Blue Cross MedicareRx (PDP)

Medicare Coverage Determination, Appeals and Grievances

Blue Cross Medicare RxSM Plans have processes in place to address Medicare coverage issues, complaints and problems. You have the right to make a complaint if you have concerns or problems related to your coverage or care. There are two different types of complaints:

  • An appeal is the type of complaint you make when you want us to reconsider and change a decision we've made about the services or benefits we've covered for you or the amount we will pay for a particular service or benefit.
  • A grievance is the type of complaint you make if you have any other type of problem with a Medicare plan.

You can find more information about the difference between appeals and grievances below, and how to file each of these with our departments. We also outline how to get in touch with us if you have any immediate concerns.

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Prescription Drug Coverage Determinations, Redeterminations and Appeals

If your doctor or pharmacist tells you that we will not cover a prescription drug, you may contact us for a coverage determination, redetermination or appeal. You can also request assistance in identifying appropriate formulary alternatives.

The following are examples of when you may want to ask us for a coverage determination and appeal:

  • If there is a limit on the quantity (or dose) of a drug and you disagree with the requirement of dosage limitation.
  • If there is a Prior Authorization requirement on the formulary drug.
  • You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower payment.
  • If you request an exception, your doctor must provide a statement to support your request.
  • You can request an appeal if we have issued an unfavorable coverage determination.

The process for requesting a coverage determination is discussed in more detail in the Evidence of Coverage.

  • 2017 Step 1: Requesting a Prescription Drug Coverage Determination
    • Contact Customer Service at: Blue Cross Medicare RxSM Plans: 1-888-285-2249 TTY/TDD: 711 to obtain information on how to request a coverage determination from the plan sponsor.
    • Different Types of Coverage Determinations
      • Prescription Drug Coverage Determination

        You, your appointed representative (see “Appointment of Representative” below), your physician or an office staff member may request a pharmacy prior authorization, step therapy exception or quantity limit exception, by faxing the form to: Blue Cross Medicare RxSM at 1-800-693-6703.

        A coverage determination request can be submitted either as standard (72 hour completion time) or expedited (24 hour completion time).

        Prior Authorization Form External link

      • Prescription Drug Formulary Exception
        • The formulary exception process is used to request coverage for a medication that's not on the drug formulary. All approvals for non- formulary medications will require a Tier 4 copay for brand name and generic drugs.

          Prescription Drug Formulary Exception Physician Form External link

      • Prescription Drug Tier Exception
        • You can also request a tier exception for your non-preferred drug to be covered at the preferred drug copay level. In other words, you can request that your non-preferred brand name drug (e.g. Tier 4) be covered at the preferred brand name (e.g. Tier 3) copay level, or your non-preferred generic drug (e.g. Tier 2) be covered at the preferred generic drug (e.g. Tier 1) copay level.
        • Prescription Drug Tier Exception Physician Form

      • Additional Information
        • If you request an exception, your doctor must provide a statement to support your request.
        • You, your appointed representative or your provider may contact us if you would like to request a coverage determination.
        • You, your appointed representative or your provider can request an appeal if we have issued an unfavorable coverage determination (see “Step 2: Requesting Prescription Drug Coverage Determinations, Appeals, and Redeterminations” below).
  • 2017 Step 2: Requesting Prescription Drug Coverage Determinations, Appeals, and Redeterminations
    • Prescription Drug Appeals and Redetermination
      • If you, your appointed representative or your doctor does not agree with the outcome of the initial coverage determination, you, your appointed representative or your doctor may appeal the decision by having your doctor request a redetermination. Include with your appeal request any information that you feel may be helpful in the appeal decision.
      • If you want to appeal, you must request your appeal within 60 calendar days after the date of the denial notice. We can give you more time if you have a good reason for missing the deadline.
    • Who May Request a Prescription Drug Appeal?
      • You, your prescriber, or your appointed representative may request an expedited (fast) or standard appeal. For an expedited (fast) or standard appeal, you, your prescriber, or your appointed representative may contact us by phone, fax, or mail at:

        Blue Cross Medicare RxSM Plan
        Phone: 1-888-285-2249 TTY/TDD: 711
        Fax Number: 1-800-693-6703

        Mailing Address:
        Blue Cross Medicare RxSM Plans
        c/o Medicare Appeals
        1305 Corporate Center Dr., Bldg N10
        Eagan, MN 55121

    The Centers for Medicare & Medicaid Services (CMS) has a model Medicare prescription drug coverage determination form developed specifically for use by all Blue Cross Medicare Advantage prescribing doctors and enrollees. These forms can be used for coverage determination, redetermination, and appeals. Have a physician complete the appropriate form below and fax or mail it in for review.

