CareAdvantage Coverage Determination

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a.m. to 8:00 p.m.</span><br>Office hours: Monday鈥揊riday 8:00 a.m. to 4:00 p.m.<br>Email: <a href="mailto:CareAdvantageSupport@hpsm.org">CareAdvantageSupport@hpsm.org</a></p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h3>More Resources</h3><p><strong>Health Insurance Counseling and Advocacy Program (HICAP)</strong></p><p>Toll Free: <strong>1-800-434-0222</strong></p><p><strong>Call the Legal Aid Society of San Mateo County</strong></p><p>Toll Free: <strong>1-800-381-8898</strong><br></p><h2><br></h2></div> </div> </div> <div class="name-and-phone-list"> <h5> </h5> </div> <div class="name-and-phone-list"> <h5> </h5> </div> </div> </div> </div> <div class="col-xs-12 col-sm-8 col-sm-pull-4"> <div class="content-area container-fluid-margin"> <div class="sf_cols" data-sf-element="Row"> <div class="sf_colsOut sf_1col_1_100"> <div id="Contentplaceholder_TACCE306D001_Col00" class="sf_colsIn sf_1col_1in_100" data-sf-element="Column 1"> <div > <div class="sfContentBlock sf-Long-text" ><p class="plan-name">CareAdvantage Dual Eligible Special Needs Plan (D-SNP) 2024<br></p><h1>Medicine Coverage Determination</h1><p>As your health plan, HPSM makes decisions about your benefits, medicine coverage and how much we will pay for your medical services and medicines. These are called coverage determinations or coverage decisions. </p><p>You or your doctor can request a coverage decision about your prescription medicine coverage when you want us to: </p><ul><li>Approve a medicine that is not in the CareAdvantage Formulary </li><li>Waive our restriction on a medicine you want </li><li>Reimburse you for a medicine you have already paid for </li><li>Approve a brand-name version of a medicine rather than the generic version </li></ul><p>For information regarding coverage decisions related to Medi-Cal Rx covered over-the-counter (OTC) medicines and vitamins, please visit the Medi-Cal Rx website (<a target="_blank" href="https://www.medi-calrx.dhcs.ca.gov" data-sf-ec-immutable="">www.medi-calrx.dhcs.ca.gov</a>). You can also call the Medi-Cal Rx Customer Service Center at <span class="phone">1-800-977-2273</span>.</p><h2 class="mt-4">How to Request a Coverage Decision</h2><p>You or your doctor can request a coverage decision (coverage determination) about your prescription medicine coverage by phone, in person or in writing. </p><p>Your doctor will need to send HPSM a written statement supporting your request. They can use the CareAdvantage Determination Request form, but we will also accept any request that is written and signed by your doctor.</p><p>For coverage decisions related to over-the-counter and certain vitamins covered through Medi-Cal Rx, your doctor will need to send a written statement supporting your request to Magellan. Magellan is the contractor that administers the pharmacy benefits under Medi-Cal Rx. </p><h3>If You Disagree with Our Decision</h3><p>If you do not agree with our coverage decision, you can submit an appeal, which is a formal request for us to review and change our coverage decision. An appeal to a plan about a Part D coverage decision is also called Coverage Redetermination.</p><p>You can submit an appeal by calling our Grievance and Appeals Unit:<br><span class="phone">1-888-576-7227</span> or <span class="phone">650-616-2850</span><br>Hours: Monday鈥揊riday 8:00 a.m. to 5:00 p.m.<br>TTY: <span class="phone">1-800-735-2929</span> or dial <span class="phone">7-1-1</span></p><p>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. You are not required, however, to hire a lawyer to ask for any kind of coverage decision or to appeal a decision.</p><p>For appeals related to Medi-Cal Rx, your doctor must submit the appeals request to Magellan. </p><h3>If You Need an Answer within 24 Hours</h3><p>Call the CareAdvantage Unit to express your specific concern or ask for a change in coverage.</p></div> </div> <div > <div class="sfContentBlock sf-Long-text" ></div> </div> <div > <div class="sfContentBlock sf-Long-text" ></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><div class="space-1"><hr><p>CareAdvantage Dual Eligible Special Needs Plan (D-SNP) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations and restrictions may apply. For more information, call the CareAdvantage Unit or read the <a href="/docs/default-source/member-manuals/careadvantage-2024-member-handbook.pdf?sfvrsn=7248966f_20" title="CareAdvantage D-SNP 2024 Member Handbook">CareAdvantage D-SNP 2024 Member Handbook</a>.</p><p>Benefits and co-pays may change on January 1 of each year.</p><p>If you speak other languages other than English, language assistance services, free of charge, are available to you. Call <span class="phone">1-866-880-0606</span> (TTY: <span class="phone">1-800-735-2929</span> or dial <span class="phone">7-1-1</span>). ( <a target="_blank" title="Download this statement in multiple languages" href="/docs/default-source/member-notices/careadvantage-cmc-non-discrimination-notice.pdf?sfvrsn=b5887102_70">Download this statement in multiple languages</a>.)