Medicare Advantage Part D Prescription Drug Plan Rights

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.

• Medicare Complaint Form
• Medicare Ombudsman

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