This section describes your Part D prescription plan rights including grievances, coverage determinations, exceptions and appeal processes. For more detailed information, refer to Chapter 9 of the Evidence of Coverage.
A coverage determination is a request for a Part D prescription drug benefit. If your physician or pharmacist tells you that your prescription drug will not be covered, you or your physician should contact us and ask for a coverage determination. You, your physician, or your designated representative can request either a standard or an expedited coverage determination. If we decide completely in your favor and you have already paid for and received the Part D drug, we will send payment to you within 30 calendar days of your appeal request.
Request a Coverage Determination
To ask for a standard or expedited coverage determination, you, your physician, or your designated representative should call us at the phone number below, fax your request to 1-617-246-8506, or submit your written request by mail:
Call 1-800-200-4255, from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. Calls to this number are free.
1-800-522-1254. This number requires special telephone equipment. Calls to this number are free.
Requests for coverage determinations and redeterminations may
be submitted through
Blue Cross Blue Shield of Massachusetts
Medicare Advantage Appeals Coordinator
P.O. Box 55007
Boston, MA 02205
When you contact us, please have the following information available:
The name of the prescription(s) that you believe you need
The name of the pharmacy or physician who told you that the prescription drug(s) is/are not covered
The date you were told that the prescription drug(s) is/are not covered
Members may also download the 2013 Request for Medicare Prescription Drug Coverage Determination form from the Center for Medicare & Medicaid Services (CMS).
Providers may download the Medicare Part D Coverage Determination Request form located on the CMS Part D appeals webpage.
If you want a friend, relative, your doctor or other provider, or other person to be your representative, you must complete this Medicare Advantage Appointment of Representative form. The form must be signed by you and by the person whom you would like to act on your behalf. You must give our plan a copy of the signed form.