BlueCHiP for Medicare Part D Exceptions and Appeals Information

Federal law guarantees that you have the right to make a complaint if you have concerns or problems with any part of your Part D coverage or care as a BlueCHiP for Medicare Please plan member.

Please be assured that you cannot be disenrolled from BlueCHiP for Medicare or penalized in any way if you make a complaint.

This page provides an overview of the Medicare Part D Prescription Drug Grievance & Appeals Process.

 

Frequently Asked Questions

BlueCHiP for Medicare Prescription Drug Coverage

Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of Part D vaccinations:

  • The first part of coverage is the cost of the vaccine medication itself. The vaccine is a prescription medication.
  • The second part of coverage is for the cost of giving you the vaccination shot. (This is sometimes called the “administration” of the vaccine.)
 
What do you pay for a Part D vaccination?

1. The type of vaccine (what you are being vaccinated for). 

  • Some vaccines are considered medical benefits. Please refer to Chapter 4 of your Evidence of Coverage to find out about your coverage of these vaccines.
  • Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s List of Covered Drugs (Formulary). 

2. Where you get the vaccine medication. 

3. Who gives you the vaccination shot. 

What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For example: 
  • Sometimes when you get your vaccination shot, you will have to pay the entire cost for both the vaccine medication and for getting the vaccination shot. You can ask our plan to pay you back for our share of the cost. 
  • Other times, when you get the vaccine medication or the vaccination shot, you will pay only your share of the cost. 
 
Remember you are responsible for all of the costs associated with vaccines (including their administration) during the Coverage Gap Stage of your benefit. (BlueCHiP for Medicare Preferred, BlueCHiP for Medicare Group Preferred and BlueCHiP for Medicare Group Preferred Unlimited Plan members: depending on which tier the vaccine is on, you may have coverage for some vaccines during the gap). 
 
Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.) 
  • You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine itself.
  • Our plan will pay for the cost of giving you the vaccination shot. 
 
Situation 2: You get the Part D vaccination at your doctor’s office. 
  • When you get the vaccination, you will pay for the entire cost of the vaccine and its administration. 
  • You will be reimbursed the amount you paid less your normal coinsurance or copayment for the vaccine (including administration). 
 
Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccination shot. 
  • You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine itself. 
  • When your doctor gives you the vaccination shot, you will pay the entire cost for this service.
  • You will be reimbursed the amount charged by the doctor for administering the vaccine. 
 
Please note: Some vaccines are considered medical benefits. You can find out about your coverage of these vaccines by going to Chapter 4, Medical Benefits Chart (what is covered and what you pay) in your Evidence of Coverage.The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first whenever you are planning to get a vaccination. We can tell you about how your vaccination is covered by our plan and explain your share of the cost.
  • We can tell you how to keep your own cost down by using providers and pharmacies in our network.
  • If you are not able to use a network provider and pharmacy, we can tell you what you need to do to get payment from us for our share of the cost.

Formulary Changes
Generally, if you are taking a drug on our 2014 for­mulary that was covered at the beginning of the. year, we will not discontinue or reduce coverage of the drug during the 2014 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier, we must notify affected members of the change at least 60 days before the change becomes ef­fective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-­day supply of the drug. If the Food and Drug Administra­tion deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formu­lary and provide notice to members who take the drug.

Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of Part D vaccinations:

  • The first part of coverage is the cost of the vaccine medication itself. The vaccine is a prescription medication.
  • The second part of coverage is for the cost of giving you the vaccination shot. (This is sometimes called the “administration” of the vaccine.)

What do you pay for a Part D vaccination?
What you pay for a Part D vaccination depends on:

  1. Where you get the vaccine medication.
  2. Who gives you the vaccination shot.

What you pay at the time you get the Part D vaccination can vary depending on the circumstances.
For example:

  • Sometimes when you get your vaccination shot, you will have to pay the entire cost for both the vaccine medication and for getting the vaccination shot. You can ask our plan to pay you back for our share of the cost by completing the  Part D Vaccine and Administration Reimbursement Form - Coming Soon.
  • Other times, when you get the vaccine medication or the vaccination shot, you will pay only your share of the cost.

Remember, you are responsible for all of the costs associated with vaccines (including their administration) during the Coverage Gap Stage of your benefit (BlueCHiP for Medicare Preferred, BlueCHiP for Medicare Group Preferred and BlueCHiP for Medicare Group Preferred Unlimited Plan members: depending on which tier the vaccine is on, you may have coverage for some vaccines during the gap).

Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.)

  • You will have to pay the pharmacy the amount of your copayment for the vaccine itself.
  • Our plan will pay for the cost of giving you the vaccination shot.

Situation 2: You get the Part D vaccination at your doctor’s office.

  • When you get the vaccination, you will pay for the entire cost of the vaccine and its administration. You can ask our plan to pay you back for our share of the cost by completing the  Part D Vaccine and Administration Reimbursement Form - Coming Soon.
  • You will be reimbursed the amount you paid less your normal copayment for the vaccine (including administration) (If you get Extra Help, we will reimburse you for this difference.)

Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccination shot.

  • You will have to pay the pharmacy the amount of your copayment for the vaccine itself.
  • When your doctor gives you the vaccination shot, you will pay the entire cost for this service. You can ask our plan to pay you back for our share of the cost by completing the  Part D Vaccine and Administration Reimbursement Form - Coming Soon.
  • You will be reimbursed the amount you paid less your normal copayment for the vaccine (including administration) (If you get Extra Help, we will reimburse you for this difference.)

Please note: Some vaccines are considered medical benefits. You can find out about your coverage of these vaccines by going to Chapter 4, Medical Benefits Chart (what is covered and what you pay) in your Evidence of Coverage.The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first whenever you are planning to get a vaccination. We can tell you about how your vaccination is covered by our plan and explain your share of the cost.

  • We can tell you how to keep your own cost down by using providers and pharmacies in our network.
  • If you are not able to use a network provider and pharmacy, we can tell you what you need to do to get payment from us for our share of the cost.

 

The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D enrollees who have reached the coverage gap and are not already receiving “Extra Help.” A 50% discount on the negotiated price (excluding the dispensing fee and vaccine administration fee, if any) is available for those brand name drugs from manufacturers that have agreed to pay the discount. The plan pays an additional 2.5% and you pay the remaining 47.5% for your brand drugs.

If you reach the coverage gap, we will automatically apply the discount when your pharmacy bills you for your prescription and your Explanation of Benefits (EOB) will show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap. You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays 28% of the price for generic drugs and you pay the remaining 72% of the price. The coverage for generic drugs works differently than the coverage for brand name drugs. For generic drugs, the amount paid by the plan (28%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as part of the cost of the drug.

If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact Customer Service.

BlueCHiP for Medicare Preferred, BlueCHiP for Medicare Group Preferred and BlueCHiP for Medicare Group Preferred Unlimited Plan Members: Because your plan offers additional gap coverage during the Coverage Gap Stage, your out-of-pocket costs will sometimes be lower than the costs described here. Please refer to Chapter 6 of your Evidence of Coverage for more information about your coverage during the Coverage Gap Stage.

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

The prescription is for a medical emergency or urgent care. You are unable to get a covered drug in a time of need because there are no 24-hour network pharmacies within a reasonable driving distance. The prescription is for a drug that is out of stock at an accessible network retail or mail service pharmacy (including high-cost and unique drugs). In these situations, please check first with Customer Service to see if there is a network pharmacy nearby.

If you fill a prescription at a non-network pharmacy, you will need to pay for the entire cost of the prescription and submit a prescription claim form (coming soon) for reimbursement.

If you paid out-of-pocket for a covered prescription drug, please complete the Prescription Reimbursement Claim Form (coming soon) and mail it to the appropriate address listed on the form.

We will pay our share of the cost based on the drug payment stage you are in.
 

