Medicare Advantage Part D Prescription Drug Plan Rights

This section describes your Part D prescription drug plan rights including grievances, coverage determinations, exceptions, and appeal processes. For more detailed information, refer to Chapter 9 of the Evidence of Coverage.

Asking for Coverage Determinations

A coverage determination is a request for a Part D prescription drug benefit. If your doctor or pharmacist tells you that your prescription drug won't be covered, you or your doctor should contact us and ask for a coverage determination. You, your doctor, or your designated representative can request either a standard or an expedited coverage determination.

Request a Coverage Determination

When:

  • Your doctor or pharmacist tells you that we won't cover a medication in the amount or form prescribed for you

  • You're asked to pay a different cost-sharing amount than you think you're required to pay for a prescription medication

To ask for a standard or expedited coverage determination or for any process or status questions, you, your doctor, 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:

Contact Information for Coverage Decisions About Your Prescription Drug Plan

Phone:

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. There is no charge for calls made using this number.

TTY/TDD:

711. There is no charge for calls made using this number.

Fax:

1-617-246-8506

Online:

Requests for coverage determinations and redeterminations may
be submitted online or through email.

Mail:

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 doctor 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 2017 Request for Medicare Prescription Drug Coverage Determination form from the Centers for Medicare & Medicaid Services (CMS).

Providers may download the Medicare Part D Coverage Determination Request form.

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.

If we make a coverage determination and you aren't 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
2017 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 doctors:

  • Won't cover or pay for prescription medications you think we should cover

  • Won't give you a prescription medication you think should be covered

  • Reduces or cuts back on prescription medications you've been receiving

Standard Appeal Review Process

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 don't 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've agreed completely in your favor for a Part D drug you haven't received, we'll 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.

Expedited Appeal Review Process

After we receive an expedited appeal, we have up to 72 hours to give you a decision. If we don't 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'll process your request through the standard appeal process. If you disagree with our decision not to expedite your request, you may file an expedited complaint.

  • If we accept your request for an expedited appeal with supporting documentation from your doctor, 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 isn't part of the health plan. Please refer to your Evidence of Coverage for your complete appeal rights and information.

Contact Information for Coverage Decisions About Your Prescription Drug Plan

Phone:

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. There is no charge for calls made using this number.

TTY/TDD:

711. There is no charge for calls made using this number.

Online:

Requests for coverage determinations and redeterminations may
be submitted through
email.

Fax:

1-617-246-8506

Mail:

Blue Cross Blue Shield of Massachusetts
Medicare Advantage Appeals Coordinator
P.O. Box 55007
Boston, MA 02205

Exclusions from Your Prescription Coverage

By law, certain types of drugs or categories of drugs aren't covered under Medicare Part D. In those cases, Medicare exempts the drugs or drug categories from the exception and appeal processes. These drugs or categories are called "exclusions." They include:

  • Non-prescription drugs (also called over-the-counter drugs)

  • Drugs when used to promote fertility

  • Drugs when used for the relief of cough or cold symptoms

  • Drugs when used for cosmetic purposes or to promote hair growth

  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

  • Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject

  • Drugs when used for treatment of anorexia, weight loss, or weight gain

  • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

However, in some cases you may use the coverage determination process to argue that a medication isn't statutorily excluded, isn't statutorily excluded from a specific indication, or is covered by the plan as a supplemental benefit. If you aren't disputing that a drug is excluded, but have a question or general complaint about an excluded drug not being covered by your Medicare Part D plan, your question or complaint will be processed as an inquiry or a grievance.

You may ask us to cover a prescription not listed on our Medicare Advantage formulary A formulary is a list of covered drugs under a Medicare Advantage Part D Plan. The list includes both brand-name and generic drugs. 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

When:

  • A prescription medication isn't listed on our Medicare drug formulary

  • You or your doctor want us to waive coverage restrictions or limits on your prescription medication

  • You or your doctor want us to provide a prescription medication at a lower cost-sharing amount (a tiering exception)

Exceptions also include providing medications at a lower cost-sharing amount (a tiering exception). The following are the tiering exceptions that can be requested:

  • If your drug is in Cost-Sharing Tier 2 (non-preferred generic) you can ask us to cover it at the cost-sharing amount that applies to drugs in Cost-Sharing Tier 1 (preferred generic). This would lower your share of the cost for the drug.

  • If your drug is in Cost-Sharing Tier 4 (non-preferred brand) you can ask us to cover it at the cost-sharing amount that applies to drugs in Cost-Sharing Tier 3 (preferred brand). This would lower your share of the cost for the drug.

  • You can't ask us to change the cost-sharing tier for any drug in Cost-Sharing Tier 3 (preferred brand) or Cost-Sharing Tier 5 (specialty medications).

Generally, we'll only approve your request for an exception if the alternative drug included on the plan's formulary or the lower-tiered drug wouldn't 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.

Contact Information for Coverage Decisions About Your Prescription Drug Plan

Phone:

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. There is no charge for calls made using this number.

TTY/TDD:

711. There is no charge for calls made using this number.

Fax:

1-617-246-8506

Mail:

Blue Cross Blue Shield of Massachusetts
Member Service
P.O. Box 55007
Boston, MA 02205

Filing a Part D Prescription Drug Grievance

There are rules for making different types of complaints in Medicare HMO Blue and Medicare PPO Blue plans coverage situations. The rules described here are for grievances or complaints you might have about your Medicare Advantage Part D prescription drug coverage. For information about our standalone Part D prescription plan, log on to Blue MedicareRx (PDP)SM.

You can file a grievance (complaint) for problems related to quality of care, waiting times, and Member Service problems.

See the following chart for other situations where you might file a grievance:

Grievance Filing Chart

You may use this chart to help you decide which situation applies to your circumstance:

File a Grievance

When:

  • You feel that you're being encouraged to leave or disenroll from your prescription drug plan

  • You have problems with the member service you receive

  • You disagree with our decision not to expedite your request for an expedited coverage determination or redetermination

Please reference your Evidence of Coverage for more examples of when to file grievances and other requests.

You may also contact Member Service at 1-800-200-4255 (TTY: 711), as follows: 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.

How to File a Grievance for Our Medicare Advantage Plans

You may submit your grievance orally or in writing within 60 days of the event.

Filing an oral grievance

Contact Member Service at 1-800-200-4255 (TTY: 711).

Filing a written grievance

Submit your grievance in writing within 60 days of the event or incident to:

 

Blue Cross Blue Shield of Massachusetts
Medicare Advantage Grievance Coordinator
P.O. Box 55007
Boston, MA 02205

Contact by email
Fax: 1-617-246-8506

 

In your letter, please include:

  • Your name, address, and membership number

  • Your signature or that of a designated representative

  • The date your letter is signed

  • A description of the event and the date on which it occurred

You'll be notified of our decision about your grievance as quickly as your health condition allows, but generally no later than 30 calendar days after receiving your complaint. We may extend the time frame by 14 calendar days if you request an extension, or if more information is required to justify your grievance.

Medicare Complaint Form

You're now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form below. The Centers for Medicare & Medicaid Services (CMS) values your feedback and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.