-19 Vaccine FQHC and RHC Incentive Program October 19, 2021- COVID-19 Treatment – RUHS Monoclonal Antibody Treatment Center October 12, 2021- Reminder - NEW COVID-19 Vaccine PCP Incentive Program - Kickoff Meeting October 6, 2021- NEW COVID-19 Vaccine PCP Incentive Program- Kickoff Meetings October 4, 2021- New COVID-19 Vaccine PCP Incentive Program September 8, 2021- CDPH Webinar: How to Have Crucial Conversations About COVID-19 Vaccines – Thursday, September 9th August 18, 2021 - Riverside County Public Townhall on COVID-19 Vaccines For additional resources regarding COVID-19, please visit: Centers for Disease Control and Prevention (CDC) Riverside County Public Health San Bernardino Public Health You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Clinical Information - Medication Therapy Management

MTM is a term to describe a broad range of services offered by Pharmacists on our health care team.  The IEHP Clinical Pharmacy Team reviews the Members’ medicines, making sure they’re taking the right ones for their health conditions. If you are a Provider for IEHP Members who qualify for the MTM Program, you can let them know to look out for a letter from us. They will be enrolled automatically—unless they opt-out. MTM is offered to Members at no additional cost. IEHP's MTM services include these core elements: Medication therapy reviews Medication education Disease management A team of Pharmacists and Doctors developed these MTM services to help provide better prescription drug coverage for our Members. For example, MTM also helps identify possible medication errors. Medicare MTM Program This is a free program under Medicare Part D for IEHP DualChoice Members who have multiple medical conditions, take many prescription drugs, and have high drug costs to assist with better medication management and overall health. IEHP DualChoice Members’ enrollment includes a yearly comprehensive medication review (CMR) and regular targeted medication review (TMR) services throughout the year. MTM services include: Comprehensive Medication Review (CMR) An IEHP Clinical Pharmacist will provide an annual comprehensive review of the IEHP DualChoice Member’s medications over the phone. The Pharmacist will review IEHP DualChoice Member’s medications and make clinical recommendations to IEHP DualChoice Members and Providers. Targeted Medication Review (TMR) The IEHP Clinical Pharmacy Team will also offer TMRs through the year by reviewing issues with the participating IEHP DualChoice Member’s medicines. The team will perform TMRs for all enrolled beneficiaries every three months. The beneficiary may get TMR recommendations by mail and their Primary Care Provider may receive recommendations by fax—if the IEHP Clinical Pharmacy Team deems it necessary. For more information, IEHP DualChoice Members eligible for CMR or TMR services can call 1-877-273-IEHP (4347), 8am-5pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.  Click here for a blank personal medication list. Medicare MTM Program services may have limited eligibility criteria. They are available for the following conditions: 1.   The IEHP DualChoice Member has a minimum of three (3) disease states: Bone Disease-Arthritis-Osteoporosis Bone Disease-Arthritis-Rheumatoid Arthritis Chronic Heart Failure (CHF) Diabetes Dyslipidemia End-Stage Renal Disease (ESRD) Hypertension Mental Health Chronic/ Disabling Mental Health Conditions Respiratory Disease – Asthma Respiratory Disease – Chronic Obstructive Pulmonary Disease (COPD) 2.   The IEHP DualChoice Member is prescribed a minimum of five (5) different medications to treat those disease states: ACE-Inhibitors Angiotensin II Receptor Blockers (ARBs) Antidepressants Antihyperlipidemic Antihypertensives Antipsychotics Beta Blockers Bronchodilators Calcium Channel Blockers Disease-Modifying Anti-Rheumatic Drugs (DMARDs) Diuretics Insulins Oral Hypoglycemics Selective Serotonin Reuptake Inhibitors (SSRIs) Tumor Necrosis Factors (TNFs) Inhaled Corticosteroids Calcimimetic Cardiac Glycoside Colony Stimulating Factors Glucagon-Like Peptide-1 Glucocorticosteroids Neprilysin Inhibitor NSAIDs Phosphate Binders Vitamin D Analogs 3. Drug costs of $1,174 (one-fourth of $4,696) for the previous three months are likely to be incurred.   For answers to frequently asked questions, please download the FAQ document below: MTM FAQs (PDF) For details, contact the IEHP Pharmaceutical Services Department at (909) 890-2049, Monday-Friday, 8am-5pm. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Information on this page is current as of October 2022. H5355_CMC_20_1900233_Accepted 