Filing a Prescription Drug Grievance

A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for prescription drug benefits. Concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process.

  • 2017 Filing a Prescription Drug Expedited (Fast) Grievance for Coverage Determinations and Redetermination

    If you requested an expedited (fast) coverage determination or redetermination and we denied your request, and you have not yet purchased or received the drug that is in dispute, you may file an expedited grievance. You may file your expedited grievance either by telephone or in writing, as described below. You may also fax your expedited grievance to us at: 1-855-674-9189. We will make our determination and notify you of our decision within 24 hours of receiving your complaint.

    To obtain an aggregate number of grievances, appeals, and exceptions filed with our Plan, contact Customer Service at: 1-888-285-2249 TTY/TDD 711.

Filing a Prescription Drug Grievance

A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for prescription drug benefits. Concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process.

Appeals and Grievances

  • 2017 Appeals

    If we deny coverage or payment for an item, medical service or prescription that you think we should cover or pay for, you may request an appeal.

    • You can ask us to expedite an appeal (give you a quick decision) if we denied coverage for a service and your health requires a quick response.
    • If we deny coverage for a drug that you think should be covered, or if you think it should be covered on a different tier, you may request an exception (see above section “Step 2: Requesting Prescription Drug Appeals and Redetermination”).
    • If you think that your covered services in a skilled nursing facility, home health or comprehensive outpatient rehabilitation facility are ending too soon, you may ask for a fast-track appeal.
  • 2017 Grievances

    If you have a complaint related to the quality of care you receive, the timeliness of services or any other concern except for the coverage or payment issues listed above, you may file a grievance.

    If you have coverage issues related to medical or pharmacy services, or if you or your appointed representative wishes to file a grievance, please contact Customer Service at:

    Blue Cross Medicare RxSM Plans:
    1-888-285-2249 TTY/TDD 711

    We are open 8:00 a.m. - 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays.

    You may also contact Blue Cross MedicareRxSM if you want information about the number of appeals, grievances, or exceptions filed with the plan.

    For more information, please see Terms Used in Filing a Complaint

    • What Types of Problems Might Lead to You Filing a Grievance?
      • You feel that you are being encouraged to leave (disenroll from) our plan.
      • Problems with the customer service you receive.
      • Problems with how long you have to spend waiting on the phone, in the pharmacy or medical office.
      • Disrespectful or rude behavior by pharmacists or other medical staff.
      • Cleanliness or condition of pharmacy or medical office.
      • You disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.
      • You believe our notices and other written materials are difficult to understand.
      • Failure to give you a decision within the required timeframe.
      • Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.
      • Failure by the plan sponsor to provide required notices.
      • Failure to provide required notices that comply with CMS standards.

      If you have a grievance, we encourage you to first call Customer Service at: Blue Cross Medicare RxSM Plan: 1-888-285-2249 TTY/TDD 711

      We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond to you in writing to you. If we cannot resolve your grievance over the phone, we have a formal procedure to review your complaints. We have made this process easy to follow to ensure you will receive a timely response to your concerns. You must file a grievance with us no later than 60 days after the event or incident that the grievance is about.

    • Telephone Grievances

      As described above, if you have a grievance, we encourage you to contact Customer Service at the number listed above. If your complaint is not resolved at the time of your initial phone call, your grievance will be forwarded to a grievance coordinator for resolution. Generally, you will be sent a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint.

      If your grievance involves the quality of the care you received, you will receive a written response. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. When we extend the deadline, we will immediately notify you in writing of the reason(s) for the delay.

    • Written Grievances

      You may file a grievance in writing by sending a letter describing your grievance to the following address:

      Blue Cross Medicare RxSM

      c/o Appeals & Grievances
      P.O. Box 4288
      Scranton, PA 18505

      You will receive a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. When we extend the deadline, we will immediately notify you in writing of the reason(s) for the delay.

      For additional forms and information, click here. External link

Appointment of Representative

You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone. You and the person you choose must sign, date, and complete a representative statement. A request may also be made in a written letter. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement. The representative needs to have the appropriate legal papers or legal authority to sign for you. If you choose a lawyer, only you need to sign the representative statement. The representative statement must include your name and Medicare claim number. You can use Form CMS-1696-U4 (see link to form below) or SSA-1696-U4, Appointment of Representative. You can also find this form at Social Security offices.

