Coverage Determinations, Appeals, and Grievances

You can ask us to cover a drug that has utilization management (UM) requirements, such as prior authorization, isn’t on our formulary, or to lower the amount you pay for your medication. This is called a coverage determination, and we’re here to help you and your prescriber through the process.

What is a Coverage Determination?

Any determination to provide or pay for a Part D drug that you believe may be covered by the plan (including a decision not to pay because the drug is not on the plan’s formulary, because the drug is determined not to be medically necessary, because the drug is furnished by an out of network pharmacy or because the Part D plan sponsor determines that the drug is otherwise excluded under section 1862(a) of the Act if applied to Medicare Part D).

Types of Requests:

• Prior Authorization or other Utilization Management Request: This applies when you need approval before we will cover a drug, or if your drug has special rules like step therapy or quantity limits. We’ll decide if these requirements have been met.
• Exception Request: This applies when we are asked to make an exception to our rules in situations like:
  • Asking us to cover a drug that isn’t on our formulary/drug list (called a Formulary Exception). Please note: Some categories of drugs are excluded from coverage under Part D, such as weight loss medications.
     Asking us to waive limits or restrictions on your drug—like increasing how much you can get (e.g., a Quantity Limit Exception).
  • Asking us to reduce what you pay for a drug by covering it on a lower-cost tier (called a Tier Exception). Note: Tier Exceptions aren’t allowed for drugs in Tier 5 or those already approved as a Formulary Exception.
• Reimbursement Request: If you already paid for a Part D drug, you can ask us to review it for possible reimbursement.

Who Can Request a Coverage Determination?

• You
• Your authorized representative
• Your prescribing physician
• You can appoint a representative to act on your behalf for filing a coverage determination by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website. 

How to Request a Coverage Determination

• Submit an Online Coverage Determination request: Request for Medicare Prescription Coverage Determination

• Call us:
     For HMO Members: (844) 918-0114 
     For PPO Members: (844) 915-0234
• Send us a fax: (888) 904-1139
• Send us your request form in writing:
  Request for Medicare Prescription Coverage Determination Printable Form
  Mass Advantage
  Attn: MPD-1000UR​
  P.O. Box 64806​
  St. Paul, MN  55164-0811

What is the Coverage Determination process?

After receipt of a request for coverage determination, we will review it and notify you or your authorized representative, and your prescribing physician (as appropriate) of our decision regarding your request for the coverage determination as expeditiously as your health condition requires.  

• Standard requests - we will advise you of our decision no later than 72 hours from the receipt of the request, or, for an exception request, no later than 72 hours from receipt of the physician's supporting statement.
• Fast requests (or expedited requests) - we will advise you of our decision no later than 24 hours from the receipt of the request, or, for an exception request, no later than 24 hours from receipt of the physician's supporting statement.
• Reimbursement requests – we will advise you of our decision no later than 14 days from receipt of the request.

Coverage Determination Approvals

If we decide the coverage determination fully in your favor and approve coverage, we will:

• Attempt to contact you by phone
• Send written approval notification to you and your prescribing physician
• Authorize the drug, which will allow the pharmacy to process your prescription

Coverage Determination Denials

For denials related to drug coverage, in whole or in part, we will send written notice of the determination and attempt to provide verbal notification. Your prescribing physician will also receive written notification if they provided a supporting statement. The denial notice will state the specific reason for the denial and contain all applicable Medicare appeals language. 

If we fail to make a coverage determination within the specified timeframe, it constitutes an adverse coverage determination. We will then send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of adjudication timeframe and the IRE will issue a determination. You will be notified in writing that your request was sent to the IRE.

An adverse coverage determination (or denial) is any unfavorable decision made by or on behalf of the plan regarding coverage or payment for a prescription drug you believe you are entitled to receive.

The following are considered adverse coverage determinations:

• A decision not to cover a drug because it is not on the plan’s formulary
• A decision not to cover a drug because it is deemed not medically necessary
  A decision not to cover a drug because it was obtained from an out-of-network pharmacy
• A decision not to cover a drug because it is excluded under Section 1862(a) of the Social Security Act, even though you believe it should be covered
• A failure to provide a timely coverage determination when a delay could negatively impact your health
   

If you disagree with a decision we have made, you have the right to appeal that decision. The first level of appeal for an adverse or denied coverage determination under Medicare Part D is called a redetermination request.  

If you are unhappy with an unfavorable or denied coverage determination (the decision made on your initial request) you may file an appeal or redetermination. When you file a redetermination, you’re asking us to review the request again. Members appeal when they think the decision made was unfair or in error. 

When you want us to reconsider an adverse coverage determination made regarding what prescription drugs are covered or what we will pay, you can request an appeal within 65 days of the initial denial. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage. 

Who can request a Redetermination?

You or your authorized representative, or your prescribing physician can request a redetermination. You can appoint a representative to act on your behalf for filing an appeal by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website at: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207 

How to request a Redetermination

• Call us at: (844)-918-0114 (HMO), (844) 915-0234 (PPO)
• Fax us at: (888) 904-1139
• Mail to: Mass Advantage, Attn: MPD-1000UR, P.O. Box 64806, St. Paul, MN  55164-0811

What is the Redetermination process?

When you request a standard appeal or redetermination, we will process your request within 7 calendar days of receipt of the request. If you or your prescriber believes that waiting 7 days could seriously harm your health, you can request a fast or expedited appeal and we will give you a decision within 72 hours. You cannot request an expedited appeal if you are asking us to pay you back or reimburse you for a drug already received.

For all appeals, we will review the request for redetermination and will provide you notice of our decision in writing (and process the change, if favorable) as expeditiously as your health condition requires.

• Attempt to contact you by phone (only for fast or expedited appeals)
• Send written notification to you and your prescribing physician
• If denied, the denial notice will state the specific reason for the denial and contain all applicable Medicare appeals language.
• If approved, authorize the drug, which will allow the pharmacy to process your prescription

If we fail to make a redetermination decision within the specified timeframe, it constitutes an adverse determination. We will then send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of adjudication timeframe and the IRE will issue a determination. You will be notified in writing that your request was sent to the IRE.

If you disagree with the decision regarding your appeal or request for redetermination, you may file an appeal with an outside entity. For further information regarding appeals, refer to your Explanation of Coverage (EOC) or call Member Services at (844) 918-0114 for HMO Members or (844) 915-0234 for PPO Members: TTY:711

Member Services is open From October 1 to March 31. You can call us 7 days a week from 8 am to 8 pm EST. From April 1 to September 30, you can call us Monday through Friday from 8 am to 8 pm EST.