Medicare Coverage Determination, Appeals and Grievances

Determinations, Appeals and Grievances

If you have issues, complaints or problems with your Medicare plan or the care you receive, you have the right to make a complaint.

• Determination: A request to make an exception to the plan services or benefits or the amount the plan will pay for a service or benefit.
• Appeal: A request to reconsider and change a decision or determination made about the plan services or benefits or the amount the plan will pay for a service or benefit.
• Grievance: A complaint about any other type of problem with a Medicare plan. The complaint can be about the quality of care or other services you get from a Medicare provider. It’s not the same as filing an appeal.

Prescription Drug Coverage Determinations, Redeterminations and Appeals

If your doctor or pharmacist tells you that a prescription drug is not covered by your plan, you may ask for an exception, a coverage determination or redetermination, or an appeal. You can also ask for help to find a different drug. Below are some examples of when you may request an exception, a coverage determination or an appeal.

• Exception
  • If you need a drug that is not on our list of covered drugs (formulary)
  • If you believe you should pay less for a drug
  • If you ask for an exception, your doctor must send a statement to support your request.
• Coverage Determination
  • If there is a required limit on the quantity (or dose) of a drug and you disagree with the limit
  • If prior authorization is required for the drug
• Appeal
  • You can appeal an unfavorable coverage determination.

Step 1: Initial Coverage Determination Request

A coverage determination request can be submitted either as standard (72-hour turnaround time) or expedited (24-hour turnaround time). The details of asking for a coverage determination are in the Evidence of Coverage.

Questions? Call Blue Cross MedicareRx Customer Service at 1-888-285-2249 (TTY 711).

There are several types of coverage determination.

Prior Authorization

To ask for a pharmacy prior authorization, step therapy exception or quantity limit exception, you or someone on your behalf must fill out and fax the form below to 1-800-693-6703.

Prior Authorization Form

Prescription Drug Formulary Exception

To request coverage of a medication that's not on the plan formulary (list of covered drugs), you can ask for a formulary exception. If we agree to make an exception and cover a drug that is not on the formulary, you will need to pay the cost-sharing amount that applies to drugs in Tier 4.

Prescription Drug Formulary Exception Physician Form

Prescription Drug Tier Exception

If our drug list contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost-sharing amount that applies to the alternative drug(s). This would lower your share of the cost for the drug. You cannot ask us to change the cost-sharing tier for any drug in Tier 5 (Specialty).

Prescription Drug Tier Exception Physician Form

Step 2: Appeals to Initial Coverage Determination and Asking for a Redetermination

Questions? Call Blue Cross MedicareRx Customer Service at 1-888-285-2249 (TTY 711).

Prescription Drug Appeals and Redetermination

Asking for a Redetermination or Appeal

An initial coverage determination decision can be appealed. To start your appeal, you (or your representative or your prescriber) must contact us. Include any information that may be helpful with your redetermination request.

You must ask for 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.

You, your prescriber or your appointed representative may ask for a standard or an expedited (fast) appeal. To request an appeal, contact us by phone, fax or mail.

1-888-285-2249 (TTY 711)

Fax Number:
1-800-693-6703

Mailing Address:
Blue Cross MedicareRx
c/o Pharmacy Benefit Manager
2900 Ames Crossing Road
Eagan, MN 55121

Forms to Use to Request Determinations and File Appeals

The Centers for Medicare & Medicaid Services (CMS) has forms developed for use by all Blue Cross MedicareRx prescribing doctors and members. These forms can be used for coverage determinations, redeterminations and appeals. Have a provider complete the correct form below and fax or mail it for review.

• Prescription Drug Coverage Determination Request Form
• Online Coverage Determination Request Form
• Prescription Drug Coverage Redetermination Request Form
• Online Coverage Redetermination Request Form

Filing a Prescription Drug Grievance

A grievance is a complaint about quality of care or other services you get from a Medicare provider. It is not a complaint about failure to cover or pay for a certain drug. For those concerns, use the determination process outlined above.

Expedited (Fast) Prescription Drug Grievance Filing

If you asked for an expedited coverage determination or redetermination that was denied, and you have not yet gotten the drug that is in dispute, you may file an expedited grievance. File your expedited grievance either by telephone or in writing, as described below. Or fax your expedited grievance to us at 1-855-674-9189.

We will tell you our decision within 24 hours of getting your complaint.

To file several grievances, appeals or exceptions with our plan, contact Blue Cross MedicareRx Customer Service at 1-888-285-2249 (TTY 711).

Find additional forms and information

You may choose someone to act on your behalf. This person can be a relative, friend, sponsor, lawyer, or doctor. A court may also appoint someone. You and the person you choose must sign, date, and complete a representative statement.

The notice or request of an appointed representative 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 the CMS Appointment of Representative form (Form CMS-1696-U4) located on the Medicare Advantage Plan Documents page by selecting your plan. You can also use the Social Security Administration Appointment of Representative form (Form SSA-1696-U4) found online or at Social Security offices.

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

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

Phone:
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.

Online:
www.medicare.gov

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