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Medicare Advantage Appeals & Grievances

Medicare Advantage Appeals & Grievances

Is Your Drug Covered By Our Plan?

If a drug you take isn’t covered by our plan and you can’t switch to another drug, you and your prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your prescriber says that you have medical reasons that justify asking us for an exception, your prescriber can help you request an exception to the rule. This is called a “coverage determination.”

You and your prescriber can complete the Coverage Determination Request Form and submit it to the CDPHP pharmacy department for consideration.

If we approve your request for a Formulary exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

If we deny your request for a Formulary exception, you can ask for a review of our decision by making an appeal. This is called a “redetermination.”

You and your prescriber can complete the Redetermination Request Form and submit it to the CDPHP appeals department for consideration.

Complaints come in two forms: appeals and grievances.

You can make an "appeal" when you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or 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 the plan doesn’t pay for a drug, item, or service you think you should be able to receive.  To file an appeal, complete and submit the Member Appeal Form posted below.

A "grievance" is the type of complaint you make if you have any other type of problem with CDPHP Medicare Choices plans or one of our network pharmacies or providers.  To file a grievance, complete and submit the complaint form posted below.  If someone is filing an appeal, grievance, or other action on your behalf, please make sure we have an Appointment of Representative form on file for that person.

Medicare Appeals and Grievance Process

You may file an appeal or grievance pertaining to either medical coverage or Part D prescription drug coverage. Please review the Medicare Appeals and Grievances Overview for a general description of the process for all CDPHP Medicare Choices plans. For a complete description of our appeals and grievance process in a specific plan, please refer to the plan's Evidence of Coverage (EOC). To view the EOC, choose Medicare Choices HMO Plans and click the tab that corresponds to your plan. Then scroll down to the bottom of the page.

Forms

CDPHP refers to both the Capital District Physicians’ Health Plan, Inc., a Medicare-approved HMO plan, and CDPHP Universal Benefits®, Inc., a Medicare-approved PPO plan. CDPHP is a health plan with a Medicare contract. Enrollment in CDPHP Medicare Choices depends on contract renewal. To join, you must have Medicare Parts A and B and live in the service area.

CDPHP is an HMO with a Medicare contract. Enrollment in CDPHP Medicare Choices depends on contract renewal.

Y0019_17_1486 Approved Last Updated 07/31/2017