Medicare Advantage Appeals and Grievances
Your Medicare Prescription Plan Rights
You have certain rights concerning your Medicare prescription drug plan. Specifically, you have the right to request that we:
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Provide a written explanation (called a Coverage Determination) of why a prescription is not covered
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Make an exception to our policy, if you disagree with the written explanation
- Medicare Advantage Appointment of Representative Form
- Medicare Part D Appointment of Representative Form
- Request for Medicare Advantage Prescription Drug Coverage Determination
To learn more about your rights and how to file appeals and grievances, use the links below:
- Exclusions from Your Prescription Coverage
- Filing a Prescription Grievance for Our Medicare Advantage Plans
- Grievance Filing Chart
- How to File a Grievance for Our Medicare Advantage Plans
- Coverage Determination
- Time Frames for Standard or Expedited Coverage Determinations
- About Our Plan Decision
- Formulary Exception
- How to File a Request for an Exception
- Review Process for Exception Requests
- Standard Appeal Review Process
- Expedited Appeal Review Process
- How to File an Appeal
- For More Information
Exclusions from Your Prescription Coverage
By law, certain types of drugs or categories of drugs are not covered under Medicare Part D. In those cases, Medicare exempts the drugs or drug categories from the exception and appeals processes. These drugs or categories are called "exclusions." They include:
- prescription vitamin and mineral products with the exception of prenatal vitamins and fluoride preparations
- agents when used for anorexia, weight loss, or weight gain
- drugs used to promote fertility
- agents when used for cosmetic purposes or hair growth
- drugs for erectile dysfunction*
- barbiturate and benzodiazepine medications**
- agents used to treat the symptoms of coughs or colds
* For discounted erectile dysfunction drugs:
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Members of Medicare HMO Blue and Medicare PPO Blue plans receive discounts on erectile dysfunction drugs
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Members will receive the Express Scripts network discount for these prescribed drugs
** For supplemental generic barbiturate and benzodiazepine medications:
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As an enhanced benefit, members of Medicare PPO Blue PlusRx (PPO) receive additional coverage on generic benzodiazepine and barbiturate medications not normally covered in a Medicare Prescription Drug plan
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If you receive extra help from Medicare in paying for your drugs, you will NOT receive extra help paying for these particular drugs
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Your copayment amount for these drugs is the generic copayment listed in the plan's Summary of Benefits
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These generic medications are covered through the doughnut hole, less your generic copayment
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As non-Medicare covered medications, these drugs do not count toward your true-out-of-pocket costs or spend down for low-cost catastrophic coverage
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They are ineligible for low-cost catastrophic cost-sharing
However, in some cases you may use the Coverage Determination process to argue that a medication is not statutorily excluded, is not statutorily excluded from a specific indication, or is covered by the plan as a supplemental benefit. If you are not 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.
Filing a Prescription Grievance for Our Medicare Advantage Plans
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 rules about medical benefit grievances, refer to your Evidence of Coverage. For information about our standalone Part D prescription plan, log on to Blue MedicareRx (PDP)*.
You have a right to make a request that we reconsider a decision about your Medicare prescription drug coverage. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member under Part D. We encourage you to let us know about your concerns.
Special rules apply to each of the following:
- Grievances
- Requests for a Coverage Determination
- Requests for Formulary Exceptions
- Requests for Appeals
Grievance Filing Chart
You may use this chart to help you decide which situation applies to your circumstance:
| File a Grievance | |
| When: |
|
| Request a Coverage Determination | |
| When: |
|
| Request a Formulary Exception | |
| When: |
|
| Request an Appeal | |
| When Blue Cross Blue Shield of Massachusetts or one of our plan physicians: |
|
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
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 Monday through Friday, 8:00 a.m. to 8:00 p.m. ET at 1-800-200-4255 (TTY: 1-800-522-1254).
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 9201
North Quincy, MA 02171-9201
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 will 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.
