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Terms & Conditions
Grievances, Appeals & Exceptions 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 Blue MedicareRx or penalized in any way if you make a complaint. An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. For example, if we refuse to cover or pay for a prescription drug you think we should cover, you can file an appeal. If Blue MedicareRx refuses to give you a prescription drug you think should be covered, you can file an appeal. If Blue MedicareRx reduces or cuts back on the prescription drugs you have been receiving, you can file an appeal. If you think we are stopping your prescription drug coverage too soon, you can file an appeal. A “grievance” is the type of complaint you make if you have any other type of problem with Blue MedicareRx or one of our network pharmacies. 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 getting the information you need, or the cleanliness or condition of a network pharmacy. You need to file your appeal within 60 calendar days from the date included on the notice of our initial decision. We can give you more time if you have a good reason for missing the deadline. To file a "standard" appeal, you can send the appeal to us in writing at ... Blue MedicareRx 60 Day Formulary Change Formulary Exceptions You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
Generally, Blue MedicareRx will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects. In most circumstances, if we do approve your request for an exception, the exception is good for the rest of the year. Once an exception request is approved, it is valid for the remainder of the plan year so long as your physician continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. Conditions & Limitations To receive benefits, you must see contracted network providers and pharmacies, except for emergency care anywhere in the world, or post-stabilization services, urgent care, out-of-area renal dialysis, or emergency ambulatory services within the U.S. and certain hospitals in Mexico and Canada. Blue MedicareRx's contract with CMS is renewed annually, therefore availability of coverage beyond the end of the current contract year is not guaranteed. Quality Assurance Policies & Procedures Drug Utilization Review
If Blue MedicareRx identifies a medication problem during our drug utilization review, we will work with your doctor to correct the problem. Medication Management Programs To learn more about our medication management programs, or to join a program, contact Customer Service at ... 1-888-285-2254 Monday through Friday, 6 a.m. to 6 p.m. MT TTY/TDD users should call ... 1-888-844-3757 Disenrollment If you leave Blue MedicareRx, it takes some time for your prescription drug coverage to end and your new prescription drug coverage to begin. Enrollment takes place November 15 through December 31 of every year. Enrollment is generally for the calendar year. In certain cases, such as if you move or enter a nursing home, you can disenroll from your plan at other times. After you request to disenroll, we will let you know, in writing, the date your coverage ends. If you don’t get a letter, call Customer Service and ask for the date. In general, you may only disenroll or switch prescription drug plans under certain circumstances. You can switch your Prescription Drug Plan during the following periods: After March 2006: An individual who becomes eligible for prescription drug coverage after March 2006 has an initial enrollment period that begins 3 months before the month the individual becomes eligible for Medicare Part A and ends 3 months after the first month of eligibility. If you join a Prescription Drug Plan after January 1, 2006, your coverage will be effective on the first day of the month after the month in which you join. For example, if you join on April 10th, your effective coverage date will be May 1st. You will have to pay a late enrollment fee if your initial enrollment period ends, and for a period of 63 days or longer if you:
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