KelseyCare Advantage Rx and KelseyCare Advantage Rx+Choice have a formulary, which is a list of drugs covered by the plan. This list must always meet Medicare's requirements, but it can change when plans get new information. We have to let you know at least 60 days before a drug you use is removed from the list or if the costs are changing.

You can request we provide a Part D covered drug that you believe KelseyCare Advantage Rx and KelseyCare Advantage Rx+Choice should provide or pay for. The word "provide" includes such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been getting.

This section gives you information on how to:

• Ask for a drug to be covered (coverage determination)
• Appeal if a drug has been denied or you disagree with the co-payment amount
• Tell us about a complaint (grievance) about our plan

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 exceptions requests. 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 an exception, your physician must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination. You, your physician or your appointed representative may file a coverage determination, including an exception, by calling KelseyCare Advantage's Prescription Drug Manager, Prescription Solutions, toll-free at 1-888-242-1009 (TTY/TDD 1-866-394-7218).

If you are requesting a Formulary Exception or Co-payment (Tiering) Exception, your physician must provide a statement to support your request.

Physician Supporting Statement for a Formulary Exception

In order for us to consider a request for a formulary exception, the prescribing physician must provide an oral or written supporting statement that the requested drug is medically necessary to treat your condition because:

• All of the covered drugs on any tier of the formulary available for treatment of your condition would either not be as effective for you as the non-formulary drug and/or would be harmful for you; or
• The prescription drug alternatives listed on the formulary or required to be used in accordance with step therapy requirements have been ineffective in treating your condition, are likely to be ineffective, or have caused or are likely to cause harm to you; or
• The number of doses available under a dose restriction has been or is likely to be ineffective in treating your condition.

Physician Supporting Statement for a Tiering Exception
In order for us to consider your request for a tiering exception, the prescribing physician must provide an oral or written supporting statement that the preferred (lower cost-sharing) drug(s) available for treatment of your condition would not be as effective for you as the requested drug, and/or would have adverse effects for you. Your physician can submit the request using the Physician Coverage Determination Request Form. The form asks your physician for information regarding your diagnosis, what other drug(s), if any, has been prescribed for the diagnosis and why it has not worked, and other questions. Your physician should send the completed form to:

KelseyCare Advantage
c/o Prescription Solutions
3515 Harbor Boulevard
Costa Mesa, California 92626
Or by fax to: 1-800-527-0531

Your physician can also provide an oral supporting statement by calling 1-800-711-4555.

Click here for the Physician Coverage Determination Request Form.

What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable (denied) 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. The KelseyCare Advantage Evidence of Coverage gives you more information about the five levels of appeals available to you.

Once your plan receives your request for an appeal, we have 7 days ( for a standard request for coverage or for a request to pay you back) or 72 hours ( for an expedited request for coverage) to notify you of our decision. What is a grievance (complaint)?

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 the KelseyCare Advantage drug benefits 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,
• The cleanliness or condition of a network pharmacy,
• Being unable to reach someone by phone or get the information you need,
• Not getting the decision about a coverage determination or appeal within the required timeframe,
• Disagreeing with plan's decision not to grant your request for an expedited determination or appeal.

How to file a grievance or appeal:
You, your physician or your appointed representative may file a grievance or appeal by writing to KelseyCare Advantage. You must file a standard request in writing. We accept expedited requests by telephone and in writing. Contact information for KelseyCare Advantage is as follows:

KelseyCare Advantage
Attn: Member Services
P. O. Box 300427
Houston, Texas 77230
Toll-free 1-866-535-8343, 8 a.m. to 8 p.m. Central time, Monday-Sunday
(TTY/TDD 1-866-302-9336, 8 a.m. to 8 p.m. Central time, Monday-Sunday)
Fax: 713-442-9536

How to appoint a representative:
If you need someone to file a grievance, coverage determination or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. 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.

If you want to appoint a representative, you should complete the Appointment of Representative form and mail it to:

KelseyCare Advantage
Attn: Member Services
P. O. Box 300427
Houston, Texas 77230

You can call us toll-free at 1-866-535-8343 (TTY/TDD 866-302-9336), 8 a.m. to 8 p.m. Central time, Monday-Sunday if you have any questions about naming your appointed representative.