• Grievances, Appeals, & Exceptions
• Disenrollment
• Conditions & Limitations
• Drug Utilization Review
• Medication Management Programs
• Plan Transition Process
• Contract Termination

Grievances, Appeals, & Exceptions

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive. Please call Customer Service at the number listed on your Member ID Card.

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 Medicare PPO 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 services or benefits are covered for you or what we will pay for a service or benefit. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. Blue Medicare PPO or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If Blue Medicare PPO or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit 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 Medicare PPO or one of our plan providers. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office.

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:

Pharmacy Claims:

Blue Medicare PPO
c/o Prime Therapeutics
P.O. Box 64813
St. Paul, Minnesota 55164-0812

Medical Claims:

Your medical claims are to be filed by your provider of services - even if the provider is not in our network. If the provider does not file the claim for you then complete the Member Claim Form and mail it to the address below.

Blue Medicare PPO
P.O. Box 833995
Richardson, TX 75083-3865

To obtain an aggregate number of grievances, appeals, and exceptions filed with Blue Medicare PPO, please call our Member Customer Service Department at 1-800-718-2031, Monday to Friday, 8 a.m. - 6 p.m., CST. For the hearing or speech impaired, please call 1-888-844-5530.

Disenrollment

"Disenrollment" from Blue Medicare PPO means ending your membership with us. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice). We are not allowed to ask you to leave the Plan because of your health. For member and plan rights and responsibilities for disenrollment, please see Section 13, Leaving Blue Medicare PPO, in the Evidence of Coverage (PDF, 371KB).

Below is a brief description of each type of disenrollment:

Voluntary Disenrollment

A member may disenroll from Blue Medicare PPO for any reason during one of the election periods by doing the following:

• Providing a signed written notice to Blue Medicare PPO, or through his or her employer, where applicable
• By calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. For the hearing or speech impaired, please call 1-877-486-2048.

Involuntary Disenrollment

HCSC Insurance Services Company (HISC) must disenroll an individual from Blue Medicare PPO in the following cases:

• A change in residence making the individual ineligible to be an enrollee of Blue Medicare PPO.
• The individual loses entitlement to Medicare.
• The individual dies.
• The Blue Medicare PPO contract is terminated or HISC discontinues offering Blue Medicare PPO in any portion of the area where it had previously been available.
• The individual materially misrepresents information to HISC regarding reimbursement for third-party coverage.

If disenrolled from Blue Medicare PPO, the Evidence of Coverage (EOC) will explain your Medicare coverage choices after you leave and the rules that apply.

If you leave Blue Medicare PPO, it takes some time for your coverage to end and your new coverage to begin. Please call our Member Customer Service at 1-800-718-2031, Monday to Friday, 8 a.m. - 6 p.m., CST. For the hearing or speech impaired, please call 1-888-844-5530.

Conditions & Limitations

• There are limits to when and how often you can change your Medicare plan options.
• To take advantage of Blue Medicare PPO, you must be entitled to Medicare Part A and enrolled in Part B and live in Harris, Jefferson, Galveston (ZIP codes 77550, 77551 and 77554 not included), Montgomery or El Paso counties in Texas. You must also maintain your Medicare Part A and Part B coverage by paying monthly Part B premiums, and if applicable, Part A premiums, if not otherwise paid for under Medicaid or another third party.
• Copayments, coinsurance, and premiums may apply.
• To receive maximum benefits and avoid additional out of pocket costs, you should use contracted network providers and pharmacies. We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To submit a paper claim, please refer to the instructions on our Medicare Prescription Drug Claim Form (PDF, 119KB).
• Blue Medicare PPO contracts with CMS are on an annual basis, therefore availability of coverage beyond the end of the current contract year is not guaranteed.   

Drug Utilization Review

Blue Medicare PPO conducts drug utilization reviews for all of our members to make sure that you are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor prescribing their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, Blue Medicare PPO looks for medication problems such as:

• Possible medication errors
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
• Drugs that are inappropriate because of your age or gender
• Possible harmful interactions between drugs you are taking
• Drug allergies
• Drug dosage errors

If Blue Medicare PPO identifies a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Medication Management Programs

Blue Medicare PPO offers medication management programs for members who have multiple chronic conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for Blue Medicare PPO by a team of pharmacists and doctors. We use these medication management programs to help us provide better care for our members. For example, these programs help us to make sure that our members are using appropriate drugs to treat their medical conditions and help us to identify possible medication errors. Please note that these programs may have limited eligibility criteria and are not considered a benefit under Blue Medicare PPO.

To learn more about our medication management programs, or to join a program, contact our Customer Service Department at 1-888-277-5507, 8 a.m. - 5 p.m. CST. For the hearing or speech impaired, please call 1-800-693-3816.

Plan Transition Process

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you experience an unplanned transition from one treatment setting to another, like entering a long-term care facility, you may be taking drugs that are not on our formulary but require prior authorization, step therapy or quantity limits. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are in a different treatment setting.

Contract Termination

Blue Medicare PPO agrees to stay in the program for a full year at a time. Each year, the plan decides whether or not to continue offering coverage for the following year. Should we decide not to continue offering Blue Medicare PPO, we will send you a letter explaining your options for Medicare Advantage and/or Medicare Part D coverage in your area. Your Medicare coverage is not affected.