Pharmacy Coverage Determinations/Exceptions, Grievances and Appeals
What is a grievance?
A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with BlueAdvantage or one of our network pharmacies that does not relate to coverage for a prescription drug. You may file a grievance with us either orally or in writing no later than 60 days after the event or incident that precipitates the grievance. We will respond to your grievance within 30 days after receiving your request.
What is a coverage determination?
A coverage determination is a decision whether or not we provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations also include exception requests. These will be reviewed within 72 hours of receiving all the information required to review your request.
What is an appeal?
An appeal is the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug. You must request an appeal within 60 days from the date of the notice of the coverage determination. Appeals are reviewed and determinations returned within 7 days upon receiving all necessary information.
What if I need my request expedited?
If you or your health care 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. Once all necessary information is received, your request will be reviewed and a determination sent to you and all necessary parties within 24 hours.
How to submit a grievance, coverage determination or appeal?
The first step to filing grievance, appeal, or seeking a coverage determination is to call:
1-800-841-7434
TTY/TDD for Hearing Impaired: 1-888-423-9490
8 a.m. to 9 p.m. ET, 7 days a week
From March 3 to September 30, you may be required to leave a voice mail on weekends and holidays. Calls will be returned within one business day.
If you would like to submit your grievance, appeal, or seek a coverage determination in writing:
How to find additional information about grievances, coverage determinations, and appeals?
You can find additional information about our pharmacy grievance, coverage determination (including exceptions), and appeals process by reviewing of your plan's Evidence of Coverage.
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