Join Our Network - Community Supports

ffer in place of services or settings covered under the Medicaid State Plan. These services should be medically appropriate and cost-effective alternatives. Beginning January 1, 2022, Inland Empire Health Plan (IEHP) is offering 11 of the 14 DHCS Preapproved Community Supports services: Asthma Remediation Community Transition Services/Nursing Facility Transition to a Home Home Modifications Housing Deposits Housing Tenancy and Sustaining Services Housing Transition Navigation Services Medically Supportive Food/Meals/Medically Tailored Meals Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Recuperative Care (Medical Respite) Short-Term Post-Hospitalization Housing Sobering Centers (Riverside County) Tentative Upcoming Services Day Habilitation (Date TBD) Personal Care and Homemaker Services (Date TBD) Respite Services (Date TBD) Community Supports FAQs (PDF) Please return the completed Community Supports Service Provider Assessment (PDF) via email at DGCommunitySupportTeam@iehp.org.   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Provider Resources - Non-Contracted Providers

bers triage, screening, and advice services by telephone 24 hours a day, 7 days a week through its Nurse Advice Line (NAL). By calling the NAL, Members receive assistance with access to urgent or emergency services from an on-call physician, or licensed triage personnel. IEHP Members can reach this 24/7 Nurse Advice Line at (888)-244-IEHP (4347) or 711 (TTY). Post-Stabilization Care IEHP requires contracted and non-contracted hospitals to obtain prior authorization for post-stabilization care for Members (patients). IEHP requests the patient’s diagnosis as indicated by the treating physician or surgeon and any other information reasonably necessary for the Plan to decide on whether to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer to another facility. The hospital should request prior authorization from IEHP’s Utilization Management (UM) Department by: Phone at (866) 649-6327; or Fax at (909) 477-8553 to send clinical notes for medical necessity review.   IEHP makes every effort to respond to requests for necessary post-stabilization care within thirty (30) minutes of receipt. The services are considered approved if IEHP does not respond within this timeframe. All subsequent hospital day are subject to review for medical necessity. IEHP will inform the provider of the Plan’s decision and will coordinate the transfer of the Member if IEHP denies the request for authorization of post-stabilization care and elects to transfer the Member to another health care provider. Non-Emergency Services If a Member presents at the emergency department for non-emergency services, please refer the Member to their IEHP Member Handbook, section 3 (How to Get Care), which outlines the process for obtaining a referral. Claims Reimbursement Complete facility claims for authorized health care services must be sent to: Inland Empire Health Plan Attn: Claims Department – IEHP Direct PO BOX 4349 Rancho Cucamonga, CA 91729-4349 Complete professional claims for authorized health care services must be sent to: For IEHP-Direct Members, please send to address above. For IEHP Members assigned to an IPA, please click for here for more information on how to send to the appropriate IPA.   Billing IEHP Members Providers under the Medi-Cal program must not submit claims to, demand or otherwise collect reimbursement from a Medi-Cal beneficiary, or from other persons on behalf of the beneficiary, for any service included in the Medi-Cal program’s scope of benefits in addition to a claim submitted to the Medi-Cal program for that service. Report an Issue To report any issues with this system or process or for any questions, please send an email to DGHospitalRelationsServiceTeam@iehp.org You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Medical Benefits & Coverage Of Medi-Cal In California

