Medicare Coverage Determination, Appeals and Grievances

If you have an issue, complaint or problem with your Medicare plan or the care you receive, you have the right to file 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.

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

• 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.
• 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
  • You should pay less for a drug.
• If you ask for an exception, your doctor must send the plan a statement to support your request.
• You can appeal an unfavorable coverage determination.

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

Below are the steps to follow if you decide to ask for a coverage determination.

Questions? Call Blue Cross Medicare Advantage Customer Service at 1-877-774-8592 (TTY 711).

There are several types of coverage determinations.

To ask us 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

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

Prescription Drug Formulary Exception Physician Form

You can ask for a tier exception for your non-preferred drug to be covered at the preferred drug copay level. In other words, you can ask 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.

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

Questions? Call Blue Cross Medicare Advantage Customer Service at 1-877-774-8592 (TTY 711).

An initial coverage determination decision can be appealed by having your doctor ask for a redetermination. 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 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:

Phone:
1-877-774-8592 (TTY 711)

Fax Number:
1-800-693-6703

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

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

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

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

If you asked for an expedited (fast) 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 have several grievances, appeals, or exceptions filed with our Plan, contact Blue Cross Medicare Advantage Customer Service at 1-877-774-8592 (TTY 711).

You may choose someone to act on your behalf. You may choose 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 the CMS Appointment of Representative form - CMS-1696-U4 or SSA-1696-U4, Appointment of Representative. You can also find this form 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.

Telephone
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.