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.
You may ask us to cover a prescription not listed on our Medicare Advantage formularyA list of certain drugs and their proper dosages. In some Medicare health plans, doctors must order or use only drugs listed on the health plan's formulary. by requesting a formulary exception to waive coverage restrictions or limits on your medication. For example, for certain medications we limit the amount of medication that we will cover. If your prescription has a quantity limit, you may ask us to waive that limit and cover more.
Request a Formulary Exception
Exceptions also include providing medications at a lower cost-sharing amount (a tiering exception). For example, if your medication is usually covered under Tier 3, you may ask us to cover it as a Tier 2 medication instead.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary or the lower tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Your doctor or other prescriber must give us a 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.
If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If we say no to your request for an exception, you can ask for a review of our decision by making an appeal.
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.
Blue Cross Blue Shield of Massachusetts
P.O. Box 55007
Boston, MA 02205