d services as a Member of IEHP. Your covered services are at no cost if they are medically necessary, and you get the approved services from our Provider network. “Medically necessary” means it is reasonable and needed to protect life, to keep you from becoming seriously ill or disabled, or to reduce pain from a diagnosed disease, illness or injury. To learn more about IEHP’s benefits and services, read Chapter 4 of the IEHP Medi-Cal Member Handbook (PDF) or call IEHP Member Services at 1-800-440-IEHP (4347), Monday–Friday, 7am–7pm, and Saturday–Sunday, 8am–5pm. TTY users should call 1-800-718-4347. IEHP offers these types of services: Outpatient (ambulatory) services* Emergency services Transgender services* Hospice and palliative care* Hospitalization* Maternity and newborn care Mental health services Prescription drugs Rehabilitative and habilitative services and devices* Laboratory and radiology services, such as X-rays* Preventive and wellness services and chronic disease management Sensitive services Substance use disorder treatment services Pediatric services Vision services* Non-emergency medical transportation (NEMT) Non-medical transportation (NMT) Long-term services and supports (LTSS) Telehealth services Some of the services listed are covered only if IEHP or your IPA approves first. Covered services that may need an approval from IEHP or your IPA or medical group first are marked by an asterisk (*). Vision services The plan covers: Routine eye exam once every 24 months; IEHP may pre-approve (prior authorization) additional services as medically necessary. Eyeglasses (frames and lens) once every 24 months; contact lens when required for medical conditions such as aphakia, aniridia and keratoconus  Limitations Single vision lenses only. Members under 18 automatically get polycarbonate lenses. Contacts in lieu of glasses only if medically necessary. Dental services The Medi-Cal Dental Program covers some dental services, such as: Diagnostic and preventive dental hygiene (e.g., examinations, x-rays, and teeth cleanings) Emergency services for pain control Tooth extractions Fillings Root canal treatments Prosthetic appliances Orthodontics for children who qualify Members can access dental services through providers enrolled in the Medi-Cal Dental Program. They will advise you on the best course of treatment and when these services may be attained. To learn more about dental services, call the Medi-Cal Dental Program at 1-800-440-IEHP (4347) / TTY (800) 718-4347. You may also visit the Denti-Cal website at www.smilecalifornia.org. Transportation services Your Medi-Cal benefits include round trip transportation for plan-covered health services and Medi-Cal-covered services, such as mental health, substance abuse and dental, within San Bernardino and Riverside counties. The plan covers: Visits to your Primary Care Doctor, Specialists and urgent care clinics. Visit for dental, mental health, substance abuse and other services. Exclusions and Limitations IEHP does not cover: One-way trips and non-medical visits. Visits to Social Security, Workers Compensation Claims, Personal Injury cases, Courts, Parole or Probation or Social Services Offices. IEHP offers two types of transportation: Bus passes* for Non-Medical Transportation (NMT): approved when you do not have any physical or medical issue that does not allow you to travel by bus, car, taxi or other forms of public transportation. Uber for Non-Medical Transportation (NMT): approved when your area doesn’t support bus passes, or you are crossing counties. For this type of transportation, you need to wait for your ride at the curb. Non-Emergent Medical Transportation (NEMT): approved when your medical or physical issue does not allow you to travel by bus, car, taxi or other forms of public transportation. For this type of transportation, your Doctor must submit a Physicians’ Certification Statement online. Effective March 1, 2020, transportation for routine medical visits including Behavioral Health and Substance Use must be scheduled five business days before your appointment. To set up transportation, call IEHP Transportation Department at 1-800-440-4347 (option two), Monday – Friday, 8am – 5pm. TTY users should call 1-800-718-4347 (option two). *For bus passes, call our transportation vendor Call the Car (CTC) at 855-673-3195 select option 1. Once you get your bus pass, you can use this for all of your health care visits. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. To download a free copy click Adobe Acrobat Reader.  The Postpartum Care Extension Program The Postpartum Care Extension Program provides extended coverage for Medi-Cal members during both the pregnancy and after pregnancy. The Postpartum Care Extension Program extends coverage by IEHP for up to 12 months after the end of the pregnancy regardless of income, citizenship, or immigration status and no additional action is needed. Rapid Whole Genome Sequencing Rapid Whole Genome Sequencing (rWGS), including individual sequencing, trio sequencing for a parent or parents and their baby, and ultra-rapid sequencing, is a covered benefit for any Medi-Cal member who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit. rWGS is an emerging method of diagnosing conditions in time to affect ICU care of children one year of age or younger. If your child is eligible for California Children’s Services (CCS), CCS may be responsible for covering the hospital stay and the rWGS. Referrals For some types of care, your PCP or specialist will need to ask IEHP for permission before you get the care. This is called asking for prior authorization, prior approval, or pre-approval. It means that IEHP must make sure that the care is medically necessary or needed based on appropriateness of care and services and existence of coverage. Care is medically necessary if it is reasonable and necessary to protect your life, keeps you from becoming seriously ill or disabled, or reduces severe pain from a diagnosed disease, illness or injury. For some services, you need pre-approval (prior authorization). Under Health and Safety Code Section 1367.01(h)(2), IEHP will decide routine pre-approvals within 5 working days of when IEHP gets the information reasonably needed to decide. For requests in which a provider indicates or IEHP determines that following the standard timeframe could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function, IEHP will make an expedited (fast) pre-approval decision. IEHP will give notice as quickly as your health condition requires and no later than 72 hours after receiving the request for services. If IEHP does not approve the request, IEHP will send you a Notice of Action (NOA) letter. The NOA letter will tell you how to file an appeal if you do not agree with the decision. IEHP will contact you if IEHP needs more information or more time to review your request. Continuity of Care  If you now go to providers who are not in the IEHP network (out-of-network), in certain cases you may get continuity of care and be able to go to them for up to 12 months. If your providers do not join the IEHP network by the end of 12 months, you will need to switch to providers in the IEHP network. If you are a new Member, you may request to keep getting medical services from an out of network provider if you were getting this care before enrolling in IEHP. IEHP will decide if this treatment with an out of network provider is medically appropriate. Continuity of care does not extend to durable medical equipment, transportation, ancillary services, carved out services or services not covered by Medi-Cal. To learn more about continuity of care and eligibility qualifications, call IEHP Member Services at 1-800-440-IEHP (4347). Prescription drugs Most prescription drugs are covered by Medi-Cal Rx, some drugs may be covered by IEHP. Your provider can prescribe you drugs that are on the Medi-Cal Rx Contract Drugs List. To find out if a drug is on the Contract Drug List or to get a copy of the Contract Drug List, call Medi-Cal Rx at 1-800-977-2273 (TTY 1-800-977-2273 and press 5 or 711), visit the Medi-Cal Rx website at www.MediCalRx.dhcs.ca.gov/home/, or call IEHP Member Services at 1-800-440-IEHP (4347), Monday-Friday, 8am-5pm. TTY users should call 1-800-718-4347 or 711. Pharmacies If you are filling or refilling a prescription, you must get your prescribed drugs from a pharmacy that works with Medi-Cal Rx. You can find a list of pharmacies that work with Medi-Cal Rx in the Medi-Cal Rx Pharmacy Directory at www.Medi-CalRx.hcs.ca.gov/home/. You can also find a pharmacy near you by calling Medi-Cal Rx at 1-800-977-2273 (TTY 1-800-977-2273 and press 5 or 711). Or call IEHP Member Services at 1-800-440-IEHP (4347), Monday-Friday, 8am-5pm. TTY users should call 1-800-718-4347 or 711.  

