Resources

Appointment of Representative Form (Printer Friendly)

Request for Medicare Prescription Drug Coverage Determination Form (Printer Friendly)

Authorization Request Form (for Prescribers) - (Printer Friendly)

Evidence of Coverage

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We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call Medco Customer Service at 1-800-572-8734. TTY users should call 1-800-716-3231. Normal business hours are from 8:00 A.M. to 9:00 P.M. Eastern Time, Monday through Friday.

The information below outlines the rules for making complaints in different types of situations. 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 someone makes a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from this Plan or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. The following section briefly discusses grievances, coverage determinations, and appeals.

What is a coverage determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug.
• You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Tier 3 drug, you can ask us to cover it as a Tier 2 instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary, the low-tiered drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of your request.

Asking for a standard decision

To ask for a standard decision, you, your doctor, or your appointed representative should refer to our Customer Service numbers (Phone: 1-800-572-8734; TTY/TDD: 1-800-716-3231). Our normal business hours are from 8:00 A.M. to 9:00 P.M. EST, Monday through Friday. Or, you can deliver a written request to the attention of Medicare Administrative Review, Educators Mutual Insurance Association, Medco Health Solutions, Inc., P.O. Box 639405, Irving, TX 75063, or fax it to 1-888-235-8551.

You, your doctor, or your appointed representative can ask us to give a fast decision (rather than a standard decision). If you are requesting a fast decision outside of normal business hours (8:00 A.M. to 9:00 P.M. EST, Monday through Friday), be sure to call (not fax) us at 1-800-753-2851 and listen to the recording for further directions. Be sure to ask for a "fast," "expedited," or "24-hour" review.

If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor's support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast coverage determination, we will give you our decision within the 72-hour standard timeframe.

What is an appeal?

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug. If coverage is denied, the letter will provide an explanation and information on how to submit an appeal.

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug. 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 get the information you need, or the cleanliness or condition of a network pharmacy.

How to file a grievance

A grievance is different from a request for a coverage determination because it usually will not involve coverage or payment for Part D prescription drug benefits (concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process discussed below).

What types of problems might lead to you filing a grievance?

• You feel that you are being encouraged to leave (disenroll from) our Plan.
• Problems with the customer service you receive.
• Problems with how long you have to spend waiting on the phone or in the pharmacy.
• Disrespectful or rude behavior by pharmacists or other staff.
• Cleanliness or condition of pharmacy.
• If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination.
• You believe our notices and other written materials are difficult to understand.
• Failure to give you a decision within the required timeframe.
• Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe.
• Failure by the plan sponsor to provide required notices.
• Failure to provide required notices that comply with CMS standards.

You may file a service grievance by calling Medco Customer Service 1-800-572-8734. TTY users should call 1-800-716-3231. Normal business hours are from 8:00 A.M. to 9:00 P.M. EST, Monday through Friday. You may also file a grievance by completing the Medco Service Complaint and Grievance form. The completed form can be submitted by mail or fax.

Mailing Address:

Attn: Medicare Administrative Review
Educators Mutual Insurance Association
Medco Health Solutions, Inc.
PO Box 639405
Irving, TX 75063
Fax: 1-888-235-8551

Medco will contact you by phone to resolve your service grievance. If your service grievance is not resolved in five days, you will receive a written acknowledgement that your grievance has been received. Expect your service grievance to be resolved within 30 days. After the service grievance is resolved, you will receive a written resolution confirmation. In the rare instance that your grievance is not resolved in 30 days, Medco may request a 14-day extension from Medicare. In certain cases, you have the right to ask for a "fast grievance," meaning your grievance will be decided within 24 hours.

Appointing a Representative

To consider a request from someone other than the member, we must have authorization. You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and the representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

Questions?

If you have questions about the grievance, coverage determination, or appeals processes outlined above, please call Medco Customer Service at 1-800-572-8734. TTY users should call 1-800-716-3231. Normal business hours are from 8:00 A.M. to 9:00 P.M. EST, Monday through Friday. You may also call Customer Service to inquire about the status of a coverage determination or appeals request.

Resources

Appointment of Representative Form (Printer Friendly)

Request for Medicare Prescription Drug Coverage Determination Form (Printer Friendly)

Authorization Request Form (for Prescribers) - (Printer Friendly)

Evidence of Coverage

You will need Adobe Acrobat Reader to view the forms. (Click here to download a free copy of Acrobat Reader.)

Educators Mutual Insurance Association is a Medicare Contractor for Utah and Idaho.