If you paid out-of-pocket for a covered prescription drug, please complete the Prescription Reimbursement Claim Form and mail it to the appropriate address listed on the form.

We will pay our share of the cost based on the drug payment stage you are in. Be sure to include all required information as referenced in Step 2.
 

We offer medication therapy management programs at no additional cost for members who:

  • Have multiple medical conditions;
  • Are taking many prescription drugs; and
  • Have high drug costs.

These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.

We may contact members who qualify for these programs. If we contact you, we hope you will join so that we can help you manage your medications. Remember, you don’t need to pay anything extra to participate.

If you are invited to join a medication therapy management program, we will send you information about the specific program, including information about how to access the program. Please note that medication therapy management programs are not considered benefits and may have limited eligibility criteria.

Please contact BlueCHiP for Medicare Customer Service for more information.

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:
 

  1. The change to your drug coverage must be one of the following types of changes:
    • The drug you have been taking is no longer on the plan’s Drug List (formulary).
    • or the drug you have been taking is now restricted in some way
  2. You must be in one of the situations described below:
    • For those members who were in the plan last year and aren’t in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
    • For those members who are new to the plan and aren’t in a long-term care facility: We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
    • For those who are a new member and a resident in a long-term care facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.
    • For those who have been a member of the plan for more than 90 days and are a resident of a long-term care facility and need a supply right away: We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
    • For those existing members whose drug has changed tier: You can contact us to request a tiering exception or switch to an alternative drug listed on ourDrug List (formulary) with your physician’s help.
    • To ask for a temporary supply, call Customer Service.

During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered.

For those members with Level of Care Changes: If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover a one-time temporary supply for up to 30 days (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. During this period, you can discuss alternative treatments with your doctor or use the plan’s exception process if you wish to continue coverage of the drug after the temporary supply is finished. Our transition policy will not cover drugs that Medicare does not normally cover, such as benzodiazepines or barbiturates.

Medicare Part D Exceptions and Appeals Information

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 vitamins 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

*As an enhanced benefit, BlueCHiP for Medicare Standard with Drugs (HMO), BlueCHiP for Medicare Plus (HMO) and BlueCHiP for Medicare Preferred (HMO-POS) plans offer additional coverage on generic benzodiazepine and generic barbiturate medications not normally covered in a Medicare Prescription Drug Plan. If you receive extra help paying for your drugs, you will NOT receive Extra Help paying for these particular drugs. The applicable non-LIS tier copayment will apply for these drugs. These generic medications are covered throughout the plan year. As non-Medicare covered medications, these drugs do not count toward your true-out-of-pocket costs or toward catastrophic coverage.

Part D Grievances & Appeals

CALL: 1-800-267-0439. Calls to this number are free.
TTY/TDD (Telecommunications Device for the Deaf):
1-877-232-8432. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Our Customer Service hours are: October 15, 2011 – February 14, 2012: Seven days a week, 8:00 a.m. to 8:00 p.m.; February 15, 2012 until the following annual enrollment period, Monday – Friday, 8:00 a.m. to 8:00 p.m.

FAX: 1-866-884-9475

WRITE:
Blue Cross & Blue Shield of Rhode Island
Grievance and Appeals Unit: BlueCHiP for Medicare
500 Exchange Street
Providence, RI 02903

Part D Coverage Determinations

CALL: 1-800-294-5979. Calls to this number are free.

TTY/TDD (Telecommunications Device for the Deaf):
1-800-863-5488. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Hours of operation are: 7:00 a.m. to 11:00 p.m., seven days a week.

FAX: (401) 459-5089

WRITE:
Caremark Appeals Department
PO Box 52000
Phoenix, AZ 85072

For more information on the Medicare Part D grievance and appeals process, please refer to your Evidence of Coverage.

BlueCHiP for Medicare plan members may obtain an aggregate number of grievances, appeals, and exceptions filed with Blue Cross & Blue Shield of Rhode Island by calling Customer Service.

