How do I obtain an aggregate number of grievances, appeals, and exceptions filed with BlueRx (PDP)? You can find additional information about our grievance, coverage determination (including exceptions), and appeals process by reviewing the Evidence of Coverage, Chapter 7, for your plan.
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How to find additional information about grievances, coverage determinations, and appeals? The enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an Appointment of Representative form (CMS-1696 Form). A representative who is appointed by the court or who is acting in accordance with State law may also file a request for a coverage determination or appeal on behalf of an enrollee. You may also submit feedback about your Medicare health plan or prescription drug plan directly by visiting, in lieu of calling 1-800-Medicare.Īn enrollee may appoint any individual (such as a relative, friend, advocate, attorney, physician, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payor) to act as his or her representative. To contact us in writing, please submit your signed grievance to: Calls will be returned the next business day. From April 1 to September 30, on weekends and holidays, you may be required to leave a message. To contact us by phone, please call BlueRx (PDP) Member Services at 1-80 (BlueRx AL) or 1-88 (BlueRx TN), 8 a.m. You may file a grievance with our Plan either by phone or in writing. Once all necessary information is received, your request will be reviewed and a determination sent to you and all necessary parties within 24 hours. If you or your healthcare provider believe that waiting for a decision under the standard time frame may place your life, health, or ability to regain maximum function in serious jeopardy, an expedited appeal may be requested. Physician Drug Authorization Request Form - Plan Version.To ask for a formal decision about the coverage if you disagree, print and complete the appropriate form below and fax it to 1-80 or mail to Prime Therapeutics LLC, Attention: Part D Appeals Department, 1305 Corporate Center Dr. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under BlueRx (PDP), that isn't a coverage determination. You must make your appeal request within 60 calendar days from the date on the written notice we sent that tells you BlueRx's (PDP) answer to your request for a coverage decision.Ī decision about whether a drug prescribed for you is covered by BlueRx (PDP) and the amount, if any, you are required to pay for the service or prescription. We must respond to your request within 72 hours after we have received your appeal. If your health requires a quick response, you can ask for an expedited appeal.
For coverage or payment appeals, we must respond to your request within 7 calendar days after we receive your appeal For example, you may ask for an appeal if BlueRx (PDP) doesn't pay for a drug, item or service you think you should be able to receive. You may also make an appeal if you disagree with a decision to stop services that you are receiving.
We will respond to your complaint within 30 days after receiving your request, but may take up to 44 days.Īn appeal is something you do if you disagree with a decision to deny a request for prescription drugs or payment for drugs you already received. Your grievance must be made within 60 days after you had the problem you want to make a complaint about. This type of complaint does not involve coverage or payment disputes. A grievance is a type of complaint you make about BlueRx (PDP) or one of our network providers or pharmacies, including a complaint concerning the quality of your care.
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