Your Rights Under This Plan

Pharmacy Coverage Determinations/Exceptions, Grievances and Appeals

What is a grievance? 

A grievance is any complaint or dispute, other than one that involves a coverage determination or a LIS or LEP determination, expressing dissatisfaction with any aspect of the operation, activities, or behavior of BlueRx, regardless of whether remedial action is requested. A grievance may also include a complaint that BlueRx refused to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.

You would file a grievance if you have any type of problem with BlueRx 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 any decision made by or on behalf of BlueRx regarding payment or benefits to which an enrollee believes he or she is entitled. Coverage determinations also include exception requests (d). These will be reviewed within 72 hours of receiving all the information required to review your request.

What is an appeal? 

An appeal is any of the procedures that deal with the review of adverse coverage determinations made by BlueRx on the benefits under a BlueRx plan the enrollee believes that he or she is entitled to receive, including a delay in providing or approving the drug coverage (when a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for the drug coverage.  These procedures include redeterminations by BlueRx, reconsiderations by the independent review entity (IRE), Administrative Law Judge (ALJ) hearings, reviews by the Medicare Appeals Council (MAC), and judicial reviews.

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:

1-888-311-7508
TTY/TDD for Hearing Impaired: 1-800-257-3384
7 a.m. to 8 p.m. CT, 7 days a week

From March 2 to September 30, you may be required to leave a voice mail on weekends and holidays. Calls will be returned the next business day.

If you would like to submit a written request an appeal, formulary exception, tiering exception, prior authorization or reimbursement for a covered prescription drug you paid for out of pocket:

Please print, complete and sign this form. 

Member Form (PDF)
Physician Form (PDF)

Send the signed and completed form to:

Preferred Care Services, Inc.
Attn: Pharmacy Review
P.O. Box 12485
Birmingham, Alabama 35202-2485
or fax to (205)220-9575

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 sections 4 and 5 of your plan's Evidence of Coverage.

Medicare Prescription Drug Plans Contract for One Full Year

All prescription drug plans with a Medicare contract agree to stay with the Medicare program for a full year at a time. The availability of coverage from a particular plan beyond the current year is not guaranteed.

If your plan leaves the Medicare program, or Medicare does not renew your plan’s contract, you will receive notification 90 days in advance along with information about your other Medicare prescription drug coverage options.

Disenrollment

If you choose to enroll in a different plan during the next Annual Coordinated Election Period, you will automatically be disenrolled from your current plan. 

There are several situations that may cause you to be disenrolled by your plan:

• You move out of your plan’s service area.
• Your plan’s Medicare contract ends.
• Your plan’s service area changes and you do not live in the revised service area.

Disenrollment due to any of the above reasons entitles you to a Special Enrollment Period. You will be given other Medicare options and the opportunity to enroll in a new plan.

You can also be disenrolled by your plan if:

• You do not pay your premiums in a timely fashion.
• You do not abide by the terms and conditions of your plan.
• You knowingly provide false information on your enrollment application or permit another individual to use your member ID card to receive medical services under the plan.

In any of the above cases you will be notified of your disenrollment, the effective date and the reason. You have a right to a hearing under our grievance procedures. See the Evidence of Coverage you receive when you enroll for more information.

Finally, you can be disenrolled if:

• You lose your entitlement to either Medicare Part A or B.

If you lose your entitlement, you will be notified by the Centers for Medicare & Medicaid Services. Your Medicare prescription drug coverage plan will automatically end on the date your entitlement ends.