Part D Prescribed Drugs Coverage
Covered Medication List (Formulary)
Pharmacy and Formulary Specifics
The formulary is a comprehensive list of Part D prescription drugs that are covered. Part D prescription drugs are available through MedImpact Healthcare Systems large network of pharmacies.
The formulary represents the prescription therapies believed to be necessary in quality treatment programs and was designed in consultation with a team of healthcare providers.
Prescribed medications are covered by the Plan as long as the drug is medically necessary, and all Plan rules are followed. Refer to your Evidence of Coverage (EOC) for additional information on Part D Prescription Drug Coverage or call Champion Health Plan.
California
Plan Year 2024 English | Plan Year 2024 Spanish
Formulary Look Up Tool
Step Therapy
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: Champion Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Champion Health Plan before you fill your prescriptions. If you don’t get approval, Champion Health Plan may not cover the drug. Learn more about our Part D Prescribed Drugs: Prior-Authorization, Coverage Determination, and Exceptions.
- Quantity Limits: For certain drugs, Champion Health Plan limits the amount of the drug that the Plan will cover. For example, Champion Health Plan provides 18 tablets per prescription for sumatriptan succinate oral.
- Step Therapy: In some cases, Champion Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Champion Health Plan may not cover Drug B unless you try Drug A first to see if it will be effective for you. If Drug A does not work for you, Champion Health Plan will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary. More information about the restrictions applied to specific covered drugs, prior authorizations, and step therapy restrictions is available on the Covered Medications section of our website or refer to your Evidence of Coverage. You can ask Champion Health Plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition.
Extra Help
Medicare beneficiaries can qualify for Extra Help paying for their monthly premiums, annual deductibles, and co-payments related to Medicare prescription drug coverage.
We estimate the Extra Help is worth about $5,100 per year. To qualify for Extra Help, you must be receiving Medicare and have limited resources and income.
If you qualify for Extra Help, Medicare will pay all or part of your Part D premium and you will have lower copayments at the pharmacy.
Extra Help Contact Information
To apply for Extra Help, call or go online
Social Security Office
Call: 1-800-772-1213; TTY 1-800-325-0778
Click here to apply for Medicare Part D Extra Help program
Mail Order
Welcome to the MedImpact Direct Mail® Program. The Program includes Birdi™ as your mail pharmacy for home delivery of maintenance medicine. These are drugs you take for conditions like high blood pressure and diabetes. You can get up to a 90-day supply of medicine. Get started today at www.medimpact.com. A one-time registration allows access to the portal or mobile app. The MedImpact app is available in the Apple App Store and Google Play Store.
Birdi makes it easy to manage the medicine you take to help stay healthy. Birdi also:
- Offers after hours service: Call Birdi at 1-855-873-8739 (TTY dial 711).
- Sends refill reminders to help you have the right amount of medicine on hand.
- Accepts manufacturer coupons to save on copay amounts.
Getting Started
Register online at www.medimpact.com to get started. Information needed includes any allergies or medical conditions, contact information and shipping address. Your doctor will need to submit a 90-day-supply prescription to Birdi to start home delivery service. Most orders are processed and shipped within 5 business days from receipt of prescription.
Download MedImpact Direct Order Form
English
MedImpact Direct Contact Information
Call: 1-855-873-8739 (TTY dial 711)
Fax: 1-888-783-1773 (prescribers only)
Hours of Operation: Monday-Friday 8am Est- 8 pm Est and Saturday 9 am- 5pm Est, closed Sundays
Email: Patientcare@birdirx.com
Website: www.medimpact.com
Generic vs. Brand Name
Generic medications have the exact same ingredients as the brand name drugs, but you aren’t paying for the “name.” Always ask the pharmacy for generic instead of brand name. Save your money for something special.
Medication Therapy Management Program
Champion Health Plan has a free voluntary program for members who have multiple medical conditions, take many prescription drugs, have high drug costs, and/or are determined to be at risk for misuse or abuse of an opioid or a frequently abused drug under the Drug Management Program (DMP). The Medication Therapy Management Program is utilized to help members manage medications and make sure our members are receiving medications according to their medical conditions, identify any possible medication interactions, duplication of therapy, and review drug dosages according to the appropriate prescribing standards.
Please note that the Medication Therapy Management Program (MTMP) is not considered a benefit. It is available to you at no cost. You will be automatically enrolled in this program if you are in a DMP to help with opioid use and/or meet all the following three criteria:
- Have three or more chronic medical conditions, such as
- Chronic Kidney Disease (CKD) or End Stage Renal Disease (ESRD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Chronic Heart Failure (CHF)
- Rheumatoid Arthritis
- Alzheimer’s Disease
- Bipolar Disorder
- Take eight or more Medicare Part D covered drugs
- Expect to spend more than a specified amount on covered Medicare Part D prescriptions:
- $5,330 or more in 2024
The MTMP offers a comprehensive review of all your medications and discusses with you over the phone on how to better manage your conditions with drug therapy. If you are eligible for this program, you will be notified by mail. We will then contact you by telephone to perform this service. Each session takes about 30-40 minutes. After the telephone session, we will send you a Personal Medication List (PML) and Medication Action Plan (MAP) which are summaries of what we’ve talked about. We will also perform Targeted Medication Review quarterly and may contact you or your doctor directly if there are questions about your medications. In addition, you will receive information on the safe disposal of prescription medications that are controlled substances.
