Exceptions and Appeals Information
Exception - Coverage Determination
Whenever you ask for a Part D prescription drug benefit, the first step is requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your doctor must provide a statement to support your request. You must contact us if you would like to request a coverage determination by completing the form listed below.
Instructions For Completing The Form
Medicare Prescription Drug Coverage Determination Request Form (for use by enrollees)
Medicare Part D Coverage Determination Request Form (for use by providers)
Appeal - Coverage Redetermination
An appeal or "redetermination" is any of the procedures that deal with 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 contact us if you would like to request a coverage redetermination by completing the form listed below.
Request For Medicare Prescription Drug Coverage Redetermination
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 us or one of our network pharmacies that does not relate coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy. For information on how and where to file a grievance, select the link below.
Complaints, Appeals and Grievances
Denial of Medicare Prescription Drug Coverage
If we deny your request, we will send you a written decision explaining the reason why your request was denied. We may decide completely or only partly against you. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision. Refer to Chapter 7 in your Evidence of Coverage for addition information. Click here to locate your Evidence of Coverage.
Notice of Denial of Medicare Prescription Drug Coverage
Prior Authorizations
Some drugs require prior authorization because our doctors feel that they should only be used after other agents have been tried first. Others are drugs that have only been used for very limited medical problems. In deciding what drugs to put on the Prior Authorization List, our committee of doctors and pharmacists consider the safety, effectiveness and cost of the drugs as well as the medical literature on the subject. These forms are available for your provider’s use and can be obtained by selecting the link below.
Prior Authorization and Exception Forms
Step Therapy
Step Therapy is a form of Prior Authorization based on previous pharmaceutical treatment. Drugs designated as stepped therapy will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. The Prior Authorization and Exception Forms are available for your provider’s use by selecting the link noted above.
First Health Part D Secure (PDP) Step Therapy Protocol
First Health Part D Premier (PDP) Step Therapy Protocol
Evidence of Coverage
Below is a link to the Evidence of Coverage (EOC) which gives the details about your Medicare prescription drug coverage. You received the EOC with your enrollment kit. It is an important legal document for you to review and keep in a safe place. Refer to Section 6. Appeals and grievances: What to do if you have complaints for additional information about the grievance, coverage determination (including exceptions), and appeals process.
Member Benefits - Evidence of Coverage
Member Designated Representative
Simply click on the link noted below, print and read the cover letter and form. Completely fill out the Member Designated Representative Form and return it to the address specified on the bottom of the form. If you have any questions, please contact Member Services at the phone number listed on the back of your ID card.
Member Designated Representative
Appointment of Representation
You, your prescribing physician, or someone you name may communicate with us on your behalf to request an initial determination or file a grievance or appeal. The person you name would be your “appointed representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative. The form is available below. Please contact Member Services at the phone number listed on the back of your ID card for more information.
Appointment of Representation Form
Contact Information
Further information is available for beneficiaries and physicians who have questions about a grievance, coverage determination, or appeals processes by calling (800) 536-6167 Monday through Friday 8am to 5pm (Eastern Standard), (TTY 866-236-1069 for the hearing or speech impaired) or by fax to: (800) 639-9158 or in writing to:
4300 Cox Road
Glen Allen, VA 23060
CMS Approved N/A
CMS Document ID M0003C0002_09MAPDPDP_502_CVTYWEBg (Pending CMS Approval)