Coverage Determination, Appeals and Payment Request

Coverage Determination, Appeals and Payment Request (Prescription Part D)

It’s possible there could be a prescription drug you are currently taking, or one that you and your provider think you should be taking, that is not on our drug list or is on our drug list with restrictions. There are things you, your representative*, or your provider can do if your drug is not covered in the way that you would like it to be covered.

If there is a restriction on the drug, you, your representative*, or your provider can ask for a coverage determination.

If you disagree with a decision made on a previous coverage decision, you, your representative, or your provider can ask for a Redetermination appeal. For more information on appeals, click here.

2025 Plans

Payment Request for Part D Drugs

Below is a brief description of some of the situations for which you may submit a paper claim for reimbursement for your Part D drug expenses. For a full description and a complete listing of all situations, refer to the Evidence of Coverage, Chapter 7. Some of the situations you may submit a paper claim include:

• When you pay the full cost for a prescription because you don’t have your plan membership card with you.
• When you pay the full cost for a prescription drug that is not on the plan’s List of Covered Drugs (Formulary), or the drug has a requirement or restriction that you didn’t know about or don’t think should apply to you.
• When you use an out-of-network pharmacy to get a prescription filled under one of the following three circumstances:

1. Non-routine situations when a network pharmacy is not available
2. If you are travelling within the United States and territories and you become ill, run out or lose your drugs
3. Prescriptions that are written as part of a medical emergency or urgent care visit

Please note, you must submit your claim to us within 36 months of the date you received the drug.

When you send us your request for reimbursement, include a copy of your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records. Make sure you are giving us all the information we need to make a decision. You don’t have to use our form, but it’s helpful for our plan to process the information faster. You can download a copy of the Direct Member Reimbursement Form or call Member Services and request it. 

Mail your 2025 request for payment and the 2025 Direct Member Reimbursement Form together with any bills or receipts to this address:

OptumRx Claims Department
P.O. Box 650287
Dallas, TX 75265-0287

You can also contact OptumRx at 1-800-707-8194 (TTY: 711).

What is an appeal?

An appeal is a special kind of complaint you can make if KelseyCare Advantage refuses to cover something you think should be covered. If you disagree with the plan’s initial decision (organization determination), you, your representative, or your treating physician can request an appeal, but you must make your request within 60 days from the date of the organization determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

Requesting an appeal means asking us to reconsider—and possibly change—the decision we made. An appeal to the plan about an organization determination is called a plan “reconsideration.” Please refer to your Evidence of Coverage that discusses the five levels of appeals. When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you or your doctor to get more information.

Who can file an appeal?

You, your representative, or your treating physician can ask for a standard or fast appeal. You will get a fast decision if we determine, or your physician tells us, that your life or health may be at risk by waiting for a standard decision. The decision request deadlines are as follows:

How do you file an appeal?

For standard appeal requests, you or your representative, or your treating physician must make your request to us in writing if services or medication have been provided.  Your written reconsideration request should include:

• Your name, address, and your member ID number.
• The items or services for which you’re asking for a reconsideration and the dates of service.
• Your signature.
• You should also include any other information that may help your case.
• If you have not received the service or medication, appeals are accepted by us in writing, in person, or over the phone.