Your Rights: Exceptions, Appeals and Complaints for 2013

We want to provide you with thorough coverage and satisfactory service in all aspects of your prescription drug plan. Therefore, we have created various procedures to help you make special kinds of requests. As a member of RxBLUE PDP, you can submit coverage determinations (exceptions), appeals and grievances (complaints), as needed, to resolve your specific problems.

You can learn more about how and why to submit coverage determinations, appeals and grievances by viewing the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 81-103), RxBLUE Plus PDP Evidence of Coverage (Chapter 7, pages 80-103) or by clicking on the individual topics below.


Coverage Determination Requests
(formulary exceptions, prior authorizations and step therapy)

What is a coverage determination?
How to request a coverage determination

Appeals

What is an appeal?
How to request an appeal

Grievances (Complaints)

What is a grievance?
How to file a grievance
How to file a complaint with CMS

Appointed Representative

Appointing a representative

Status of a Request

Member or appointed representative inquiries
Physician inquiries

Data

Grievances, appeals and exceptions data


What is a coverage determination?

A coverage determination is a decision (approval or denial) made by RxBLUE PDP regarding payment or benefits to which you believe you are entitled. This includes decisions with respect to one of the following issues:

  • Whether to provide or pay for a Part D drug 
  • Tiering exceptions 
  • Formulary exceptions 
  • Cost sharing for a drug 
  • Prior authorization requirements or step therapy restrictions

Your doctor must provide a statement to support these types of requests. Complete details on coverage determinations can be found in the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 81-103) or the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 80-103).

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How to request a coverage determination

As an RxBLUE PDP member, you, your appointed representative or your prescribing physician may request a coverage determination. All coverage determinations and first-level appeals (redeterminations) are administered by Express Scripts, Inc.* on behalf of Blue Cross and Blue Shield of Louisiana. Full details of coverage determination requests can be found in the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 81-103) or the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 80-103).

You or an appointed representative can complete the RxBLUE PDP form to request a coverage determination for Medicare Prescription Drug Coverage or complete the CMS Request for Medicare Prescription Drug Determination Request form, which is located on the CMS website.

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Member or appointed representative requests

RxBLUE PDP members or their appointed representatives can call, fax or mail in a request for a coverage determination to Express Scripts, Inc. However, the preferred method is to have your prescribing physician call Express Scripts, Inc. with a supporting statement of your request. Be sure to have your doctor provide a supporting statement for your request as indicated on the form below.

To file your request, please use the following form and contact information:

Form: Request for Medicare Prescription Drug Coverage Determination
Phone: 1.800.899.2130
TTY: 1.800.899.2114
Fax: 1.877.837.5922
Mail: Express Scripts, Inc., Attention: Prior Authorization-Part D, Mail Route: BL0345, 6625 West 78th Street, Bloomington, MN 55439

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Physician requests

Prescribing physicians can file coverage determinations on behalf of members via phone or fax. The preferred method of request is for a prescribing physician to call Express Scripts, Inc. directly to ensure the receipt of his or her supporting statement.

For a prescribing physician to file a coverage determination request, he or she should use the following form and contact information:

Form: Physician Coverage Determination Request
Phone: 1.800.417.8164, option 1
TTY: 1.800.899.2114
Fax: 1.877.837.5922

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What is an appeal?

If you are unsatisfied with the outcome of a coverage determination request, you can ask for an appeal. An appeal is a procedure that will review your unfavorable coverage determination.

The first level of appeal is called a redetermination. You may file for a redetermination if you want us to reconsider a decision regarding payment or benefits to which you believe you are entitled. There are five levels of appeals. Details of all levels can be found in the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 81-103) or the RxBLUE Plus PDP Evidence of Coverage (Chapter 7, pages 80-103).

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How to request an appeal

As an RxBLUE PDP member, you, your appointed representative or your prescribing physician may file for an appeal of a coverage determination. All coverage determinations and first-level appeals (redeterminations) are administered by Express Scripts, Inc. on behalf of Blue Cross and Blue Shield of Louisiana. Full details of appeal requests can be found in the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 81-103) or the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 80-103).

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Member or physician Appeal Level 1 (redetermination) requests

RxBLUE PDP prefers that a prescribing physician handles a redetermination request for a member. Members and appointed representatives should print the request form below and provide it to the prescribing physician. Appeals should be filed within 60 calendar days of the date included on the notice of the RxBLUE PDP coverage determination. More time may be granted depending on circumstances.

