Complaints & Appeals
What is a grievance?
A grievance is a type of complaint you make about BlueRx (PDP) or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
Your grievance must be made within 60 days after you had the problem you want to make a complaint about. We will respond to your complaint within 30 days after receiving your request, but may take up to 44 days.
What is an appeal?
An appeal is something you do if you disagree with a decision to deny a request for prescription drugs or payment for drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if BlueRx doesn't pay for a drug, item or service you think you should be able to receive.
There are two kinds of Part D appeals:
- Standard appeal. For coverage or payment appeals, we must respond to your request within 7 calendar days after we receive your appeal
- Expedited appeal. If your health requires a quick response, you can ask for an expedited appeal. We must respond to your request within 72 hours after we have received your appeal.
You must make your appeal request within 60 calendar days from the date on the written notice we sent that tells you BlueRx's answer to your request for a coverage decision.
What is a coverage determination?
A decision about whether a drug prescribed for you is covered by BlueRx and the amount, if any, you are required to pay for the service or prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under BlueRx (PDP), that isn't a coverage determination. To ask for a formal decision about the coverage if you disagree, print and complete the appropriate form below and fax it to 1-800-693-6703 or mail to Prime Therapeutics LLC, Attention: Part D Appeals Department, 1305 Corporate Center Dr. Building EC, Eagan, MN 55121:
- Request for Coverage Determination
- Request for Redetermination or Physician Drug Authorization Request Form - Plan Version
What if I need my request expedited?
If you or your healthcare provider believe that waiting for a decision under the standard time frame may place your life, health, or ability to regain maximum function in serious jeopardy, an expedited appeal may be requested. Once all necessary information is received, your request will be reviewed and a determination sent to you and all necessary parties within 24 hours.
How to submit a grievance?
You may file a grievance with our Plan either by phone or in writing. To contact us by phone, please call BlueRx Member Services at 1-800-327-3998 (BlueRx AL) or 1-888-311-7508 (BlueRx TN), 8 a.m. to 8 p.m., seven (7) days a week. From February 15 to September 30, on weekends and holidays, you may be required to leave a message. Calls will be returned the next business day. TTY users should call 711. To contact us in writing, please submit your signed grievance to:
P.O. Box 995
Birmingham, AL 35298
You may also submit feedback about your Medicare health plan or prescription drug plan directly by visiting https://www.medicare.gov/MedicareComplaintForm/home.aspx, in lieu of calling 1-800-Medicare.
How to appoint a representative?
An enrollee may appoint any individual (such as a relative, friend, advocate, attorney, physician, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payor) to act as his or her representative. A representative who is appointed by the court or who is acting in accordance with State law may also file a request for a coverage determination or appeal on behalf of an enrollee. The enrollee making the
appointment and the representative accepting the appointment must sign, date, and complete an Appointment of Representative form (CMS-1696 Form).
How to find additional information about grievances, coverage determinations, and appeals?
You can find additional information about our grievance, coverage determination (including exceptions), and appeals process by reviewing the Evidence of Coverage, Chapter 7, for your plan.
How do I obtain an aggregate number of grievances, appeals, and exceptions filed with BlueRx?
To obtain an aggregate number of grievances, appeals, and exceptions filed with BlueRx contact Member Services at 1-800-327-3998 (BlueRx AL) or 1-888-311-7508 (BlueRx TN), 8 a.m. to 8 p.m., seven (7) days a week. From February 15 to September 30, on weekends and holidays, you may be required to leave a message. Calls will be returned the next business day. TTY users should call 711