A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, 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:

• Usually, there is no problem. We decide that the drug or service is covered and pay our share of the cost.
• But in some cases we might decide the drug or 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.

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were being fair and following all of the rules properly. When we have completed the review we give you our decision.

If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.

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.

You can use a Request for Medicare Prescription Drug Determination Request Form to request an exception. If your Provider is making this request on your behalf, they should use the "Medicare Part D Coverage Determination Request Form".

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 two 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).
• If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drugs in Tier 3. You cannot ask for an exception to the copayment or co-insurance amount we require you to pay for the drug.
• You cannot ask for coverage of any “excluded drugs” or other non-Part D drugs which Medicare does not cover.
• Removing a restriction on the plan’s coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on the plan’s List of Covered Drugs.
• The extra rules and restrictions on coverage for certain drugs include:
• Being required to use the generic version of a drug instead of the brand-name drug.
• Getting plan approval in advance before we will agree to cover the drug for you. (This is sometimes called “prior authorization.”)
• Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”)
• Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have.
• If our plan agrees to make an exception and waive a restriction for you, you can ask for an exception to the copayment or co-insurance amount we require you to pay for the drug.

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.

• 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.

• How to ask for a coverage decision about drug coverage, including an exception
• What if you miss the deadline for making your Level 1 Appeal?
• How to make a Level 1 Alternate Appeal
• How to make a Level 2 Alternate Appeal
• Levels of Appeal 3, 4, and 5 for Part D Drug Appeals

Step 1: You ask our plan to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a “fast decision.” You cannot ask for a fast decision if you are asking us to pay you back for a drug you already bought.

What to do

• Request the type of coverage decision you want. Start by writing, or faxing our plan to make your request. You, your representative, or your doctor (or other prescriber) can do this.
• You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. You can give written permission to someone else to act as your representative*. You can also have a lawyer act on your behalf, but you do not need a lawyer to request an exception.

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, you must complete an Appointment of Representation (Form CMS-1696). You can get a copy of the form here.
• Or you can call Member Services 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.
• If you want to ask our plan to pay you back for a drug, you may need to ask for reimbursement.
• If you are requesting an exception, provide the “doctor’s statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception you are requesting. (We call this the “doctor’s statement.”) Your doctor or other prescriber can fax (1-888-333-4316) or mail the statement to our plan at PO Box 62, Buffalo NY 14240-0062. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing the signed statement.

If your health requires it, ask us to give you a “fast decision”

• When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard decision means we will give you an answer within 72 hours after we receive your doctor’s statement. A fast decision means we will answer within 24 hours.
• To get a fast decision, you must meet two requirements:
• You can get a fast decision only if you are asking for a drug you have not yet received. (You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought.)
• You can get a fast 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 decision,” we will automatically agree to give you a fast decision.
• If you ask for a fast decision on your own (without your doctor’s or other prescriber’s support), our plan will decide whether your health requires that we give you a fast decision.
• If we decide that your medical condition does not meet the requirements for a fast 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 decision, we will automatically give a fast decision.
• The letter will also tell how you can file a complaint about our decision to give you a standard decision instead of the fast decision you requested. It tells how to file a “fast” complaint, which means you would get our answer to your complaint within 24 hours.

Step 2: Our plan considers your request and we give you our answer.

Deadlines for a “fast” coverage decision

• If we are using the fast deadlines, we must give you our answer within 24 hours.
• Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.
• If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization.
• If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request.
• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Deadlines for a “standard” coverage decision

• If we are using the standard deadlines, we must give you our answer within 72 hours.
• Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.
• If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we tell about this review organization and explain what happens at Appeal Level 2.
• If our answer is yes to part or all of what you requested –
• If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request.
• If we approve your request to pay you back for a drug you already bought, we are also required to send payment to you within 30 calendar days after we receive your request or doctor’s statement supporting your request.
• If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 3: If we say no to your coverage request, you decide if you want to make an appeal.

If our plan says no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.

Back to List

You can appeal to our plan instead

You must act quickly to contact the Quality Improvement Organization to start your first appeal of your hospital discharge. (“Quickly” means before you leave the hospital and no later than your planned discharge date). If you miss the deadline for contacting this organization, there is another way to make your appeal.

If you use this other way of making your appeal, the first two levels of appeal are different.

Back to List

Step 1: Contact our plan and ask for a "fast review."

• Contact our plan by calling, writing or faxing us and ask for a “fast review.”
• Call Member Services at 1-800-329-2792. (Calls to this number are free. From November 15 to March 1 we are available to take your calls from 8:00 am to 8:00 pm seven days a week. From March 2 to November 14 we are available to take your calls Monday through Friday from 8:00 am to 7:00 pm. All times are in Eastern Time.) TTY 1-877-834-6918; this number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
• Or write to us at:
  PO Box 62
  Buffalo, NY 14240-0062
• Or fax us at 1-888-333-4316
• Be sure to ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2: Our plan does a "fast" review of your planned discharge date, checking to see if it was medically appropriate.

• During this review, our plan takes a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We will check to see if the decision about when you should leave the hospital was fair and followed all the rules.
• In this situation, we will use the “fast” deadlines rather than the standard deadlines for giving you the answer to this review.

Step 3: Our plan gives you our decision within 72 hours after you ask for a “fast review” (“fast appeal”).

• If our plan says yes to your fast appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.)
• If our plan says no to your fast appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your hospital services ends as of the day we said coverage would end.
• If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. You will be responsible for the cost of care starting from noon on the day after our plan says no to your appeal.

Step 4: If our plan says no to your fast appeal, your case will automatically be sent on to the next level of the appeals process.

To make sure we were being fair when we said no to your fast appeal, our plan is required to send your appeal to the “Independent Review Organization.” When we do this, it means that you are automatically going on to Level 2 of the appeals process.

Back to List

Step 1: We will automatically forward your case to the Independent Review Organization.

We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal.

Step 2: The Independent Review Organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours.

• The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
• Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge.
• If this organization says yes to your appeal, then our plan must reimburse you (pay you back) for our share of the costs of hospital care you have received since the date of your planned discharge. We must also continue the plan’s coverage of your hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services.
• If this organization says no to your appeal, it means they agree with our plan that your planned hospital discharge date was medically appropriate.
• The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge.

Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further

There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accept their decision or go on to Level 3 and make a third appeal.

Back to List

Back to List