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Best Medicare Advantage Plans for 2019 Rating is from U.S. News and World Report, a leading publisher of annual authoritative rankings including Best Medicare Plans. Our plan does not have a direct relationship with U.S. News. This award was not given by Medicare. Our overall rating from Medicare for 2019 is 5.0. Our plan’s official CMS Star Rating can be found at www.Medicare.gov.

​Appeals, Grievances And Coverage Determinations

As a member of KelseyCare Advantage, you may ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon.
 

Appeal

An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services and/or prescription drugs or payment for services and/or prescription drugs you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for a drug/item/service you think you should be able to receive.
 

Grievances

A type of complaint you make about us or one of our network providers/pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
 

Part D Coverage Decision

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs. For more information on asking for coverage decisions about your Part D prescription drugs, please click link below or refer to Chapter 9 in your Evidence of Coverage (EOC).
 
 

Part D Coverage Determination

Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to our plan’s List of Covered Drugs (Formulary). An initial coverage decision about your Part D drugs is called a “coverage determination.” You may ask us to make an exception, satisfy any applicable coverage rules, or ask us to pay for a prescription drug you already bought. You can print the form below or submit a coverage determination request electronically.
 
 

Part D Coverage Redetermination

Because KelseyCare Advantage denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You must make your redetermination within 60 days from the date on the written notice we sent you notifying you of our decisions. If you miss the deadline and have a good reason for missing it we may give you more time to submit your appeal. You can print the form below or submit a redetermination request electronically.
 
Who May Make a Request: Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.