This section describes your Part D prescription drug plan rights, including:
- Grievances
- Coverage determinations
- Exceptions
- Appeal processes
For more detailed information, refer to Chapter 9 of your 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, depending on the urgency of the request.
When to Request a Coverage Determination
- Your doctor or pharmacist tells you that we won't cover a medication in the amount or form prescribed to you
- You're asked to pay a different cost-sharing amount than you think you're required to pay for a prescription medication
Contact Information for Coverage Decisions About Your Prescription Drug Plan
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
Resources
Members may download the 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 another 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 our decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage determination.
- To start an appeal, you (or your representative or your doctor or other provider) must contact us.
- Download the Request for Redetermination form to ask us for a redetermination (appeal).
When to 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). This means:
- 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 agree 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.
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.
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.
Contact Information for Coverage Decisions About Your Prescription Drug Plan
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 used to promote fertility
- Drugs used for the relief of cough or cold symptoms
- Drugs used for cosmetic purposes or to promote hair growth
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Drugs used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
- Drugs 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 by requesting a formulary exception to waive coverage restrictions on your medication. A formulary is a list of brand-name and generic drugs covered by your plan. In some Medicare health plans, doctors must prescribe or use only drugs listed on the formulary.
Additionally, certain medications have limits for the amount that the health plan will cover. If your prescription has a quantity limit, you may ask us to waive that limit and cover more.
When to Request a Formulary Exception
- 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)
A tiering exception means providing medications at a lower cost-sharing amount. You can request the following tiering exceptions:
- 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).
More on Exceptions
- 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 is usually valid until the end of the plan year, 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 deny 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
Filing a Part D Prescription Drug Grievance
There are rules for making a formal complaint against 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, Visit to Blue MedicareRx (PDP).
You can file a grievance (complaint) for problems related to:
- Quality of care
- Waiting times
- Member Service problems
When to File a Grievance
- 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 grant an expedited coverage determination or redetermination
Please reference your Evidence of Coverage for more examples of when to file grievances and other requests.
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.
In your grievance, 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 can 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.