CMS Appointment of Representative Form

Others may already be authorized under State law to be your representative.

Medicare Contact Information

Contact Medicare for more information about Medicare benefits and services, including general information about Medicare Advantage Prescription Drug coverage.

Call
1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.
If you are hearing or speech impaired, please call 1-877-486-2048.

Web
www.medicare.gov External link

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form External link or contact the Office of the Medicare Ombudsman External link.

Prescription Drug Coverage Determinations, Redeterminations and Appeals

If your doctor or pharmacist tells you that we will not cover a prescription drug, you may contact us for a coverage determination, redetermination or appeal. You can also request assistance in identifying appropriate formulary alternatives.

The following are examples of when you may want to ask us for a coverage determination and appeal:

  • If there is a limit on the quantity (or dose) of a drug and you disagree with the requirement of dosage limitation.
  • If there is a Prior Authorization requirement on the formulary drug.
  • You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower payment.
  • If you request an exception, your doctor must provide a statement to support your request.
  • You can request an appeal if we have issued an unfavorable coverage determination.

The process for requesting a coverage determination is discussed in more detail in the Evidence of Coverage.

  • 2016 Step 1: Requesting a Prescription Drug Coverage Determination
    • Contact Customer Service at: Blue Cross Medicare RxSM Plans: 1-888-285-2249 TTY/TDD 711 to obtain information on how to request a coverage determination from the plan sponsor.
    • Different Types of Coverage Determinations
      • Prescription Drug Coverage Determination

        You, your appointed representative (see “Appointment of Representative” below), your physician or an office staff member may request a pharmacy prior authorization, step therapy exception or quantity limit exception, by faxing the form to: Blue Cross Medicare RxSM at 1-800-693-6703.

        A coverage determination request can be submitted either as standard (72 hour completion time) or expedited (24 hour completion time).

        Prior Authorization Form

      • Prescription Drug Formulary Exception
        • The formulary exception process is used to request coverage for a medication that's not on the drug formulary. All approvals for non- formulary medications will require a Tier 4 copay for brand name and generic drugs.

          Prescription Drug Formulary Exception Physician Form

      • Prescription Drug Tier Exception
        • You can also request a tier exception for your non-preferred drug to be covered at the preferred drug copay level. In other words, you can request that your non-preferred brand name drug (e.g. Tier 4) be covered at the preferred brand name (e.g. Tier 3) copay level, or your non-preferred generic drug (e.g. Tier 2) be covered at the preferred generic drug (e.g. Tier 1) copay level.
        • Prescription Drug Tier Exception Physician Form

      • Additional Information
        • If you request an exception, your doctor must provide a statement to support your request.
        • You, your appointed representative or your provider may contact us if you would like to request a coverage determination.
        • You, your appointed representative or your provider can request an appeal if we have issued an unfavorable coverage determination (see “Step 2: Requesting Prescription Drug Coverage Determinations, Appeals, and Redeterminations” below).
  • 2016 Step 2: Requesting Prescription Drug Coverage Determinations, Appeals, and Redeterminations
    • Prescription Drug Appeals and Redetermination
      • If you, your appointed representative or your doctor does not agree with the outcome of the initial coverage determination, you, your appointed representative or your doctor may appeal the decision by having your doctor request a redetermination. Include with your appeal request any information that you feel may be helpful in the appeal decision.
      • If you want to appeal, you must request your appeal within 60 calendar days after the date of the denial notice. We can give you more time if you have a good reason for missing the deadline.
    • Who May Request a Prescription Drug Appeal?
      • You, your prescriber, or your appointed representative may request an expedited (fast) or standard appeal. For an expedited (fast) or standard appeal, you, your prescriber, or your appointed representative may contact us by phone, fax, or mail at:

        Blue Cross Medicare RxSM Plan
        Phone: 1-888-285-2249 TTY/TDD: 711
        Fax Number: 1-800-693-6703

        Mailing Address:
        Blue Cross Medicare RxSM Plans
        c/o Medicare Appeals
        1305 Corporate Center Dr., Bldg N10
        Eagan, MN 55121

    The Centers for Medicare & Medicaid Services (CMS) has a model Medicare prescription drug coverage determination form developed specifically for use by all Blue Cross Medicare Advantage prescribing doctors and enrollees. These forms can be used for coverage determination, redetermination, and appeals. Have a physician complete the appropriate form below and fax or mail it in for review.

Filing a Prescription Drug Grievance

A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for prescription drug benefits. Concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process.

