CurrentBlue Cross Blue Shield - IowaPolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Explains the process and form for a Medicare Part D enrollee (or their representative/prescriber) to request a redetermination (appeal) of a denied prescription drug coverage/payment decision from Wellmark Advantage Health Plan (Blue Medicare Advantage PPO/Enhanced PPO). Applies to affected enrollees and their authorized representatives.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a redetermination within 60 days of the Notice of Denial via mail, fax (1-855-633-7673), website, or expedited phone request (1-855-344-0930) and include CMS-1696 if filing on behalf of the enrollee.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daystimeframe to request redetermination

72 hoursexpedited decision target

7 daysstandard decision timeframe

1-855-633-7673fax

1-855-344-0930

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Appeal Submission Requirements and Process

Appeal submission criteria and process

Steps and information required to submit an appeal (redetermination) for a denied prescription drug claim:

Request must be filed within 60 days of the Notice of Denial of Medicare Prescription Drug Coverage.

Submission methods

Mail: CVS Caremark Part D Appeals, PO Box 52000, MC109, Phoenix, AZ 85072-2000.
Fax: 1-855-633-7673.
Online: submit via the plan website.
Expedited appeals by phone: 1-855-344-0930 (TTY 711), available 24 hours a day, 7 days a week.

Who may request: The enrollee, the enrollee's prescriber, or an authorized representative may request a redetermination; contact the plan to name a representative.

Required information

Enrollee identifying information (name, date of birth, address, phone, member/prescriber ID).
Prescription drug details (name, strength/quantity/dose).
If drug was purchased pending appeal: date purchased, amount paid and copy of receipt, and pharmacy name/telephone.
Supporting documentation such as prescriber statement and relevant medical records; explain reasons for appeal and, if available, address Plan's coverage criteria in the denial letter.

Expedited appeal rules

You or your prescriber may request an expedited decision if waiting up to 7 days for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function.
If the prescriber indicates waiting could seriously harm the enrollee, the plan will automatically give a decision within 72 hours.
If prescriber support is not provided, the plan will determine whether a fast decision is required.
Expedited appeals are not available for requests for reimbursement of a drug already received.

Codes and Deadlines

No clinical codes providedmixed

No codes listed

Appeal submission deadline

Submission deadline60 days from date of Notice of Denial

Where to send form (mail)CVS Caremark Part D Appeals PO Box 52000, MC109 Phoenix, AZ 85072-2000

Fax number to submit appeal form1-855-633-7673

Website submission optionPlan website (www.wellmark.com/medicare/advantages/resources)

How to Request a Redetermination (Appeal)

Denial Risk

How to Request a Redetermination (Appeal)

Because Wellmark Advantage Health Plan (Blue Medicare Advantage PPO and Enhanced PPO) denied coverage or payment for a prescription drug, you or your authorized representative have the right to request a redetermination (appeal). You have 60 days from the date of the Notice of Denial of Medicare Prescription Drug Coverage to ask for a redetermination. Expedited (fast) requests are available when waiting for a standard decision could seriously harm life, health, or ability to regain maximum function.

Mail: CVS Caremark Part D Appeals, PO Box 52000, MC109, Phoenix, AZ 85072-2000
Fax: 1-855-633-7673
Web: Submit an appeal via the plan website (Wellmark Medicare Advantage resources)
Phone for expedited appeal requests: 1-855-344-0930, TTY 711 — available 24 hours a day, 7 days a week

Key Definitions and Representative Documentation

Expedited appeal (definition and timeframe)

DefinitionAn expedited appeal is a request for a fast decision when the enrollee or prescriber believes that waiting for a standard decision (up to 7 days) could seriously harm the enrollee's life, health, or ability to regain maximum function.

Prescriber certification requirementPrescriber must indicate that waiting 7 days could seriously harm the enrollee; attach prescriber statement to the request.

Decision timeframe with prescriber supportTarget decision within 72 hours if prescriber indicates harm.

Standard decision timeframe (for comparison)Standard decision timeframe is up to 7 days.

LimitationExpedited appeals are not available for requests seeking reimbursement for a drug already received.