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Part D Coverage Decision

Your benefits as a member of our plan include coverage for many outpatient prescription drugs. Medicare calls these outpatient prescription drugs "Part D drugs." You can get these drugs as long as they are included in our plan's List of Covered Drugs (Formulary) and they are medically necessary for you, as determined by your primary care doctor or other provider. Also, the drug must be used for a medically accepted indication. (A "medically accepted indication" is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5 of your Evidence of Coverage for more information about a medically accepted indication.)
 
You can request we provide a Part D covered drug that you believe the KelseyCare Advantage Rx or Rx+Choice plans 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
For more detailed coverage information, please review your Evidence of Coverage.

What is a coverage decision?
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. A coverage decision is often called an "initial determination" or "initial decision." When the coverage decision is about your Part D drugs, the initial determination is called a "coverage determination."

Here are examples of coverage decisions you ask us to make about your Part D drugs:
  • You ask us to make an exception, including:
    • Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs (Formulary)
    • Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)
    • Asking to pay a lower cost-sharing amount for a covered non-preferred drug
  • You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan's List of Covered Drugs but we require you to get approval from us before we will cover it for you.)
  • You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment.  KelseyCare Advantage Direct Member Reimbursement Form
  • If you disagree with a coverage decision we have made, you can appeal our decision. See bottom of this page for more information.

Asking for coverage decisions

The process for coverage decisions and appeals deals with problems related to your benefits and coverage for medical services, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.
 
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
 
We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.


What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an "exception." An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:
  • Covering a Part D drug for you that is not on our plan's List of Covered Drugs (Formulary).
  • Removing a restriction on the plan's coverage for a covered drug.
  • Changing coverage of a drug to a lower cost-sharing tier.

What is important about asking for exceptions?

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.
 
Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception.
 
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
Attn: Pharmacy Services
11511 Shadow Creek Parkway
Pearland, TX 77584
 
FAX Number: 1-844-541-8508 or 713-442-4848
TTY/TDD: 1-855-815-2061
 
Your physician can also provide an oral supporting statement by calling 1-844-541-8507 or 713-442-4810, or submit a request electronically using the Part D Coverage Determination Online Form.

Our plan can say yes or no to your request
  • If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
  • If we say no to your request for an exception, you can ask for a review of our decision by making an appeal.
When you can expect our plan’s decision
When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast coverage decision means we will answer within 24 hours.

To get a fast coverage decision, you must meet two requirements:

  • You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
  • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor or other prescriber tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision.

If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether your health requires that we give you a fast coverage decision.

  • If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
  • This letter will tell you that if your doctor or other prescriber asks for the fast coverage decision, we will automatically give a fast coverage decision.
  • The letter will also tell how you can file a complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested.
 

What is an appeal?
If you disagree with the plan's initial denial (coverage determination), you can request an appeal, but you must make your request within 60 days from the date of the coverage 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 a Part D drug coverage decision is called a plan “redetermination.”  Please refer to your Evidence of Coverage that discusses the five (5) 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 or other prescriber to get more information.

If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.  If we are using the standard deadlines, we must give you our answer within seven (7) calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.
 
What is a grievance (complaint)?
The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process:
  • Do you believe that someone did not respect your privacy or shared information about you that you feel should be confidential?
  • Has someone been rude or disrespectful to you?
  • Do you feel you are waiting too long on the phone or when getting a prescription?
  • If you have asked us to give you a “fast response” for a coverage decision or an appeal, and we have said we will not, you can make a complaint.
  • If you believe our plan is not meeting deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.

You must file a grievance within 60 days from the date of the event that led to the complaint. Grievances are reviewed on an individual basis and we will resolve the grievance as quickly as your health status requires.  If you call us with a complaint, we may be able to give you an answer on the same phone call. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. Expedited or fast grievances will be responded to within 24 hours if the grievance is related to the plan’s refusal to make a fast coverage determination or redetermination and you haven’t purchased or received the drug.  We will address other grievance requests within 30 days after receiving your complaint.  If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint.

How to contact us when you are making an appeal or a complaint about your Part D prescription drugs:

1-866-535-8343 (TTY/TDD: 866-302-9336)

Hours of Operation: 8:00 AM – 8:00 PM CST, Monday – Sunday.
TTY:  1-866-302-9336  This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.  Calls to this number are free.

FAX:  713-442-9536
 
WRITE:
KelseyCare Advantage
Attn:  Member Services
P.O. Box 841569
Pearland, Tx 77584-9832 
 
You or your physician submit an appeal orally, in writing or can submit a request electronically by using the Part D Appeal Online Form.
 
You can ask someone to act on your behalf.
If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.
  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services toll free at 1-866-535-8343 (TTY/TTD 866-302-9336), 8 a.m. to 8 p.m. Central time, Monday – Sunday and ask for the form to give that person permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.