</p></div></div> </div> <div > <div class="sfContentBlock sf-Long-text" ><div class="mt-3 text-center"><div class="centered mx-auto"><p>H6019_Web2024_M </p><p>Page updated November 1, 2023</p></div></div></div> </div> </div> </div> </div> </div> <div class="container-fluid-margin"> <div > <div class="sfContentBlock sf-Long-text" ></div> </div> </div> </div> </div> </div>  <div id="SpecialWidgetContent_T52A760D8037_Col00" class="sf_colsIn container container-fluid-margin" data-sf-element="Container"> </div> <div class="pre-footer reveal-fade-in"> <div class="container-fluid"> <div class="row"> <div class="col-sm-12"> </div> </div> </div> </div> </main> <footer> <div class="row pb-3"> <div class="col-xs-12 col-sm-3 col-md-3"> <div> <img style="width:150px;" role="presentation" src="/assets/_img/hpsm-logo.png" /> <p class="notranslate"><span class="block">801 Gateway Blvd., Suite 100</span><span class="block">South San Francisco, CA 94080</span></p> <p> Phone: <span style="color:#2e9947;">650-616-0050</span> <br />Fax: <span style="color:#2e9947;">650-616-0060</span> <br />TTY:  <span style="color:#2e9947;">1-800-735-2929</span> <br />or dial <span style="color:#2e9947;">7-1-1</span> </p> <p class="mt-3"> <a style="margin-left:0.5rem;margin-right:1.0rem;" rel="noreferrer" target="_blank" href="https://www.facebook.com/healthplanofsanmateo"> <img style="display: inline;" width="24" height="24" src="https://www.hpsm.org/images/default-source/logos/facebook.svg?Status=Temp&sfvrsn=ac66c4ba_2" role="presentation" alt="facebook" /> </a> <a style="margin-left:1.0rem;" target="_blank" rel="noreferrer" href="https://www.instagram.com/healthplanofsanmateo/"> <img style="display: inline;" width="24" height="24" src="https://www.hpsm.org/images/default-source/logos/instagram.svg?Status=Temp&sfvrsn=d4ddac80_2" role="presentation" alt="instagram" /> </a> </p> </div> </div> <div class="col-xs-12 col-sm-3 col-md-3"> <div> <a id="MemberFooterLink" class="text-lg text-capitalize" title="Members" href="/member">Members</a> <a id="ProviderFooterLink" class="text-lg notranslate" title="Providers" href="/provider">Providers</a> <a id="HealthTipsFooterLink" class="text-lg" title="Health Tips" href="/health-tips">Health Tips</a> <a id="CareerFooterLink" class="text-lg" title="Careers" href="/job-seeker">Careers</a> <a id="AboutUsFooterLink" class="text-lg" title="About HPSM" href="/about-us">About HPSM</a> </div> </div> <div class="col-xs-12 col-sm-3 col-md-3"> <div> <ul style="line-height:1.5rem;"> <li class="nav-item"><a id="ContactFooterLink" href="/contact-us">Contact Us</a></li> <li class="nav-item"><a id="LanguageFooterLink" href="https://www.hpsm.org/docs/default-source/member-notices/language-assistance-tagline.pdf">Language Assistance</a></li> <li class="nav-item"><a id="PrivacyFooterLink" href="/privacy-policy">Privacy Policy</a></li> <li class="nav-item"><a id="NDNFooterLink" href="/non-discrimination-notice">Non-Discrimination Notice</a></li> <li class="nav-item"><a id="AccessibilityFooterLink" href="/help/accessibility">Accessibility Statement</a></li> <li class="nav-item"><a id="ComplianceFooterLink" href="/about-us/governance/compliance">Compliance</a></li> </ul> </div> </div> <div class="col-xs-12 col-sm-3 col-md-3"> <div> <div id="tagline"> <p>Helping San Mateo County鈥檚 vulnerable and underinsured residents live the healthiest lives possible.</p> </div> <br /><br /> <small class="notranslate">Ⓒ 2024 Health Plan of San Mateo</small> </div> </div> </div> </footer>  <script src="/assets/_js/vendor/jquery.easing.1.3.js" type="text/javascript"></script> <script src="/assets/_js/vendor/bootstrap.min.js" type="text/javascript"></script> <script src="/assets/_js/vendor/jasny-bootstrap.js" type="text/javascript"></script> <script src="/assets/_js/vendor/enquire.min.js" type="text/javascript"></script> <script src="/assets/_js/vendor/jQuery.headroom.js" type="text/javascript"></script> <script src="/assets/_js/vendor/hoverIntent.js"></script> <script src="/assets/_js/vendor/jquery.matchHeight.js" type="text/javascript"></script> <script src="https://unpkg.com/scrollreveal/dist/scrollreveal.min.js"></script> <script src="/assets/_js/vendor/bootstrap-responsive-tabs.min.js" type="text/javascript"></script> <script src="/assets/vendor/cubeportfolio/js/jquery.cubeportfolio.min.js"></script>  <script src="/assets/_js/hs.core.js"></script> <script src="/assets/_js/hs.cubeportfolio.js"></script> <script src="/assets/_js/main.js" type="text/javascript"></script> <script src="/Frontend-Assembly/Telerik.Sitefinity.Frontend.Search/Mvc/Scripts/SearchBox/Search-box.min.js?v=MTMuMy43NjQwLjA%3d" type="text/javascript"></script> </body> </html>

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