Drug Coverage Determinations

Medicare Prescription Drug Coverage and Your Rights

Medicare Prescription Drug Coverage and Your Rights 

What to do if you have complaints

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call Express Scripts Customer Care line at 1-877-657-2498 or TTY/TDD 1-800-899-2114.

Please note that chapter 9 of the Evidence of Coverage addresses complaints about your Part D prescription drug benefits. If you have complaints about your MA benefits, you must follow the rules outlined in chapter 9 of the Evidence of Coverage.

This page gives the rules for making complaints in different types of situations. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Central Health Medicare Plan or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. The following briefly discusses grievances, coverage determinations, and appeals.

What is a grievance?
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 Central Health Medicare Plan 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, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

Please refer to Grievances for information on how to file a grievance.

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.

Please refer to Coverage Determinations for information on how to request a coverage determination.

What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable 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.

Please refer to Appeals for information on how to request a coverage determination.

The Evidence of Coverage gives the details about your Medicare health coverage and explains how to get the care you need.

For information on how to obtain a summary of information regarding the grievances, appeals, and exceptions filed against our plan, or if you have process or status questions, please call Express Scripts Customer Care line at 1-877-657-2498 or TTY/TDD 1-800-899-2114, 24 hours a day, 7 days a week.

Medicare Complaint Form

You may also file a complaint directly with Medicare by following the link below and completing a Medicare Complaint Form.
https://www.medicare.gov/medicarecomplaintform/home.aspx

Please refer to Appointment of Representative for information on how to appoint someone to act as your representative.