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Starting Your Prescription Coverage
What to Expect
You may receive a letter from CareAdvantage (HMO) that tells you that your prescription has been covered under the Part D transition process.
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You may be taking a drug that is not in the CareAdvantage formulary, or
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You may be taking a drug that is in the formulary that requires prior
approval from CareAdvantage, or has coverage restrictions.
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CareAdvantage will cover a temporary prescription for a 1 month supply of a drug that is not in the formulary, or has restrictions.
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After your first 30-day supply, we will not pay for these drugs.
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Talk to your doctor about how to get your drugs covered by CareAdvantage
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Your doctor can switch your current prescription to a different drug that is covered in the formulary.
You can call the CareAdvantage Unit to ask about other drugs used to treat your medical condition that are in the formulary.
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If you don’t want to switch to a drug in the formulary, you or your doctor can request a formulary exception. Read below …
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Residents of long-term care facilities
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CareAdvantage will cover a temporary 31-day transition supply. Refills will be covered for the first 180 days you are a member of CareAdvantage.
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After your first 180 days of membership, CareAdvantage will cover a 31-day emergency supply of your drug while you request a formulary exception.
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Formulary exceptions
You can ask CareAdvantage to make a formulary exception to cover a drug if your doctor confirms one of the following situations:
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None of the drugs in the CareAdvantage formulary are medically appropriate for treating your condition, or
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A prior authorization, quantity limit, or other limit that CareAdvantage places on a drug you are taking
is not medically appropriate for treating your condition.
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How do I Request a Formulary Exception?
There are 2 ways to request a formulary exception. Choose one.
All formulary exceptions require a medical explanation from your doctor.
To cover a prescription that is not on the list of covered drugs: Your doctor must explain why the prescription is
medically necessary for treating your condition. They need to state if the covered drugs would have negative effects for you, or
would not be as effective as the requested drug.
To change the conditions related to using a drug: To remove a prior authorization, quantity limit, or other
restrictions we have placed on a drug that you are taking, your doctor must state if those conditions would be medically
inappropriate for treating your condition.
Ask for a decision within 1 day or 3 days.
If waiting 3 days for a decision on your formulary exception could seriously harm your health, you can ask for an expedited decision.
If your doctor asks for an expedited decision for you, they can call the CareAdvantage Unit or fax a written statement. HPSM will
make a decision within 1 day if your doctor believes that waiting 3 days could seriously harm you.
If you do not obtain your doctor’s support, HPSM will decide if your health condition requires a fast decision.
HPSM will notify you of the decision on your formulary exception.
We will let you know of a decision no later than 1 day or 3 days, depending on whether your doctor asks for an expedited decision.
How to Make an Appeal if Your Request is Denied
If you receive a denial notice from us, you can request an appeal. You must submit your request for an appeal within 2 months from the date
of your denial notice. If your health could be seriously harmed by waiting up to 7 days, we will expedite your appeal if your doctor asks for
an expedited appeal for you (3 days), or supports you in asking for one.
Complete the Medicare Redetermination Request Form.
For an expedited appeal within 3 days after we receive your request.
- Call the CareAdvantage Unit at 650-616-2174 or
- Fax the Medicare Redetermination Request Form to 650-616-2190
For a standard appeal within 7 days after we receive your request.
Mail the Medicare Redetermination Request Form.
CareAdvantage Unit
650-616-2174
Fax: 650-616-2190
(TTY) 1-800-735-2929
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Health Plan of San Mateo
Attn: Grievance and Appeals Coordinator
701 Gateway Blvd. Suite 400
South San Francisco, CA 94080
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Include this information in your appeal
- name, address, and CareAdvantage member ID number
- reason (s) for appealing the HPSM decision
- evidence from your doctor that supports your appeal
We will review your appeal and give you a decision
If your request is still denied, you can request an independent review of your case by a reviewer outside of our plan.
If you disagree with that decision, you will have the right to further appeal. You will be notified of your appeal rights if this happens.
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