Pharmacy Services - Academic Detailing

treach program for our providers and pharmacies. We perform phone and one-on-one outreaches with physicians, nurse practitioners, physician assistants, and pharmacy staff. Our goal is to transform the prescriber and pharmacy practice and enhance the provider, pharmacist and member experience. Clinical Drug Education Clinical Drug Education provides materials that focus on a specific drug, drug class, and/or disease state. These materials contain pharmacological and clinical practice information to assist providers and pharmacies in their practice. As new drug information is available, it is important to stay up to date on clinical research findings to assist with member care and medication-use decisions.   Practice Development Practice development education provides materials that focus on enhancing provider and member experience. The materials contain guidance on Formulary Utilization and PA submissions as well as insights regarding electronic prescribing and electronic health records. It is our commitment to provider practice optimization tools and resources to enhance member care.   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader.  By clicking on this link, you will be leaving the IEHP website. Biosimilars A growing trend in healthcare is the use of biosimilar drugs. The following information will assist you and your practice on prescribing biosimilars. What is a Biosimilar? (PDF) Biological Product Definitions (PDF) Prescribing Biosimilar Products (PDF) Prescribing Interchangeable Products (PDF) Opioid and Chronic Pain Management In collaboration with Riverside University Health System (RUHS) and Centers for Disease Control and Prevention (CDC), IEHP would like to provide the following information to assist you and your practice on prescribing opioids for chronic pain management. CURES CURES FAQ (PDF) CURES 2.0 User Guide (PDF) CURES tips and tricks (PDF) Naloxone Naxolone Drug facts (PDF) Naxolone instructions for use (PDF) First Responder Naxolone administration fact sheet (PDF) Opioid Prescribing Guidelines Medication Assisted Treatment (MAT) and Opioid Treatment Program (OTP) FAQ (PDF) CDC Guideline Infographic (PDF) CDC Guidelines Factsheet (PDF) TurnTheTide Pocket Guide for Prescribing Opioids for Chronic Pain (PDF) CDC Guideline at a Glance  Opioid Tapering Clinical Pocket Guide to Tapering (PDF) Tapering Resource-AAFP (PDF) Opioid Tapering Resource pack (PDF) Pharmacy Medication Assisted Treatment (MAT) for Substance Abuse (PDF) Urine Drug Testing CDC Clinical Practice Guideline for Prescribing Opioids for Pain UDT for monitoring opioid therapy-AAFP (PDF) X-Waiver  X-Waiver resources Removal of DATA Waiver (X-Waiver) Requirement https://www.samhsa.gov/medications-substance-use-disorders/removal-data-waiver-requirement All prescriptions for buprenorphine will now only require a standard DEA registration number. For additional information on the removal of the DATA-Waiver requirement, see the Removal of DATA Waiver (X-Waiver) Requirement. Practice Optimization   Electronic Prescribing (e-Rx) Electronic prescribing is a growing standard in the healthcare industry. Most electronic health record systems offer electronic prescription capabilities. The information below will provide insight to the practice of e-prescribing. Benefits of e-Rx brochure (PDF) Formulary Utilization The IEHP Formulary offers a variety of drugs based on safety and efficacy for any condition. The information below will help you find out how to access and interpret the formulary Medicare FAQ (PDF) The process of submitting a prior authorization may be cumbersome for your practice. The information below will help you understand this process and assist with receiving a proper decision in a timely manner.   For any questions regarding Pharmacy Academic Detailing Training please contact: PharmacyAcademicDetailing@iehp.org     You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website. Information on this page is current as of January 1. 2022  