Coverage Determination
A coverage determination is a request for a Part D prescription drug benefit. Complete, sign, and return a 
Medicare Part D Appointment of Representative Form if you would like someone to represent you or speak on your behalf. 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.
To ask for a standard or expedited coverage determination, you, your physician, or your designated representative should call us Monday through Friday, 8:00 a.m. to 8:00 p.m. ET at 1-800-200-4255 (TTY: 1-800-522-1254). Fax your request to 1-617-246-8506 or submit your written request by mail, or in person (for expedited requests) to:
Blue Cross Blue Shield of Massachusetts
Medicare Advantage Appeals Coordinator
P.O. Box 9201, One Enterprise Drive
North Quincy, MA 02171-9201
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
Time Frames for Standard or Expedited Coverage Determinations
Standard coverage determinations are made within 72 hours of receipt of your request but we will make it sooner if your health condition requires. However, if your request is for an exception—including a formulary exception, tier cost-sharing exception, an exception for dosage or quantity limits, or an exception for step therapy requirements—we must make our decision no later than 72 hours after we have received your physician's supporting documentation explaining why the drug is medically required.
A fast or expedited coverage determination is made within 24 hours of receipt of your request or within 24 hours of receiving your physician's supporting documentation explaining the medical necessity for the request. You can ask for a fast or expedited coverage determination only if you or your physician believe that waiting for a decision within the standard time frame could seriously harm your health or your ability to function.
(Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received. When you contact us about this type of coverage determination be sure to ask for a "fast," "expedited," or "24-hour" review.)
About Our Plan Decision
We may decide completely in your favor authorizing or providing the benefit you have requested as quickly as your health requires. If we deny your request partially or in whole, we will send you a written notice explaining the reason why your request was denied. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision.
Formulary Exception
You may ask us to cover a prescription not listed on our Medicare Advantage 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.
Exceptions also include providing medications at a lower cost-sharing amount (a tier 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.
How to File a Request for an Exception
You, your designated representative, or your physician should contact us to ask for an exception. Your doctor must support your request by submitting either a written statement or by completing and returning a Request for Medicare Advantage Prescription Drug Coverage Determination.
Complete, sign and return a Medicare Part D Appointment of Representative Form if you would like someone to represent you or speak on your behalf.
Review Process for Exception Requests
We must make our exception decision as quickly as possible, but no later than 72 hours of receiving your prescribing physician's supporting documentation. If we approve your exception request for a non-formulary drug, you cannot request an exception to the copayment we require you to pay for the drug.
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 calendar days. If we do not give you our decision within seven 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 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 72 hours or sooner 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 business 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
How to File an Appeal
You need to file your appeal within 60 calendar days from the date included on your coverage determination notice from us. You or your designated representative can submit a written request for a standard redetermination by fax at 1-617-246-8506. To file your standard appeal request to us in writing or deliver it in person, submit a detailed letter to:
Blue Cross Blue Shield of Massachusetts
Medicare Advantage Appeals Coordinator
One Enterprise Drive
P.O. Box 9201
North Quincy, MA 02171-9201
For expedited appeals in cases where you, your designated representative, or your doctor believe that not having your medication or waiting for a standard decision could seriously harm your health or your ability to function, call Member Service at 1-800-200-4255 (TTY: 1-800-522-1254), Monday through Friday, 8:00 a.m. to 8:00 p.m. ET.
If you would like someone to represent you or speak on your behalf, complete, sign, and return a Medicare Part D Appointment of Representative Form.
If we deny your request partially or in whole for a Medicare Advantage prescription coverage determination, including an exception to the formulary, you or your designated representative can request a standard redetermination or you, your designated representative or your prescribing physician can ask for an expedited redetermination. Redeterminations are requests asking us to reconsider or change our decision.
For More Information
If you have any questions about these procedures, call Member Service at 1-800-200-4255 (TTY: 1-800-522-1254), Monday through Friday between 8:00 a.m. to 8:00 p.m. ET.
Additional information on these processes is also included in your Evidence of Coverage.
* Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare approved Part D Sponsor.
