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Blue Cross MedicareRxSM Plans have processes in place to address Medicare coverage issues, complaints and problems. You have the right to make a complaint if you have concerns or problems related to your coverage or care. There are two different types of complaints:
You can find more information about the difference between appeals and grievances below, and how to file each of these with our departments. We also outline how to get in touch with us if you have any immediate concerns.
If your doctor or pharmacist tells you that we will not cover a prescription drug, you may contact us for a coverage determination, redetermination or appeal. You can also request assistance in identifying appropriate formulary alternatives.
The following are examples of when you may want to ask us for a coverage determination and appeal:
The process for requesting a coverage determination is discussed in more detail in the Evidence of Coverage.
You, your appointed representative (see "Appointment of Representative" below), your physician or an office staff member may request a pharmacy prior authorization, step therapy exception or quantity limit exception, by faxing the form to: Blue Cross MedicareRx at 1-800-693-6703.
A coverage determination request can be submitted either as standard (72 hour completion time) or expedited (24 hour completion time).
The formulary exception process is used to request coverage for a medication that's not on the drug formulary. All approvals for non- formulary medications will require a Tier 4 copay for brand name and generic drugs.
You, your prescriber, or your appointed representative may request an expedited (fast) or standard appeal. For an expedited (fast) or standard appeal, you, your prescriber, or your appointed representative may contact us by phone, fax, or mail at:
Blue Cross MedicareRx Plan
Phone: 1-888-285-2249 TTY/TDD: 711
Fax Number: 1-800-693-6703
Blue Cross MedicareRx Plans
c/o Medicare Appeals
1305 Corporate Center Dr., Bldg N10
Eagan, MN 55121
The Centers for Medicare & Medicaid Services (CMS) has a model Medicare prescription drug coverage determination form developed specifically for use by all Blue Cross Medicare Advantage prescribing doctors and enrollees. These forms can be used for coverage determination, redetermination, and appeals. Have a physician complete the appropriate form below and fax or mail it in for review.
A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for prescription drug benefits. Concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process.
If you requested an expedited (fast) coverage determination or redetermination and we denied your request, and you have not yet purchased or received the drug that is in dispute, you may file an expedited grievance. You may file your expedited grievance either by telephone or in writing, as described below. You may also fax your expedited grievance to us at: 1-855-674-9189. We will make our determination and notify you of our decision within 24 hours of receiving your complaint.
To obtain an aggregate number of grievances, appeals, and exceptions filed with our Plan, contact Customer Service at: 1-888-285-2249 TTY/TDD 711.
If we deny coverage or payment for an item, medical service or prescription that you think we should cover or pay for, you may request an appeal.
If you have a complaint related to the quality of care you receive, the timeliness of services or any other concern except for the coverage or payment issues listed above, you may file a grievance.
If you have coverage issues related to medical or pharmacy services, or if you or your appointed representative wishes to file a grievance, please contact Customer Service at:
Blue Cross MedicareRx Plans:
1-888-285-2249 TTY/TDD 711
We are open 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays.
You may also contact Blue Cross MedicareRx if you want information about the number of appeals, grievances, or exceptions filed with the plan.
For more information, please see Terms Used in Filing a Complaint
If you have a grievance, we encourage you to first call Customer Service at: Blue Cross MedicareRx Plan: 1-888-285-2249 TTY/TDD 711
We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond to you in writing to you. If we cannot resolve your grievance over the phone, we have a formal procedure to review your complaints. We have made this process easy to follow to ensure you will receive a timely response to your concerns. You must file a grievance with us no later than 60 days after the event or incident that the grievance is about.
As described above, if you have a grievance, we encourage you to contact Customer Service at the number listed above. If your complaint is not resolved at the time of your initial phone call, your grievance will be forwarded to a grievance coordinator for resolution. Generally, you will be sent a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint.
If your grievance involves the quality of the care you received, you will receive a written response. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. When we extend the deadline, we will immediately notify you in writing of the reason(s) for the delay.
You may file a grievance in writing by sending a letter describing your grievance to the following address:
Blue Cross MedicareRx
c/o Appeals & Grievances
P.O. Box 4288
Scranton, PA 18505
You will receive a written response to your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. When we extend the deadline, we will immediately notify you in writing of the reason(s) for the delay.
You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone. You and the person you choose must sign, date, and complete a representative statement. A request may also be made in a written letter. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement. The representative needs to have the appropriate legal papers or legal authority to sign for you. If you choose a lawyer, only you need to sign the representative statement. The representative statement must include your name and Medicare number. You can use Form CMS-1696-U4 (see link to form below) or SSA-1696-U4, Appointment of Representative. You can also find this form at Social Security offices.
Others may already be authorized under State law to be your representative.
Contact Medicare for more information about Medicare benefits and services, including general information about Medicare Advantage Prescription Drug coverage.
1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.
If you are hearing or speech impaired, please call 1-877-486-2048.