P4P - Proposition 56 - GEMT - Proposition 56 & GEMT

2016, now includes proposed supplemental payments for physicians participating in Medi-Cal Fee-For-Service (FFS) and Medi-Cal Managed Care. Proposition 56 FAQs SFY 19/20 (PDF) Published: February 18, 2020 Click on the following links to jump to that specific section: Electronic Payments Ground Emergency Medical Transport (GEMT) Payment Adverse Childhood Experiences Screening (ACES) Services HYDE Developmental Screening Services Proposition 56 and GEMT Payment Schedule Family Planning Services Proposition 56 Payment Dispute Process Electronic Payments With the current public health situation that our country is experiencing, it is necessary for IEHP to take additional precautions to ensure the health and well-being of our community. These precautions are being reviewed, and discussed daily, by our Executive leadership team and will be implemented as deemed necessary.  Future COVID-19 precautions may include reduced on-site staffing and prioritization of electronic payments over printed checks. To minimize any disruption or delay in payment, we recommend that you sign up for electronic payments as soon as possible if you have not done so already. Our team is available to assist you with the necessary paperwork required to make this change or to answer any questions you may have. The team can be reached by e-mailing vendormaintenance@iehp.org or by calling (909) 294-3928 and selecting Option 1. Our priority remains keeping our Members, Providers, Vendors, and Team Members safe while doing what we can to minimize the potential spread of the virus. We will continue to work hard to provide you with the level of service you have come to expect during this uncertain time. (Back to Prop 56 Menu) Adverse Childhood Experiences Screening (ACES) Services Proposition 56 Adverse Childhood Experience Screening (ACES) Services (PDF) Published: May 15, 2020 FAQs on Proposition 56 Payment - Adverse Childhood Experience Screening (ACES) Services (PDF) Published: October 14, 2021 PSA Videos: Do More Ask Resilience (Back to Prop 56 Menu) Developmental Screening Services Proposition 56 Developmental Screening Services (PDF) Published: March 19, 2020 FAQs on Proposition 56 - Developmental Screening Services (PDF) Published: October 14, 2021 (Back to Prop 56 Menu) Family Planning Services Proposition 56 - Family Planning Services (PDF) Published: June 1, 2022 FAQs on Proposition 56 - Family Planning Screening Services (PDF) Published: October 13, 2022 (Back to Prop 56 Menu) Ground Emergency Medical Transport (GEMT) Payment The Department of Health Care Services (DHCS) has established a Ground Emergency Medical Transport (GEMT) Quality Assurance Fee (QAF) program. In accordance with 42 USC Section 1396u-2(b)(2)(D), Title 42 of the Code of Federal Regulations part 438.114(c), and WIC Sections 14129-14129.7, Medi-Cal Managed Care Health Plans must provide increased reimbursement rates for specified GEMT services to non-contracted GEMT providers. SPA 18-004 implements a one-year QAF program and reimbursement add-on for GEMT provided by emergency medical transportation providers effective for State Fiscal Year (SFY) 2018-19 from July 1, 2018, to June 30, 2019. GEMT Program Overview (PDF) FAQs on GEMT (PDF) GEMT Dispute Request Form (PDF) Please email completed forms to Prop56Inquiry@iehp.org or fax to (909) 296-3550. (Back to Prop 56 Menu) HYDE Proposition 56 HYDE Services (PDF) Published: May 15, 2020 FAQs on Proposition 56 - HYDE Services (PDF) Published: October 14, 2021 (Back to Prop 56 Menu) Proposition 56 and GEMT Payment Schedule Proposition 56 and GEMT Supplemental Payment Schedule CY2023 Updated: January 6, 2023 (Back to Prop 56 Menu) Proposition 56 Payment Dispute Process Proposition 56 - Paid Claims Dispute Request Form (PDF) Proposition 56 - Encounter Dispute Request Form (PDF) Please email completed forms to Prop56Inquiry@iehp.org or fax to (909) 296-3550. (Back to Prop 56 Menu) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Governing Board - Yxstian Gutierrez

