Exceptions and Appeals
If your drug is not included in the Independence Blue Cross (IBC) Drug Formulary, you, your prescribing doctor, or someone you name (see Appointment of a Representative below), can ask IBC to make an exception to our prescription drug coverage rules. The Exception and Appeals process is as follows:
Coverage determination
The coverage determination is a decision made by the plan about whether a drug prescribed for you is covered and the amount, if any, you are required to pay. If you need a drug that is not on the plan’s formulary or you have been using a drug that has been removed during the plan year, use this form to request a formulary exception. You, your doctor, or someone you’ve authorized may make a written or oral request. For more information see Section 5 of the Evidence of Coverage for the following plans.
2012 Coverage determination instructions
2012 Keystone 65 HMO Medical with Prescription Drug Y0041_H3952_KS12_02a File & Use 09/12/2011- 2012 Personal Choice 65 PPO Medical with Prescription Drug Y0041_H3909_PC11_06 File & Use 09/20/2010
Appeals
If you, or your doctor does not agree with the outcome of the initial coverage determination, you or your doctor (on your behalf) may appeal the decision by having your doctor request a redetermination. For more information see Section 5 of the Evidence of Coverage for the following plans.
2012 Appeals
- 2012 Keystone 65 HMO Medical with Prescription Drug Y0041_H3952_KS12_02a File & Use 09/12/2011
- 2012 Personal Choice 65 PPO Medical with Prescription Drug Y0041_H3909_PC12_02 File & Use 9/15/2011
Grievances
You may file a grievance if you have a complaint other than one that involves a coverage determination (see Appeals above). You would file a grievance if you have any type of problem with us or one of our network pharmacies. Contact Us for more information. For more information see Section 4 of the Evidence of Coverage for the following plans.
2012 Grievances
- 2012 Keystone 65 HMO Medical with Prescription Drug Y0041_H3952_KS12_02a File & Use 09/12/2011
- 2012 Personal Choice 65 PPO Medical with Prescription Drug Y0041_H3909_PC12_01 File & Use 09/15/2011
Appointment of a representative
You can ask us for a coverage determination or appeal, or your prescribing doctor or someone you name may do it for you. The person you name would be your appointed representative. You may name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.
- Appointment of Representative statement form
This statement must be mailed to:
Member Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652
You can call the Customer Service Department to learn how to name your appointed representative.
Evidence of Coverage
The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage and is considered a legal document. See the EOC for more information on grievance, coverage determination, and appeals processes.
Contact information
Members and providers who have questions about the Exceptions and Appeals processes or would like to inquire about the status of a coverage determination can contact Customer Service.
When you ask for it, the government requires IBC to provide you with reports that describe what happened to formal complaints that IBC received from their Medicare members. To request this report please contact Customer Service.
- Members can call 1-800-645-3965 (1-888-857-4816 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from February 15 through October 14, your call may be sent to an answering machine.
- Send us an email.
- Members can mail any inquiries to P.O. Box 7799, Philadelphia, PA 19101-7799
You must continue to pay your Medicare Part B premium.
The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions. Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
- Your State Medicaid Office.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.”
You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Keystone 65 HMO or Personal Choice 65 PPO will be responsible for the costs.
Please contact Keystone 65 HMO or Personal Choice 65 PPO Customer Service for more information.
Y0041_HM_12_300a Pending CMS Approval
- Generic and Brand Name
- Prior Authorization
- Exceptions and Appeals
- Transition Supply Process
- Pharmacy Network
- Quality Assurance
- Formulary