To file a standard redetermination request, please use the following form and contact information:

Form: Request for Medicare Prescription Drug Redetermination
Fax: 1.877.852.4070
Mail: Express Scripts, Inc., Attention: Pharmacy Appeals-Part D, Mail Route: BL0390, 6625 West 78th Street, Bloomington, MN 55439

For immediate service, your physician's office can call Express Scripts, Inc. directly.

Phone: 1.800.344.3405, Ext. 2373022

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What is a grievance?

A grievance is any dispute (other than one that involves a coverage determination) that expresses dissatisfaction with the operations, activities or behavior of RxBLUE PDP or one of our network pharmacies. For example, a grievance can involve a problem with waiting times when you fill a prescription, behavior of a network pharmacist, ability to get the information you need or the condition of a network pharmacy. Complete details on grievances can be found in the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 81-103) or the RxBLUE Plus PDP Evidence of Coverage (Chapter 7, pages 80-103).

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How to file a grievance

If you have a grievance, you should first call Customer Service 8 a.m.-8 p.m., seven days a week, at the numbers below. We will try to resolve any complaint that you might have over the phone.

Phone: 1.888.223.BLUE (2583)
TTY: 1.800.947.5277

If you request a written response to your phone complaint, we will respond to you in writing. If we cannot resolve your complaint over the phone, we have a formal grievance procedure to review your complaints.

You can also file a grievance in writing.

Fax: 225.298.2727
Mail: RxBLUE PDP, P.O. Box 98023, Baton Rouge, LA 70898-9023

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How to file a complaint with CMS

If you have a grievance, you should first call Customer Service 8 a.m.-8 p.m., seven days a week, at the numbers below. We will try to resolve any complaint that you might have over the phone.

To register a complaint with CMS, please use the form below:

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Appointing a representative

An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

Those not authorized under state law to act for you will need to sign an Appointment of Representative form and mail it to: RxBLUE PDP, P.O. Box 98023, Baton Rouge, LA 70898-9023.

If you want to give someone legal permission to act as your appointed representative in the appeals process, then you and that person must fill out the CMS Appointment of Representative form, which is located on the CMS website.

For further information, you can call Customer Service 8 a.m.-8 p.m., seven days a week, at the numbers below.

Phone: 1.888.223.BLUE (2583)
TTY: 1.800.947.5277

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Status of a request: Member or appointed representative inquiries

All coverage determinations and first-level appeals (redeterminations) are administered by Express Scripts, Inc. on behalf of Blue Cross and Blue Shield of Louisiana. For questions regarding the process or status of a coverage determination or redetermination request, you or your appointed representative should call the Express Scripts, Inc. Patient Care Contact Center at the following toll-free numbers:

Phone: 1.800.899.2130
TTY: 1.800.899.2114
Fax: 1.877.837.5922

If your first appeal is denied or if you disagree with any part of our Appeal Level 1 (redetermination) decision, you can request further appeal levels. Complete details on all appeal levels can be found in the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 81-103) or the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 80-103).

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Status of a request: Physician inquiries

Your physician can inquire about the process or status of a coverage determination or redetermination request by calling the Express Scripts, Inc. Physician Prior Authorization Center at the following toll-free numbers:

For Coverage Determination Inquiries
Phone:
1.800.417.8164, option 1
TTY: 1.800.899.2114
Fax: 1.877.837.5922

For Appeal Level 1 Inquiries
Phone:
1.800.344.3405, Ext. 2373022
Fax: 1.877.852.4070

If your first appeal is denied or if you disagree with any part of our Appeal Level 1 (redetermination) decision, you can request further appeal levels. Complete details on all appeal levels can be found in the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 81-103) or the RxBLUE Basic PDP Evidence of Coverage (Chapter 7, pages 80-103).

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Grievances, appeals and exceptions data

RxBLUE PDP will track and maintain records about the receipt and handling of grievances, appeals and exceptions. We will also disclose grievances, appeals and exceptions data to you upon request.

To obtain this data, you should call Customer Service at 1.888.223.BLUE (2583) or TTY: 1.800.947.5277, 8 a.m.-8 p.m, seven days a week.

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Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company, a Medicare-approved Part D sponsor.

*Express Scripts, Inc. is an independent company that serves as the pharmacy benefit manager for Blue Cross and Blue Shield of Louisiana.

S5937_MKT101813
Pending CMS Approval
Page Last Updated: 10:00 a.m. on 10.18.2013