Appeals Procedures

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Appeals and grievances: What to do if you have complaints
We encourage Prescription Pathway members to contact us with questions, concerns, or problems related to prescription benefits. Please call us at 888-875-0774 to discuss your concerns. Complaints and inquiries are grouped by type. Federal law guarantees Prescription Pathway members’ rights to make complaints regarding concerns or problems with any part of the plan. The Medicare program has helped set the rules about what’s needed to make a complaint, and what Prescription Pathway is required to do when we receive a complaint. If a complaint is filed, we must be fair in how we handle it. A Prescription Pathway member may not be disenrolled from Prescription Pathway or penalized in any way for making a complaint.

What are appeals and grievances?
Prescription Pathway members have the right to make a complaint regarding concerns or problems related to coverage or care. “Appeals” and “grievances” are the two different types of complaints that can be filed.

An “appeal” is the type of complaint a member can make when the member wants Prescription Pathway to reconsider and change a decision we have made about what prescription drug benefits are covered or what we will pay for a prescription drug. For example, if we refuse to cover or pay for a prescription drug a member thinks we should cover, an appeal can be filed. If Prescription Pathway refuses to provide a prescription drug the member thinks should be covered, the member can file an appeal. If Prescription Pathway reduces or cuts back on the prescription drugs a member has been receiving, the member can file an appeal. If the member thinks we are stopping prescription drug coverage too soon, the member can file an appeal.

A “grievance” is the type of complaint a member can make if the member has any other type of problem with Prescription Pathway or one of our network pharmacies. For example, a member should file a grievance if the member has problems with things such as waiting times when filling a prescription, the way the network pharmacist or others behave, being able to reach someone by phone or getting the needed information, or the cleanliness or condition of a network pharmacy.

Appeals can be filed in the following situations:

•	If a member is not getting a prescription drug the member believes may be covered by Prescription Pathway.
•	If a member receives a Part D prescription drug that the member believes may be covered by Prescription Pathway, but we have refused to pay for it.
•	If we will not provide or pay for a Part D prescription drug that a member’s doctor has prescribed because it is not on our list of covered drugs (called a “formulary”). A member can request an exception to our formulary.
•	If the member disagrees with the amount that we require to pay for a Part D prescription drug a member’s doctor has prescribed. A member can request an exception to the co-payment we require to pay for a drug.
•	A member requests an exception to our formulary or to the co-payment for a drug and we denied the request.
•	If a member is being told that coverage for a Part D prescription drug will be reduced or stopped.
•	If there is a requirement that a member try another drug before we pay for the drug the member’s doctor prescribed, or if there is a limit on the quantity (or dose) of the drug and the member disagrees with the requirement or dosage limitation.
•	A member bought a drug at a pharmacy that is not in our network and the member wants to request reimbursement for the expense.
•	We do not make a decision on a member’s request within the required time frame.

Requesting an appeal from Prescription Pathway.
If a member is having a problem getting a Part D benefit or payment for a Part D prescription drug that the member has already received, the member can request an appeal. After we have made the initial coverage determination, there are five levels of appeal. At each level, the request is considered and a decision is made. If the member is unhappy with the decision, the member may be able to ask for the next level of appeal if the member wants to continue requesting the benefit or payment.

What kinds of decisions can be appealed?
A member can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. A member may also appeal our decision not to reimburse the payment for a Part D drug. In addition, if the member thinks we should have paid or reimbursed more than the member received, or the amount paid is more than the member is supposed to pay under the plan, the member can appeal. Finally, if we deny an exception request, the member can appeal. Here are some examples of situations where a member might want to file an appeal:

•	If the member is not getting a prescription drug that the member believes may be covered by Prescription Pathway.
•	If the member has received a Part D prescription drug believed to be covered by Prescription Pathway, but we have refused to pay for the drug.
•	If we will not provide or pay for a Part D prescription drug that the member’s doctor has prescribed because it is not on our list of covered drugs (called a “formulary”). A member can request an exception to our formulary.
•	If the member disagrees with the amount that we require to pay for a Part D prescription drug a doctor has prescribed, the member can request an exception to the co-payment we require you to pay for a drug.
•	The member has requested an exception to our formulary or to the co-payment for a drug and we have denied.
•	If a member is being told that coverage for a Part D prescription drug will be reduced or stopped.
•	If there is a requirement that a member try another drug before we pay for the prescribed drug, or if there is a limit on the quantity (or dose) of the drug and the member disagrees with the requirement or dosage limitation.
•	A member bought a drug at a pharmacy that is not in our network and the member wants to request reimbursement for the expense.
•	We do not make a decision on a member’s request within the required time frame.

Please Note: If we approve an exception request for a non-formulary drug, the member cannot request an exception to the co-payment we require to pay for the drug.

How does the appeals process work?
There are five levels to the appeals process. Here are a few things to keep in mind as you read the description of these steps in the appeals process:

Moving from one level to the next. At each level, the request for Part D benefits or payment is considered and a decision is made. The decision may be partly or completely in the member’s favor (giving some or all of what the member asked for), or it may be completely denied (turned down). If the member is unhappy with the decision, there may be another step to get further review of the request. Whether the member is able to take the next step may depend on the dollar value of the requested drug or on other factors.

“Initial decision” vs. “making an appeal.” Whenever the member asks for a Part D benefit, the first step is called an “initial decision” or a “coverage determination.” If the member is unhappy with the initial decision, the member can ask for an appeal, which is called a redetermination. Members may send Medicare's Redetermination Request Form to CVS Caremark Corporation, Medicare Clinical PA Department, P.O. Box 519, Lincoln, RI, 02865, or you may fax it to 800-373-1266. There are also four other levels of appeal that a member may request.

Who makes the decision at each level. A member can make a request for coverage or payment of a Part D prescription drug directly to Prescription Pathway. We review this request and make an initial decision. If our initial decision is to turn down the request (in whole or in part), the member can go on to the first level of appeal by asking us to review our initial decision. If the member is still dissatisfied with the outcome, the member can ask for further review. The appeal is then sent outside of Prescription Pathway, where people who are not connected to us conduct the review and make the decision. To request an external appeal, members may send Medicare’s Reconsideration Request Form to:

MAXIMUS Part D QIC 1040 First Avenue, Suite 200 King of Prussia, PA 19406 OR Fax to (484) 688-5601 or (866) 589-5241 (toll-free)

OR

MAXIMUS Part D QIC 50 Square Drive Victor, NY 14564 OR Fax to (585) 425-5301 or (866) 825-9507 (toll-free)

Please reference your most recent denial letter to identify the appropriate location to which you should submit your case. If you are unsure of the correct location, you may call our Medicare Clinical PA Department for assistance at (800) 311-0594 Monday through Friday 8:00am – 9:00pm Eastern Time.

After the first level of appeal, all subsequent levels of appeal will be decided by someone who is connected to the Medicare program or the federal court system. This will help ensure a fair, impartial decision.

You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with Prescription Pathway. You may do so by filing a written request with Prescription Pathway to Prescription Pathway Grievance Department, 1001 Heathrow Park Lane, Suite 5001, Lake Mary, FL 32746.

Last updated: 01/08/2008