What is a coverage decision?A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. A coverage decision is often called an "initial determination" or "initial decision." When the coverage decision is about your Part D drugs, the initial determination is called a "coverage determination."
What is an exception?If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an "exception." An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
To get a fast coverage decision, you must meet two requirements:
If your doctor or other prescriber tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision.
If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether your health requires that we give you a fast coverage decision.
What is an appeal?If you disagree with the plan's initial denial (coverage determination), you can request an appeal, but you must make your request within 60 days from the date of the coverage determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made. An appeal to the plan about a Part D drug coverage decision is called a plan “redetermination.” Please refer to your Evidence of Coverage that discusses the five (5) levels of appeals. When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information.
You must file a grievance within 60 days from the date of the event that led to the complaint. Grievances are reviewed on an individual basis and we will resolve the grievance as quickly as your health status requires. If you call us with a complaint, we may be able to give you an answer on the same phone call. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. Expedited or fast grievances will be responded to within 24 hours if the grievance is related to the plan’s refusal to make a fast coverage determination or redetermination and you haven’t purchased or received the drug. We will address other grievance requests within 30 days after receiving your complaint. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint.
How to contact us when you are making an appeal or a complaint about your Part D prescription drugs: