Exceptions and Appeals

Resources

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We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call Express Scripts Customer Service at 1-800-572-8734. TTY users should call 1-800-716-3231. Normal business hours are from 8:00 A.M. to 9:00 P.M. Eastern Time, Monday through Friday.

The information below outlines the rules for making complaints in different types of situations. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when someone makes a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from this Plan or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. The following section briefly discusses grievances, coverage determinations, and appeals.

What is a coverage determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called 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. There are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug.
You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Tier 3 drug, you can ask us to cover it as a Tier 2 instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary, the low-tiered drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of your request.

Asking for a standard decision

To ask for a standard decision, you, your doctor, or your appointed representative should refer to our Customer Service numbers (Phone: 1-800-572-8734; TTY/TDD: 1-800-716-3231) . Our normal business hours are from 8:00 A.M. to 9:00 P.M. EST, Monday through Friday. Or, you can deliver a written request to the attention of Medicare Administrative Review, EMI Health, Express Scripts Health Solutions, Inc., P.O. Box 639405, Irving, TX 75063, or fax it to 1-888-235-8551.

Asking for a fast decision

You, your doctor, or your appointed representative can ask us to give a fast decision (rather than a standard decision). If you are requesting a fast decision outside of normal business hours (8:00 A.M. to 9:00 P.M. EST, Monday through Friday), be sure to call (not fax) us at 1-800-753-2851 and listen to the recording for further directions. Be sure to ask for a "fast," "expedited," or "24-hour" review.

If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor's support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast coverage determination, we will give you our decision within the 72-hour standard timeframe.

What is an appeal?

An appeal 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. If coverage is denied, the letter will provide an explanation and information on how to submit an appeal.

What is a 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 to 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.

How to file a grievance

A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for Part D prescription drug benefits (concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process discussed below).

What types of problems might lead to you filing a grievance?

You feel that you are being encouraged to leave (disenroll from) our Plan.
Problems with the customer service you receive.
Problems with how long you have to spend waiting on the phone or in the pharmacy.
Disrespectful or rude behavior by pharmacists or other staff.
Cleanliness or condition of pharmacy.
If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.
You believe our notices and other written materials are difficult to understand.
Failure to give you a decision within the required timeframe.
Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.
Failure by the plan sponsor to provide required notices.
Failure to provide required notices that comply with CMS standards.

You may file a service grievance by calling Express Scripts Customer Service 1-800-572-8734. TTY users should call 1-800-716-3231. Normal business hours are from 8:00 A.M. to 9:00 P.M. EST, Monday through Friday. You may also file a grievance by completing the Express Scripts Service Complaint and Grievance form. The completed form can be submitted by mail or fax.

Mailing Address:

Attn: Medicare Administrative Review
EMI Health
Express Scripts Health Solutions, Inc.
PO Box 639405
Irving, TX 75063
Fax: 1-888-235-8551

Express Scripts will contact you by phone to resolve your service grievance. If your service grievance is not resolved in five days, you will receive a written acknowledgement that your grievance has been received. Expect your service grievance to be resolved within 30 days. After the service grievance is resolved, you will receive a written resolution confirmation. In the rare instance that your grievance is not resolved in 30 days, Express Scripts may request a 14-day extension from Medicare. In certain cases, you have the right to ask for a "fast grievance," meaning your grievance will be decided within 24 hours.

Appointing a Representative

To consider a request from someone other than the member, we must have authorization. You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and the representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

Instructions for Appointment of Representative Form

If you want a friend, relative, your doctor or other prescriber, or other person to be your representative, you may call Customer Service at (888) 236-4823, Monday through Friday, 8:00 am – 5:00 pm MST and ask for the Appointment of Representative Form to give that person permission to act on your behalf. The Appointment of Representative Form is also available on the Internet at: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1696.pdf

The form must be signed by you and by the person who you would like to act on your behalf. You must give our Plan a copy of the signed form. You may mail the completed and signed form to:

EMI Health
Attention: Enrollment Department
5101 S Commerce Street
Murray, UT 84107

You may also fax the completed and signed form to: (801) 269-9734.

When can you use a pharmacy that is not in the plan’s network?

Your prescription might be covered in certain situations. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

In a medical emergency. We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care.
When traveling away from our plan’s service area. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our mail-order pharmacy service. If you are traveling within the United States and need to fill a prescription because you become ill or you lose or run out of your covered medications, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules. Prior to filling your prescription at an out-of-network pharmacy, call the Customer Service at (800) 572-8734, seven days a week, 24 hours a day, to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency
To obtain a covered drug in a timely manner. In some cases, you may be unable to obtain a covered drug in a timely manner within our service area. If there is no network pharmacy within a reasonable driving distance that provides 24-hour service, we will cover your prescription at an out-of-network pharmacy.
If a network pharmacy does not stock a covered drug. Some covered prescription drugs (including orphan drugs or other specialty pharmaceuticals) may not be regularly stocked at an accessible retail network pharmacy or through our mail-order pharmacy service. We will cover prescriptions at an out-of-network pharmacy under these circumstances. In these situations, please check first with Customer Service to see if there is a network pharmacy nearby.

How do you ask for reimbursement from the Plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost.

Instructions for Prescription Drug Coverage Determination Form

You ask us to make an exception, including:

Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs
Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
Asking to pay a lower cost-sharing amount for a covered non-preferred drug
You ask us 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 but we require you to get approval from us before we will cover it for you.)
You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.

If you would like to make a prescription drug coverage determination request, you may call Customer Service at (800) 572-8734, seven days a week, 24 hours a day and ask for the Prescription Drug Coverage Determination Form to begin the process of a redetermination. The Prescription Drug Coverage Determination Form is also available here.

The form must be signed by you and by the person who you would like to act on your behalf. You must give our Plan a copy of the signed form. You may mail the completed and signed form to:

EMI Health
c/o Express Scripts Health Solutions, Inc.
Attn: Coverage Redetermination
P.O. Box 639405
Irving, TX 75063-9405

You may also fax the completed and signed form to:1-888-235-8551.

Questions?

If you have questions about the grievance, coverage determination, or appeals processes outlined above, please call Express Scripts Customer Service at 1-800-572-8734. TTY users should call 1-800-716-3231. Normal business hours are from 8:00 A.M. to 9:00 P.M. EST, Monday through Friday. You may also call Customer Service to inquire about the status of a coverage determination or appeals request.

Resources

Appointment of Representative Form (Printer Friendly)

Request for Medicare Prescription Drug Coverage Determination Form (Printer Friendly)

Authorization Request Form (for Prescribers) - (Printer Friendly)

Medicare Appeals (on medicare.gov)

Evidence of Coverage

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EMI Health is a Medicare Contractor for Utah and Idaho.