CVS Caremark is the pharmacy benefits manager for Blue Cross & Blue Shield of Rhode Island (BCBSRI). CVS Caremark administers Part B and Part D prescription drug coverage,
including making Part D coverage determinations and reconsiderations for BlueCHiP for Medicare.

Complete the Appointment of Representative Form and mail it to:

Blue Cross & Blue Shield of Rhode Island
Attn: Customer Service
500 Exchange Street
Providence, RI 02903

Download the Appointment of Representative Form in Spanish.

You must file the appeal request within 60 calendar days from the date that appears on thenotice of the initial determination you receive.You may ask for a “standard” or “fast/expedited” appeal, depending on your health.

To ask for a standard appeal about a Part D prescription drug issue, a signed, written appeal request must be sent to the plan. Please see contact information below. Only “fast/
expedited” appeals may be done verbally over the phone.

An appeal is a special kind of complaint you make if you disagree with a decision (determination) made by the Plan.
For example, you may disagree with the decision (determination) that your request for prescription drugs was denied, or reimbursement for prescription drugs you have already
received was denied.

An appeal to BlueCHiP for Medicare about a Part D prescription drug coverage determination is called a prescription plan “redetermination.” You, your doctor, or other medical provider may file an appeal of the initial determination (decision), or you can name (appoint) someone to do it for you.

If you have questions about the coverage determination process or the status of your request, you should contact Customer Service.

Your prescribing provider should call the Physician and Provider Service Center.

If BlueCHiP for Medicare denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. To request a redetermination, you can either complete the rededermination request form and mail or fax it to the contact information included on the form, or you may log in to your BCBSRI member account and complete and submit the form electronically.

Generally, BlueCHiP for Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

You, your doctor, or your appointed representative may request a Medicare Prescription Drug coverage determination. To request a coverage determination, you can either complete the Coverage Determination Request Form and mail or fax it to the contact information included on the form, or you may log in to your BCBSRI member account and complete and submit the form electronically.

An “exception” is a type of coverage determination. You, your doctor, or your appointed representative may ask for an exception to our Part D coverage rules in a number of
 Please situations such as:
• Asking the Plan to cover your drug even if it is not on the formulary.
• Asking the Plan to waive coverage restrictions or limits on your drug.
• Asking the Plan for a non-preferred Part D drug at the preferred cost sharing level. This is a request for a “tiering exception.”

An initial determination is a decision made by the plan about a specific problem you have.

You need to request that an initial determination (decision) be made by the BlueCHiP for  Medicare plan if you are having problems getting:
• The Part D prescription drugs you need
• Payment for a Part D drug you have already received

There are different types of determinations based on the type of service involved. If it is related to a Part D prescription drug problem, it is called a coverage determination.

These are some examples of issues you may have relative to your Part D prescription drug benefits that would require a coverage determination:
• You ask the Plan to pay for a prescription drug you have already received.
• You ask BlueCHiP for Medicare to pay you back for the cost of a drug you bought at an out-of-network pharmacy.
• You ask for a Part D drug that is not on the formulary. This is a request for a "formulary exception."

If you have an issue of this type, you, your doctor, or another provider may ask for an initial decision (in this case a coverage determination) on your behalf, or you can name
(appoint) someone to do it for you.

You may submit your BlueCHiP for Medicare Part D grievance verbally or in writing within 60 days of the event. Please see below for contact information.
Be sure to include the following in the letter:
• Your name, address, and subscriber ID
• Your signature or that of a designated representative
• The date your letter is signed
• A description of the event and the date which it occurred

These are some examples:
• Problems with how long you have to spend waiting in a network pharmacy.
• Disrespectful or rude behavior by network pharmacists.
If you have problems of this type and want to make a complaint, it is called “filing a grievance.”

A Part D “grievance” is any type of complaint you make about your BlueCHiP for Medicare Plan or one of our network pharmacies.
Please A grievance can also include a complaint you may have about the quality of care you Please note that this type of complaint does not involve coverage or payment disputes relating to prescription drugs.