Click on the link below for a sample of the Personal Medication List:
If you would like additional information about the program, please call our Member Services Department at 1-800-885-8000 | TTY 711, 8:00 a.m. to 8:00 p.m., 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free. Member Services also has free language interpreter services available for non-English speakers. TTY requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
- Prior-Authorization, Coverage Determination, and Exceptions
A coverage determination is any determination (i.e. an approval or denial) made by Champion Health Plan regarding your Medicare Part D prescription drug coverage. Your requests for Part D coverage determination may include:
Asking whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the Plan’s List of Covered Drugs (Formulary) but requires our approval before it is covered.)
Asking us to pay for a prescription drug you already bought.
Asking 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 for coverage of a drug that is not on the drug list
- Asking to pay a lower cost-sharing amount for a covered non-preferred drug
- Asking us to remove the extra rules and restrictions on the Plan’s coverage for a drug such as:
- Being required to use the generic version of a drug instead of the brand name drug
- Getting plan approval in advance before we will agree to cover a drug for you
- Quantity Limits
Exceptions
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 approved. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.
What to Do
You (or your representative or your doctor or other prescriber) may use the form below to submit your request for a Part D Coverage Determination:
Medicare Prescription Drug Determination Request Form
Download the Coverage Determination Request Form
Please note: If you do not use this form, you will need to provide us the same information indicated in the form so we can process your request in a timely manner. The form cannot be used to request Medicare non-covered drugs, including fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).
Once the form is completed, submit it to MedImpact Healthcare Systems, Inc. at the contact information located below.
MedImpact – Prior Authorization Department
To start your Part D Coverage Determination Request, please contact or submit your form to:
MedImpact – Prior Authorization Department
Call: 844-282-5341
Fax: 858-790-7100
Hours of Operation: PA staff is available 6:00am – 6:00pm Monday – Friday (PST) and 6:00am-2:30pm PST on weekends
Mailing Address: 10181 Scripps Gateway Court, San Diego, CA 92131
Website: www.medimpact.com
Additional Assistance and Information
If you need additional assistance on Part D Prescribed Drug benefits, you may call Champion Health Plan of California, Inc. or Renal Payer Solutions, Inc. Pharmacy Services Department at 1-800-885-8000 | TTY 711, 8:00 a.m. to 8:00 p.m., 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free. Member Services also has free language interpreter services available for non-English speakers. TTY requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Prescription Drug Transition Policy
As a new or continuing member, you may be taking drugs that are not on our Part D Formulary or on our Part D Formulary and require a prior authorization or are step therapy and/or have quantity limits.
In these instances, talk to your doctor about choosing the right alternative medications or therapies available on our Part D Formulary. If there are no appropriate alternative therapies on our Part D Formulary, you or your doctor can request an exception and ask the Plan to cover the drug or remove restrictions from the drug.
While you are talking with your doctor to determine the course of action, we may cover up to a 30-day transition supply of Part D drugs that are not on our Part D Formulary or on our formulary and require a prior authorization or are step therapy and/or have quantity limits during your first 90 days of coverage.
If you would like additional information or assistance with Prescription Drug Transitions, please call our Member Services Department at 1-800-885-8000 | TTY 711, 8:00 a.m. to 8:00 p.m., 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free. Member Services also has free language interpreter services available for non-English speakers. TTY requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Transition Policy for Long-Term Care Facility
If you are a resident of a long-term care facility, we may cover at least a 91-day and up to a 98-day transition supply, depending on the dispensing increment, during the first 90 days of coverage. After the first 90 days, we may also provide a 31-day emergency supply unless you have a prescription written for fewer days.
Transition Policy for Level of Care Change
If you are a member with a level of care change, we may cover a 31-day transition supply if you are moving from home, or a hospital stay to a long-term care facility. We may cover a 30-day transition supply if you are moving from a long-term care facility, or a hospital stay to home.
If you have any questions about our transition policy or need help asking for a formulary exception, please call Champion Health Plan of California, Inc. or Renal Payer Solutions, Inc. at the contact listed below.
Member Services Department at 1-800-885-8000 | TTY 711, 8:00 a.m. to 8:00 p.m., 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free. Member Services also has free language interpreter services available for non-English speakers. TTY requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
File an Appeal for Part D Prescription Drugs
This page was last updated on 10/15/23. Pending CMS approval.