ted to the Moreno Valley City Council in 2013, also serving as a three-term mayor and the city’s first directly elected mayor. Supervisor Gutierrez grew up in Moreno Valley, attending all local public schools. He went on to earn an associate degree from Moreno Valley College, a bachelor’s from California Baptist University, a master’s in education from American InterContinental University and a doctoral degree in special education from Northcentral University. He was appointed to the IEHP Governing Board in January 2023.  

IEHP DualChoice - Prescription Drugs

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. What Prescription Drugs Does IEHP DualChoice Cover? 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.  Find a covered drug below: 2023 Formulary (PDF) Formulary Change (PDF) 2023 Step Therapy (PDF) 2023 Drugs Requiring Prior Authorization (PDF) Which Pharmacies Does IEHP DualChoice Contract With? 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.  2023 IEHP DualChoice Provider and Pharmacy Directory (PDF) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy 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), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347. Out of Network Coverage 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. Changes to the IEHP DualChoice Formulary 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 may make other changes that affect the drugs you take. 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. How will you find out if your drugs coverage has been changed? 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. Getting Plan Approval 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 Medicare Prescription Drug Coverage Determination (PDF) Model Form Instructions 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. Applicable Conditions and limitations 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. Getting a temporary supply 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. To get a temporary supply of a drug, you must meet the two rules below: 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. 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. OR 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 Prescription Drug Coverage and Your Rights Notice- Posting of Member Drug Coverage Rights: 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.   Drug Utilization Management 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. Information on this page is current as of October 01, 2022 H8894_DSNP_23_3241532_M

Upcoming Events - Eat Healthy, Be Active Workshop (Riverside)

arn how to eat healthy on a budget, how to make healthy selections when dining out, and it also reviews the importance of physical activity. Click here to register for this in-person class Location IEHP Community Resource Center (Riverside) 3590 Tyler St Riverside, CA 92503

Upcoming Events - Eat Healthy, Be Active Workshop (Riverside)

how to make small healthy changes to food/drinks choices. Click here to register for this in-person class Location IEHP Community Resource Center (Riverside) 3590 Tyler St Riverside, CA 92503

Upcoming Events - Eat Healthy, Be Active Workshop (Online)

how to eat healthy on a budget, how to make healthy selections when dining out, and it also reviews the importance of physical activity.  Click here to register for this WebEx class   Session Number: 24665575126 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

Upcoming Events - Eat Healthy, Be Active Workshop (Online)

arn how to eat healthy on a budget, how to make healthy selections when dining out, and it also reviews the importance of physical activity. Click here to register for this WebEx class   Session Number: 24657194373 Download Webex for Apple users Download Webex for Android users Download Webex for PC users  

Upcoming Events - Eat Healthy, Be Active Workshop (Online)

to make small healthy changes to  food/drinks choices. Click here to register for this WebEx class   Session Number: 24677191358 Download Webex for Apple users Download Webex for Android users Download Webex for PC users  

Upcoming Events - Eat Healthy, Be Active Workshop (Online)

w to make small healthy changes to food/drinks choices. Click here to register for this WebEx class   Session Number: 24651390587 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

Upcoming Events - Eat Healthy, Be Active Workshop (San Bernardino)

rn how to eat healthy on a budget, how to make healthy selections when dining out, and it also reviews the importance of physical activity. Click here to register for this in-person class Location IEHP Community Resource Center (San Bernardino) 805 W 2nd St San Bernardino, CA 92410

Upcoming Events - Eat Healthy, Be Active Workshop (San Bernardino)

how to make small healthy changes to food/drinks choices. Click here to register for this in-person class Location IEHP Community Resource Center (San Bernardino) 805 W 2nd St San Bernardino, CA 92410