Medicare Advantage Part D exceptions and appeals information

Medicare Advantage Part D coverage decisions 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 Medicare Advantage plan member.

Please be assured that you cannot be disenrolled from Medicare Advantage 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.

What is Prime?

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

What is a Part D grievance?

A Part D “grievance” is any type of complaint you make about your Medicare Advantage Plan or one of our network pharmacies.

A grievance can also include a complaint you may have about the quality of care you receive. Please note that this type of complaint does not involve coverage or payment disputes relating to prescription drugs.

What type of problems might lead to your filing a grievance?

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.”

How do I file a Part D grievance with Medicare Advantage?

You may submit your Medicare Advantage 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

What is a Part D initial coverage decision?

An initial coverage decision about your Part D drugs is called a "coverage determination."

These are some examples of coverage decisions you ask us to make about your Part D prescription drugs:

You ask us to make an exception, including:

Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary). This is a “formulary exception” request.

If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the “supporting statement.”) Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary.

The physician's or other prescriber's supporting statement must indicate that the drug in the lower cost-sharing tier for the treatment of the enrollee's condition--

(1) Would not be as effective as the requested drug in the higher cost-sharing tier; and/or

(2) Would have adverse effects.

Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get). This is a “formulary exception” request.
Asking to pay a lower cost-sharing amount for a covered non-preferred drug. This is a “tiering exception” request.

You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules.

For example, when your drug is on the plan’s List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.

Please note: If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision.

You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

How do I ask for a Part D coverage determination?

Generally, Medicare Advantage 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.

What if my request for coverage of (or payment for) a prescription drug is denied?

If Medicare Advantage 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 60 days 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 redetermination 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.

Who do I contact for an update on the status of a coverage determination request?

If you have questions about the coverage determination process or the status of your request, you should contact the Medicare Concierge team.

Your prescribing provider should call 1-800-693-6651.

What is an appeal?

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 Medicare Advantage 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.

How do I file an appeal with Medicare Advantage?

You must file the appeal request within 60 calendar days from the date that appears on the notice 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.

How do I appoint another person as my representative?

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

Are there any exclusions from my Part D Prescription Drug Coverage?

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:

Non-prescription drugs (also called over-the-counter drugs)
Drugs when used to promote fertility
Drugs when used for the relief of cough or cold symptoms
Drugs when used for cosmetic purposes or to promote hair growth
Prescription vitamin and mineral products, except prenatal vitamins and fluoride preparations
Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
Drugs when 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

Contact Information

Part D Grievances

CALL: 1-800-267-0439. Calls to this number are free. Monday through Friday, 8:00 a.m. to 8:00 p.m.; Saturday, 8:00 a.m. to noon. (Open seven days a week, 8:00 a.m. to 8:00 p.m., October 1 - March 31.) You can use our automated answering system outside of these hours.
TTY/TDD (Telecommunications Device for the Deaf): 711. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

FAX: (401) 459-5668

WRITE:

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

Part D Coverage Determinations

CALL: 1-800-693-6651. Calls to this number are free. Monday – Friday, 8:00 a.m. to 8:00 p.m. ET. Saturday 8:30 a.m. to 4:00 p.m. ET.
TTY/TDD (Telecommunications Device for the Deaf): 711. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.

FAX: 1-800-693-6703

WRITE:

Prime Therapeutics
Attn: Clinical Review Department
2900 Ames Crossing Road
Eagan, MN 55121

Part D Appeals

FAX: 1-800-693-6703

WRITE:
Prime Therapeutics
Attn: Clinical Review Department
2900 Ames Crossing Road
Eagan, MN 55121

Where can I get more detailed information on the Medicare Part D grievances and appeals process?

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

How can I obtain an aggregate number of grievances, appeals, and exceptions filed with the Blue Cross & Blue Shield of Rhode Island?

Medicare Advantage plan members may obtain an aggregate number of grievances, appeals, and exceptions filed with Blue Cross & Blue Shield of Rhode Island by calling the Medicare Concierge team.