Exceptions and Appeals
Grievance, Coverage Determinations,
Exceptions and Appeals Procedures
Grievance
Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. RxAmerica will try to resolve any grievance that you may have over the phone. If our customer service agent is unable to achieve a resolution, we have a formal procedure to have your complaint reviewed. Please call our customer service number 1-800-429-6686 or TTY 1-877-279-0371 for assistance with any grievance. You can fax a written notice to RxAmerica at 1-877-667-1895. (these faxes are routed to RxAmerica´s Member Relations Department)
You can mail a written notice to:RxAmerica Medicare
Attn: Member Relations
221 North Charles Lindbergh Dr.
Salt Lake City, UT 84116
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. You must contact us if you would like to request a coverage determination. Coverage determinations include exception requests. Please call our customer service number 1-800-429-6686 or TTY 1-877-279-0371 for assistance with any coverage determination request.
You can ask us for a coverage determination yourself, or your prescribing doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at:
RxAmerica Medicare
Attn: MMA Coverage Determination
P.O. Box 22690
Salt Lake City, UT 84122-0690
Exceptions
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 a formulary exception, your doctor must provide a statement to support your request. Please call our customer service number 1-800-429-6686 or TTY 1-877-279-0371 for assistance with any exception request.
Requests must be faxed to 1-866-855-2676 for standard medication coverage determinations during or outside of regular business hours by your physician or designee appointed by your physician. Please have your physician or their appointed representative submit your request on the RxAmerica Medicare Part D Formulary Exception/ Prior Authorization Form. you can mail a written request to:
RxAmerica Medicare
Attn: MMA Coverage Determination
221 North Charles Lindbergh Dr.
Salt Lake City, UT 84116
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. You cannot request an appeal if we have not issued a coverage determination.
We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you. You have the right to get and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor´s records or opinion to help support your request. You may need to give the doctor a written request to get information. You can give us your additional information in any of the following ways:
By telephone -- if it is a fast appeal -- at 1-866-546-0662 or you can fax a written appeal to: 1-877-667-1895 Or you can mail a written appeal to:
RxAmerica Medicare
Attn: MMA Appeals
P.O. Box 22690
Salt Lake City, UT 84122-0690
Evidence of Coverage:
Refer to the Evidence of Coverage, Section 6 - Appeals and Grievances for the complete Grievance, Coverage Determinations, Exceptions and Appeals Procedures.
Forms:
- Formulary Exception - Prior Authorization Form
- Part B vs. Part D Determination - Prior Authorization Form
- Appointment of Representative Form
