Medicare Advantage Part D Prescription Drug Plan Rights

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.

Asking for Coverage Determinations

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

When:

  • Your physician or pharmacist tells you that we will not cover a medication in the amount or form prescribed for you

  • You are asked to pay a different cost-sharing amount than you think you are 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 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:

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. Calls to this number are free.

FAX
1-617-246-8506

TTY/TDD

1-800-522-1254. This number requires special telephone equipment. Calls to this number are free.

ONLINE

Requests for coverage determinations and redeterminations may
be submitted 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 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 PDF 2014 Request for Medicare Prescription Drug Coverage Determination form from the Centers for Medicare & Medicaid Services (CMS).

Providers may download the PDF 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
PDF 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.