GHP Pharmacy and Part D Program Description
General Information
GEMCare Health Plan is a locally owned and operated MA-PD plan that provides Medicare Prescription Drug Coverage (also call Part D benefits) alongside coverage for medical services available under Medicare Parts A and B. As a member of GEMCare Health Plan you are automatically enrolled in Medicare Part D, Medicare’s prescription drug coverage program. As a result, you are not required to enroll in a separate Part D plan. In fact, as a member of GHP you are not allowed to have another Part D Plan and must receive your Medicare Part D drug benefits through GEMCare Health Plan.
GEMCare Health Plan Contact Information
To contact GEMCare Health Plan for more information, Click here.
Service Area
As a local MA-PD plan, GEMCare Health Plan and the GHP Part D Pharmacy program is local and serves the Kern County geographic area.
Pharmacy Benefits, Premiums, Cost-sharing Information
For more information regarding pharmacy benefits, premiums, and cost-sharing click here and review Sections 2, 9, and 10 of the Evidence of Coverage Document.
If you feel you need help with prescription drug plan costs, read more by linking to Pharmacy FAQ's or to Medicare information about receiving assistance. You may also call 1-800-MEDICARE (1-800-633-4227) to speak with a Medicare Customer Service Representative. TTY/TDD users may call 1-877-486-2048, 24 hours a day/7 days a week.
Pharmacy Access
Part D pharmacy benefits are provided through a network of contracted pharmacies administered by GHP’s Pharmacy Benefits Manager, Pharmaceutical Technologies, Inc. Currently, there are over 100 pharmacies in the GHP network and service area which exceeds CMS requirements for pharmacy access in GHP's coverage area.
To obtain the maximum benefit from the Part D program, you should use a network pharmacy for your prescription needs. You can obtain and be reimbursed for covered drugs received at out-of network pharmacies only in emergency situations or when you are traveling. Click here for detailed information about Out of Network services .
Mail Order Pharmacy Access
The GHP mail-order service is available to fill prescriptions for any drug on the formulary. The process is as follows:
For First Time Users: For your first order, Integrated HMO Pharmacy (IHMO) requires that you fill out the order form and include the original prescriptions from your doctor. This initial order form must include information about you, including the current medications, any known drug allergies, and chronic medical conditions.
If you have any questions, contact IHMO at 1-800-633-7928.
For Ordering Refills: You should order refills when you have 14-21 days supply left. To reorder medications, you have options:
- You can call 1-800-633-7928;
- You can fill out the order form you receive with each order , or,
- You can order your refills online at the IHMO web site: http://ihmo.pti-nps.com.
Note: Remember to include your payment with your refill order to avoid possible delays in processing your prescription order.
When you order prescription drugs by mail-order you must order at least a 60-day supply, and no more than 90-day supply of the drug. Please allow 14-21 days to process and ship your order. If mail order is delayed, you can always obtain a prescription from a local network pharmacy.
Please call Member Services at 1-877-697-2464, (TTY users should call 1-888-833-9312) for more information.
Formulary Terminology and Information
Part D pharmacy benefits are administered through the GHP formulary. The formulary is a list of all prescription drugs covered by GHP. The formulary is created and maintained by physicians and pharmacists. Medications chosen to be on the formulary are reviewed and selected based upon their safety, effectiveness, and, cost. Drugs chosen to be in the formulary are called “formulary drugs”. Drugs not included are called “non-formulary drugs”.
GHP covers both “brand name” and “generic” medications.
Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the FDA to be as safe and effective as the brand name drug.
Newer brand name drugs are under patent and may not have a generic equivalent. As a GHP member you get unlimited formulary generic drugs covered through the Part D coverage gap. That means that even if you reach your initial coverage limit on Part D, GHP will provide coverage for generic drugs (Note: co-payments may still apply).
Brand name drugs are produced and sold under the manufacturer’s brand name. Brand name drugs chosen to be on the formulary are classified as “Preferred” or “Non-Preferred” brand name drugs.
- Preferred brand drugs are drugs determined to be the preferred choice for treatment of a specific condition over other available drugs.
- Non-Preferred brand drugs are drugs that are on the formulary but have not demonstrated superior efficacy and/or safety over listed preferred brand or generic drugs.
If you present a prescription for a brand name drug and a generic alternative is available, the pharmacy is required to dispense the generic form.
If you or your physician request a brand name or non-formulary medication, you or your doctor must submit the exception request. The request must be reviewed and approved by GHP before the requested prescription can be filled.
You may also request GHP to consider changing your cost-sharing responsibility for GHP approved exceptions.
The process whereby GHP reviews the requests for consideration from you or your physician is called the Exception Process. The process includes review of whether or not to cover your medication (Coverage Determination), whether or not to grant approval for a medication no on the formulary (Exception Process). If your request is denied you have the right to file an Appeal.
For more information about the Exception process, click on the link for Coverage Determinations, Exceptions, Appeals and Grievances.
To review a current copy of the formulary, click here to review a Copy of the Formulary.
Both industry best practices and the best interest of Medicare beneficiaries call for limited formulary changes during the benefit year. However, at times the formulary requres change. You will be notified of changes if they adversly affect you. Click here and go to the "Prescription Drugs" Section at the bottom of the page to review this year's Changes and Updates to the Formulary.
Out of Network Coverage
To obtain the maximum benefit from the Part D program, you should use a network pharmacy for your prescription needs. If necessary you can obtain and be reimbursed for covered drugs received at out-of network pharmacies only in emergency situations or when you are traveling. Click here for detailed information about Out of Network service.
Coverage Determinations, Exceptions, Appeals and Grievances
If you are ever dissatisfied with a Coverage Determination or any aspect of our plans, we encourage you to first call Member Services.
You also have the right to file a Grievance or an Appeal. To learn more about Coverage Determinations, Grievances and Appeals, click here.
Quality Assurance
For information about quality assurance and medication safety, click here.
Potential for Contract Termination
GEMCare Health Plan has contracts with Medicare and its provider organizations to provide contracted services to eligible members in the Kern County contract area. At times and for various reasons, the these contracts with GHP may be altered or even terminated, causing a reduction or change in services to you.
If any contract between CMS and GHP or between GHP and the Provider network is altered for any reason, you will be notified of the change in a timely manner in accordance with Medicare regulations and provided with information on the steps you must take to continue to receive services from Medicare.
Member Rights and Responsibilities
For information related to Member Rights and Responsibilities, click here.
Other Pharmacy and Part D Links
Frequently Asked Questions (FAQ's) RE: Pharmacy and Part D