APPEALS

Understanding the Appeal process

Appeals

You can request an appeal within 60 days when you want us to reconsider an adverse coverage determination made regarding what prescription drugs are covered or what we will pay. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage. You can submit an appeal through one of the options below.

When you request a standard appeal, EnvisionRxPlus will process your request within 7 calendar days. If you or your prescriber believes that waiting 7 days could seriously harm your health, you can request a fast appeal and we will give you a decision within 72 hours. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

After you file a Standard Appeal

EnvisionRxPlus will review the standard appeal (request for redetermination) and will provide you notice of our decision in writing (and process the change if favorable) as expeditiously as your health condition requires but no later than seven calendar days of receipt of the appeal request.

After you file a Fast Appeal

If additional medical information is required to process the request, EnvisionRxPlus must request it within 24 hours of receiving the fast appeal request. Even if additional information is required, EnvisionRxPlus must still issue notice of the decision within the 72 hour timeframe.

If EnvisionRxPlus determines that your request is not time-sensitive, where your health is not seriously jeopardized, we will notify you verbally and in writing and will automatically begin processing your request under the standard appeals process. If you disagree and believe the review should be expedited, you may file an expedited grievance with EnvisionRxPlus. The written notice will include instructions on how to file an expedited grievance.

Failure to meet the timeframes for either a standard or an expedited appeal constitutes an adverse determination and EnvisionRxPlus must forward your request to the Independent Review Entity (IRE) within 24 hours of the expiration of the adjudication timeframe for the IRE to issue the appeal (redetermination) decision. You will be notified in writing by EnvisionRxPlus if your request is sent to the IRE. The approval or denial for auto-forwarded cases will be sent by the IRE directly to you or your appointed representative.

You can appoint a representative to act on your behalf for filing a coverage determination or appeal by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website at www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp. Please note by clicking on this link, you will be leaving the EnvisionRxPlus website.

Further Appeals

If you disagree with a decision EnvisionRxPlus made regarding your appeal (request for redetermination), you may file an appeal with an outside entity. For further information regarding appeals, refer to Chapter 7 of your Evidence of Coverage or call Member Services at 1-866-250-2005 (TTY users may call 711). Member Services is open 24 hours a day, 7 days a week.

How Can I Request Information Related to Grievances, Appeals and Exceptions?

You may request aggregate numbers of grievances, appeals, and exceptions filed with EnvisionRxPlus, or specific information regarding the status of grievances or appeals you have filed, by calling Member Services at 1-866-250-2005 (TTY 711) available 24 hours a day, 7 days a week.

For more information regarding grievances, coverage determination requests, or appeals, refer to Chapter 7 of your Evidence of Coverage or visit the Medicare website. If we cannot help with your issue and you wish to file a formal complaint, you may contact Medicare. Please note: by clicking on a link, you will be leaving the EnvisionRxPlus website.

Information Required

Please enter the requested information below for us to provide you with relevant information.