  • 2016 Filing a Prescription Drug Expedited (Fast) Grievance for Coverage Determinations and Redetermination

    If you requested an expedited (fast) coverage determination or redetermination and we denied your request, and you have not yet purchased or received the drug that is in dispute, you may file an expedited grievance. You may file your expedited grievance either by telephone or in writing, as described below. You may also fax your expedited grievance to us at: 1-855-674-9189. We will make our determination and notify you of our decision within 24 hours of receiving your complaint.

    To obtain an aggregate number of grievances, appeals, and exceptions filed with our Plan, contact Customer Service at: 1-888-285-2249 TTY/TDD 711.

Appeals and Grievances

  • 2016 Appeals

    If we deny coverage or payment for an item, medical service or prescription that you think we should cover or pay for, you may request an appeal.

    • You can ask us to expedite an appeal (give you a quick decision) if we denied coverage for a service and your health requires a quick response.
    • If we deny coverage for a drug that you think should be covered, or if you think it should be covered on a different tier, you may request an exception (see above section “Step 2: Requesting Prescription Drug Appeals and Redetermination”).
    • If you think that your covered services in a skilled nursing facility, home health or comprehensive outpatient rehabilitation facility are ending too soon, you may ask for a fast-track appeal.
  • 2016 Grievances

    If you have a complaint related to the quality of care you receive, the timeliness of services or any other concern except for the coverage or payment issues listed above, you may file a grievance.

    If you have coverage issues related to medical or pharmacy services, or if you or your appointed representative wishes to file a grievance, please contact Customer Service at:

    Blue Cross Medicare RxSM Plans:
    1-888-285-2249 TTY/TDD 711

    We are open 8:00 a.m. - 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays.

    You may also contact Blue Cross MedicareRxSM if you want information about the number of appeals, grievances, or exceptions filed with the plan.

    For more information, please see Terms Used in Filing a Complaint

    • What Types of Problems Might Lead to You Filing a Grievance?
      • You feel that you are being encouraged to leave (disenroll from) our plan.
      • Problems with the customer service you receive.
      • Problems with how long you have to spend waiting on the phone, in the pharmacy or medical office.
      • Disrespectful or rude behavior by pharmacists or other medical staff.
      • Cleanliness or condition of pharmacy or medical office.
      • You disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.
      • You believe our notices and other written materials are difficult to understand.
      • Failure to give you a decision within the required timeframe.
      • Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.
      • Failure by the plan sponsor to provide required notices.
      • Failure to provide required notices that comply with CMS standards.

      If you have a grievance, we encourage you to first call Customer Service at: Blue Cross Medicare RxSM Plan: 1-888-285-2249 TTY/TDD 711

      We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond to you in writing to you. If we cannot resolve your grievance over the phone, we have a formal procedure to review your complaints. We have made this process easy to follow to ensure you will receive a timely response to your concerns. You must file a grievance with us no later than 60 days after the event or incident that the grievance is about.

    • Telephone Grievances

      As described above, if you have a grievance, we encourage you to contact Customer Service at the number listed above. If your complaint is not resolved at the time of your initial phone call, your grievance will be forwarded to a grievance coordinator for resolution. Generally, you will be sent a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint.

      If your grievance involves the quality of the care you received, you will receive a written response. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. When we extend the deadline, we will immediately notify you in writing of the reason(s) for the delay.

    • Written Grievances

      You may file a grievance in writing by sending a letter describing your grievance to the following address:

      Blue Cross Medicare RxSM Plan Members:

      Blue Cross Medicare RxSM
      c/o Appeals & Grievances
      P.O. Box 4288
      Scranton, PA 18505

      You will receive a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. When we extend the deadline, we will immediately notify you in writing of the reason(s) for the delay.

      For additional forms and information, click here. External link

Appointment of Representative

You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone. You and the person you choose must sign, date, and complete a representative statement. A request may also be made in a written letter. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement. The representative needs to have the appropriate legal papers or legal authority to sign for you. If you choose a lawyer, only you need to sign the representative statement. The representative statement must include your name and Medicare claim number. You can use Form CMS-1696-U4 (see link to form below) or SSA-1696-U4, Appointment of Representative. You can also find this form at Social Security offices.

CMS Appointment of Representative Form

Others may already be authorized under State law to be your representative.

Medicare Contact Information

Contact Medicare for more information about Medicare benefits and services, including general information about Medicare Advantage Prescription Drug coverage.

Call
1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.
If you are hearing or speech impaired, please call 1-877-486-2048.

Web
www.medicare.gov External link

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form External link or contact the Office of the Medicare Ombudsman External link.