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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.
If we make a coverage determination and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage determination. Members may download the 2014 Request for Redetermination form to ask us for a redetermination (appeal).
To start an appeal, you (or your representative or your doctor or other prescriber) must contact us.
Request an Appeal
When Blue Cross Blue Shield of Massachusetts or one of our plan physicians:
We must make a decision regarding your standard appeal within certain time frames designated by the Centers for Medicare & Medicaid Services (CMS). Every reasonable attempt will be made to resolve your complaint within seven (7) calendar days. If we do not give you our decision within seven (7) calendar days, your request will automatically go to an independent review organization where a reconsideration or review will be made.
If we have agreed completely in your favor for a Part D drug you have not received, we will provide authorization for the drug within seven (7) calendar days after we received your appeal or sooner if your health requires it. Please refer to your Evidence of Coverage for your complete appeal rights and information.
After we receive an expedited appeal, we have up to 72 hours to give you a decision. If we do not give you our decision within 72 hours, your request will automatically go to an independent reviewer where a reconsideration or review will be made. Please refer to your Evidence of Coverage for more information.
We may accept or decline your request for an expedited appeal as follows:
If we decline your request for an expedited appeal, we will process your request through the standard appeal process. If you disagree with our decision not to expedite your request, you may file an expedited grievance.
If we accept your request for an expedited appeal with supporting documentation from your physician, a decision will be made within 72 hours.
If we deny any part of your appeal, you or your designated representative have the right to ask an independent organization to review your case. This independent review organization contracts with the federal government and is not part of the health plan. Please refer to your Evidence of Coverage for your complete appeal rights and information.
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