Part D Appeals and Exceptions

A complaint about the way you receive your Medicare Prescription Drug or Health Plan's coverage. For example, if you do not like the way you are treated by the Medi-CareFirst staff when you call, you would file a grievance. (Note: if you are unhappy with a coverage decision, you would file an appeal.)

If you have any kind of problem with your plan, please call us at:

Claims Customer Service
1-800-693-1434
1-800-693-0765 (TTY/TDD)
24 hours a day, 7 days a week

We will try to resolve any problem during that call.

If we cannot solve your problem during that call, we will send your problem to someone in our company who can help you. They will then contact you.

If you want a written response to your phone call, we will respond in writing to you.

If you prefer to write or fax us about your problem:

Mail to:
Medicare Prescription Drug Plan Claims Customer Service
c/o Argus Health Systems
Dept. #303
PO Box 419019
Kansas City, MO 64141

We will respond to your problem as fast as we can and no later than 30 days after the day we get it. There are times when we may need more information to resolve your problem. In these cases, we may need up to 14 more days. If we need more time, we will let you know.

Note: You must tell us about your problem no more than 60 days after it happened.

More Information

More information about the grievance, appeals, exceptions and coverage determination processes is available in your Evidence of Coverage.

2010: Evidence of Coverage

• Blue Rx Standard (PDP) (1.18 MB, 120 pgs., PDF)*
• Blue Rx Enhanced (PDP) (1.57 MB, 119 pgs., PDF)*

*Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

A request to Medi-CareFirst to pay for a drug that is not covered, to pay for a drug at a different cost, or to waive restrictions or limits on your drug.

1. Call

Call Claims Customer Service for assistance at 1-800-693-1434 (TTY/TDD: 1-800-693-0765), 24 hours a day/7 days a week.

2. Fax

Fax the “Request for Medicare Prescription Drug Coverage Determination” form.

• Complete the form.
• Fax or mail the form and the required doctor’s statement* to:

Fax to:
Medicare Prescription Drug Plan Claims Center
Attention: Prior Authorization Department
Fax: 1-800-315-4025 (This fax machine is located in a secure location as required by HIPAA regulations.)

3. Mail
Mail to:
Medicare Prescription Drug Plan Claims Center
c/o Argus Health Systems
Dept # 303
PO Box 419019
Kansas City, MO 64141

You will receive a decision within 72 hours after it is received.

*Your prescribing doctor must give us a written statement telling us why you need this exception.

Note – One exception will not be considered:

• You cannot get a brand-name drug and pay a generic drug copay.

If waiting 72 hours for a decision could seriously harm your life or health, you can ask for an expedited (fast) decision:

1. Ask your prescribing doctor to call us at 1-800-932-0169.
2. The doctor must tell us that waiting 72 hours for a decision could seriously harm your life or health.
3. Your prescribing doctor could also use the Request for Coverage Determination form and fax it, as noted above.

You will receive a decision within 24 hours. If we don’t hear from your doctor, Medi-CareFirst will decide if your health condition requires a fast decision.

There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Medi-CareFirst limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit.
• You can ask us to provide a higher level of coverage for your drug. For example, if your drug is a non-preferred brand-name drug, you can ask us to cover it as a preferred brand-name drug instead. This would lower the amount you must pay for your drug.
• Please note: if we grant your request to cover a drug that is not on our formulary, we will not change the pricing level for that drug.

Generally, Medi-CareFirst 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 it would cause you to have an adverse medical reaction.

Additional information about the grievance, appeals, exceptions and coverage determination processes is available in your Evidence of Coverage.

2010: Evidence of Coverage

• Blue Rx Standard (PDP) (1.18 MB, 120 pgs., PDF)*
• Blue Rx Enhanced (PDP) (1.57 MB, 119 pgs., PDF)*

*Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

A request to reconsider and change a decision made about a health care service, drug authorization, or prescription or medical claim.

If you do not agree with a decision, you have the right to appeal. To begin the appeals process, or to follow up on an appeal, call Claims Customer Service for assistance at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

They will give you specific instructions, depending on the nature of your request.

If you prefer, you can write to the Appeals Unit. Written appeals can be sent via fax or mail:

Fax to:
Medicare Central Appeals Unit
410-605-2566

Mail to:
Medi-CareFirst BlueCross BlueShield
Central Appeals Unit
PO Box 17636
Baltimore, MD, 21297

The following is the full appeals process:

Level 1 – Appeal to the Plan
You may ask us to review our initial determination, even if only part of our decision is not what you requested. An appeal to the plan about a Part D drug is also called a plan"redetermination." When we receive your request to review the initial determination, we give the request to people at our organization who were not involved in making the initial determination. This helps ensure that we will give your request a fresh look. If the plan says no to all or part of your Level 1 appeal, you can go to a Level 2 (IRE) appeal.

Level 2 – Independent Review Entity (IRE)
At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.

Level 3 – Administrative Law Judge (ALJ) Hearing
If the IRE does not rule completely in your favor, you or your representative may ask for a review by an Administrative Law Judge (ALJ) if the dollar value of the Part D drug you asked for meets the minimum requirement provided in the IRE’s decision. During the ALJ review, you may present evidence, review the record, and be represented by counsel.

Level 4 – Medicare Appeals Council (MAC)
If the ALJ does not rule completely in your favor, you or your representative may ask for a review by the Medicare Appeals Council (MAC).

Level 5 – Federal Court
You have the right to continue your appeal by asking a Federal Court Judge to review your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and:

• The decision is not completely favorable to you, or
• The decision tells you that the MAC decided not to review your appeal request.

More Information:
More information about the grievance, appeals, exceptions and coverage determination processes is available in your Evidence of Coverage.

2010: Evidence of Coverage

• Blue Rx Standard (PDP) (1.18 MB, 120 pgs., PDF)*
• Blue Rx Enhanced (PDP) (1.57 MB, 119 pgs., PDF)*

*Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

Approval in advance for certain prescription drugs or medical services. If Prior Authorization is not received, Medi-CareFirst may not pay for your drug or service.

Note: Prior Authorization forms must be completed and submitted by the prescribing physician.

The form is specific to the drug, and is displayed in the formulary listing. You can also get a list of all drugs that require Prior Authorization on our formulary page.

Medicare Prescription Drug Plan Claims Center
Attention: Prior Authorization Department
Fax: 1-800-315-4025

If your doctor has any questions about a prior authorization request or the process, he or she can contact Argus Health Systems at 1-800-314-2872.

If you have questions about prior authorization, please call:

Claims Customer Service
1-800-693-1434
1-800-693-0765 (TTY/TDD)
24 hours a day, 7 days a week

More Information
More information about the grievance, appeals, exceptions and coverage determination processes is available in your Evidence of Coverage.

2010: Evidence of Coverage

• Blue Rx Standard (PDP) (1.18 MB, 120 pgs., PDF)*
• Blue Rx Enhanced (PDP) (1.57 MB, 119 pgs., PDF)*

*Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

A person who represents your interests when you are unable to represent yourself.

Complete the Appointment of Representative Form (92 KB, 2 pgs., PDF) and send it to:

Medicare Prescription Drug Plan Enrollment Center
c/o CGI
P.O. Box 8100
Lancaster, SC 29721

Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.