  Provider resources and informationCoverage determinationsWhen Blue Medicare HMO and Blue Medicare PPO make a coverage determination, they are making a decision whether or not to provide or pay for a Part D drug and what the member share of the cost is for the drug. (Also see the description of the exceptions process.) The member must contact the plan if they would like to request a coverage determination, including an exception. Members cannot request an appeal if the plan has not issued a coverage determination. The following are examples of when members may ask for a coverage determination:
How do I make a request for a coverage determination?To ask for a standard decision, the member or their appointed representative may call the Customer Service Department at 1-888-310-4110 for Blue Medicare HMO and 1-877-494-7647 for Blue Medicare PPO (TTY/TDD: 1-888-451-9957) 7 days a week, 8:00 a.m. - 8:00 p.m. Members can also deliver a written request to BCBSNC, 5660 University Parkway, Winston-Salem, NC 27105, Monday-Friday from 8 a.m. - 5 p.m. Members may fax their requests to 1-888-375-8836. To ask for a fast decision, the member, their physician, or their appointed representative may call the plan at the Customer Service Department at 1-888-310-4110 for Blue Medicare HMO and 1-877-494-7647 for Blue Medicare PPO (TDD/TTY is 1-888-451-9957), seven days a week, 8 a.m. - 5 p.m. Members can also deliver a written request to BCBSNC, 5660 University Parkway, Winston-Salem, NC 27105, Monday-Friday from 8 a.m. - 5 p.m. Members may fax their request to 1-888-375-8836. After regular business hours, members should consult with a network pharmacy regarding their need for an emergency or temporary supply of medication until they can contact the Plan the next business day. Members should be sure to ask for a "fast," "expedited," or "24-hour" review. NOTE: Members cannot ask for a fast decision on a request for coverage of a drug already purchased. When will I hear back with a decision?Generally, the plan must make its decision no later than 72 hours after they the plan has received the member’s request, but will make it sooner if the member’s health condition requires. If the member’s request involves a request for an exception (including a formulary exception or an exception from utilization management rules, such as dosage or quantity limits), the plan must make its decision no later than 72 hours after the plan has received the doctor’s "supporting statement," which explains why the drug being requested is medically necessary. If the member is requesting an exception, they should submit their prescribing doctor's supporting statement with the request, if possible. The plan will give the member a decision in writing about the prescription drug they have requested. Members will get this notification when the plan makes its decision under the timeframe explained above. If the plan does not approve the member’s request, the plan must explain why and tell the member of their right to appeal the plan’s decision. If the member gets a fast review, the plan will give the member its decision within 24 hours after the member or their doctor asks for a fast review-sooner if the member’s health requires. If the request involves a request for an exception, the plan must make its decision no later than 24 hours after the plan gets the member’s doctor’s "supporting statement." Exceptions are part of the coverage determination process. The member, their authorized representative, or their prescribing physician may request an exception to seek coverage of a drug that:
Example of an exception request: How do I make an exception request? Phone: Physicians should call: Mail: A specific form is not required for the member to make an exception request. The request must include their prescribing physician’s statement that he/she has determined that the preferred drug either would not be as effective for the member and/or would have adverse effects for the member. When will I receive a decision on my exception request? If the decision is not in the member’s favor, the notice will be given by phone followed by a written notice within three business days. The notice will tell the member how to pursue their appeal rights if they are dissatisfied with the plan’s decision.
Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc., a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS do not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association. |