PRESCRIPTION DRUG EXCEPTION AND APPEALS PROCESS
Giving you the best care possible is important to Mercy Care Advantage (MCA), so we have designed a process for prescription drugs with you in mind. We encourage you to let us know right away if you have questions, concerns or problems related to your prescription drug coverage. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Mercy Care Advantage or penalized in any way if you make a complaint.
Grievances
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 Mercy Care Advantage
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. Please see
Section 10 of the Evidence of Coverage (EOC)
for detailed information and timelines for filing a grievance. Click
HERE for the EOC.
Coverage Determinations
The coverage determination and appeals process provides you with the opportunity to challenge the exclusion of a drug from the formulary or the placement of a drug on a higher cost sharing tier. You receive a notice from your pharmacist explaining how you can obtain a coverage determination or request an exception.
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 exceptions requests.
You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower copayment. If you request an exception, your physician must provide a statement to support your request.
You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination. Please see Section 12 of the
Evidence of Coverage for more information about requesting a coverage determination.
For the Request for
Medicare Prescription Drug Coverage Determination Form, click
HERE.
Exceptions
The exception process, which makes sure that you have access to prescription drugs you need, is unique to the prescription drug benefit. It provides a straightforward process for you to obtain a covered drug at a more favorable cost sharing level or obtain a drug that is not on the formulary.
You may request an exception under any of the following circumstances:
- You are using a drug covered on the formulary that has been removed during the plan year for reasons other than safety
- Your doctor prescribed a drug that is not on the formulary because it is medically necessary
- You are using a drug that has been moved during the plan year from the preferred to the non-preferred cost sharing tier
- Your doctor prescribed a drug that is in the more expensive cost sharing tier because the drug in the less expensive cost sharing tier is medically inappropriate for you
How to Request an Exception
If MCA makes an unfavorable coverage determination or denies your exception request, you, your representative or your doctor may appeal the decision within 60 days from the date of the coverage determination notice. If you need more information about filing an appeal, refer to the instructions on your coverage determination notice or contact an MCA Appeals representative at:
Telephone:
Local: (602) 263-3000
Toll Free: (800) 624-3879
Expedited (Fast) Appeals (602) 351-2314
M-F 8a.m. - 5p.m., S 7 a.m. - 5 p.m.
TTY/TDD
Toll Free: (866) 602-1982 M-F 7a.m.-6p.m. (602)454-9208 all other times
FAX (602) 351-2300
Coverage Determination and Appeals The coverage determination and appeals
process for prescription drugs consists of the following:
| |
DESCRIPTION |
STANDARD |
EXPEDITED* |
| 1 |
Coverage determination and exception request by MCA |
Upon receipt of a coverage determination request, MCA will notify you of a decision within 72 hours.
Upon receipt of your doctor's supporting statement for an exception request, MCA will notify you of a decision within 72 hours.
|
Same as standard, except the timeframe is 24 hours for you to be notified of a decision.
If you were informed of the decision verbally, you will be sent a confirmation letter describing the decision within 3 days.
|
| 2 |
Redetermination by MCA |
If the initial coverage determination or exception request if unfavorable, you may request a redetermination by MCA.
Upon receipt of an appeal, the Appeals Department sends you an acknowledgement letter to confirm the facts and basis of the appeal.
Your appeal is evaluated by the Appeals Department and a clinical expert if necessary.
A decision letter is sent to you within 7 days.
|
Same as standard except the timeframe is 72 hours for an appeal representative to make a decision |
| 3 |
Reconsideration by Independent Review Entity (IRE) |
If the redetermination is unfavorable, you may request a
reconsideration by the IRE within 60 days of the date of the redetermination letter. |
Your expedited request will be forwarded to the IRE within 24 hours. |
| 4 |
Administrative Law Judge (ALJ) |
If the RIE decision is unfavorable, and the amount in controversy meets at
least the minimum $110 dollar requirement, you may request a hearing with an ALJ.
This must be filed in writing within 60 days to the date of the notice sent by the IRE.
Refer to this notice for more information.
|
Not available |
| 5 |
Medicare Appeals Council (MAC) |
If the ALJ decision is unfavorable, you may appeal to the MAC,
which is within the Department of Health and Human Services, which reviews ALJ's decisions.
|
Not available |
| 6 |
Judicial Review |
If the MAC denied your request for appeal, and the amount in dispute meets the minimum required, you may request judicial review of the ALJ decision.
If the MAC decision is unfavorable, and the amount in controversy meets at least the minimum dollar requirement of $1,130 you may request judicial review of the MAC decision.
You must file a civil action in a district court to request a judicial review. Refer to the MAC decision notice for more information.
|
Not available |
* An expedited decision is requested based on the urgency of your health condition.
Redeterminations
To request a redetermination, please call the Appeals Department at the numbers listed below.
Appointment of Representation
If you would like to appoint someone (your doctor or guardian, etc.) to act as your representative during the Appeals process,
you may fill out an
Appointment of Representation Form and send or FAX it to the Appeals Department at the address or
FAX number listed below. Click
HERE for the form and instructions on how to fill out the form.
The form is valid for one (1) year.
Contact Information:
Telephone:
Local: (602) 263-3000
Toll Free: (800) 624-3879
Expedited (Fast) Appeals (602) 351-2314 M-F 8a.m. - 5p.m., S 7 a.m. - 5 p.m.
TTY/TDD
Toll Free: (866) 602-1982 M-F 7a.m.-6p.m. (602) 454-9208 all other times
FAX (602) 351-2300
Mercy Care Advantage Mailing Address:
Mercy Care Advantage
Appeals Department
4350 E Cotton Center Blvd.
Bldg. D
Phoenix, AZ 85040
Medicare Appeals Council Mailing Address:
Department of Health and Human Services Departmental Appeals Board,
MS 6127 Medicare Appeals Council
330 Independence Avenue, S.W.
Cohen Building, Room G-644
Washington, DC 20201