There are many ways you can request a review or appeal made about your care or the behavior of those providing your care. These take the form of coverage determinations, including exceptions, appeals, and grievances.
Appointing a representative (AOR): You may have a representative who is either appointed by you or authorized by the State to act on your behalf in filing a grievance, requesting a coverage determination, or requesting an appeal.
If you have an appointment of representative or would like to appoint one, please fax or mail authorization documentation to the appropriate address listed below. An AOR or any legal appointment of representative documentation needs to be filed for each coverage determination and exception appeal request.
Coverage determinations/exceptions and appeals are decisions we make about your benefits and coverage or about the amount we will pay for your prescription drugs covered under the Part D benefit included in your plan.
MedicareBlue Rx will be accepting Coverage Determination requests for 2019 beginning November 1, 2018.
Below are examples of coverage determination exceptions you may ask us to make for your Part D drugs:
- covering a Part D drug that is not on the plan's List of Covered Drugs (Formulary)
- waiving a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
- paying a lower cost-sharing amount for a covered drug on a higher cost-sharing tier
- asking whether a drug is covered for you and whether you satisfy any applicable coverage rules
- For example, when your drug is on the plan's list of covered drugs (Formulary) but we require you to get approval from us before we will cover it for you.
- asking us to pay for a prescription drug you already bought: this is a request for a coverage decision about payment
Requesting a coverage determination can be done by online form, phone, mail or fax.
- Forms: Instructions and forms (online or PDF download) for requesting a drug coverage determination or exception are in the documents section. Or, you or your provider can use Medicare's standard forms for coverage determinations and appeals found on the CMS website and use the Request for Medicare Prescription Drug Determination Request Form.
- About mailing forms: Send mailed forms to the address below. You don't have to have all the information complete on the form before submitting, however, all information will need to be completed for a timely decision.
Coverage determinations and appeals about prescription drugs can be sent to:MedicareBlue Rx (PDP)
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000
Appeals, also called redeterminations, are a formal way of asking us to review and change a coverage decision we have made. There are five levels of appeals you can make if any part of a request for a coverage determination is denied. Instructions on how to appeal are included if you receive a denial on a coverage determination decision letter or you can call us at 1-866-412-5393. TTY users should call 711
Grievances are any complaint or dispute, other than a coverage determination or a Late Enrollment (LEP) determination, expressing dissatisfaction with any aspect of MedicareBlue Rx operations, activities, or behavior. A grievance may also include a complaint that MedicareBlue Rx 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 can file a grievance by calling or writing customer service using the contact information below, or directly with Medicare by calling 1-800-MEDICARE (1-800-633-4227), or by using the Medicare online complaint form.
Grievances can be sent to:MedicareBlue Rx
P.O. Box 3147
Scranton, PA 18505
You may a request an aggregated number of grievances, exceptions or appeals filed with the plan by contacting our customer service team
Further Information and Assistance
- If you have questions on coverage determinations, appeals, or would like to file a grievance,
- or questions about making an appointment of representation (AOR)
- or if you need help in completing the AOR form
Acceptable Forms of Authorization Documentation:
- Power of Attorney (POA) documentation.
- Document showing surrogate appointed by a court or authorized under State or other applicable law. Note: A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney or a health care proxy, or a person designated under a health care consent statute.
- The CMS-1696 Appointment of Representative form. Note: A completed AOR form is valid for one year from the date of signature.
- Written Equivalent Notice which includes your contact information, your plan ID or Health Insurance Claim Number (HICN)1, contact information of the individual being appointed, authorization statement and acceptance of authorization, your signature/date and signature/date of individual being appointed.