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For Members

Coverage Determination, Appeals, and Grievances

Coverage Determination for Part D Drugs

Coverage determination is the process by which the plan makes a decision about whether a Part D drug prescribed for you is covered and the amount, if any, you are required to pay. An initial coverage decision about your Part D drugs is called a coverage determination. You, your doctor, or someone you've authorized may make an oral or written, standard or expedited request.

If you are a Keystone 65 Rx HMO or Personal Choice 65SM Rx PPO member, you can file a coverage determination by using one of the methods below.

  • Submit an online request.
  • Print and mail or fax the coverage determination form.
    If you do not see a specific form for your request, please utilize our generic coverage determination request form.
  • Call 1-888-678-7015.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-671-5285.
  • Write FutureScripts® Secure
    1650 Arch Street
    Suite 2600
    Philadelphia, PA 19103

As part of the coverage determination process, you can ask us to make an exception, including requesting coverage of drug that is not on the formulary, waiving restrictions on the plan's coverage for a drug or asking to pay a lower-cost sharing amount. This process is called a formulary or tier cost-sharing exception. You may use the Coverage Determination Form to request an exception.

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

Coverage Determination Process

2017 Coverage Determination Process



Prior Authorization for Part D Drugs

For certain Part D drugs, you, your physician, or representative may need to obtain prior authorization from us before we will cover the drug.

For Keystone 65 HMO members, the plan requires prior authorization (approval in advance) of certain covered prescription drugs that have been approved by the FDA for specific medical conditions.

2017 Prior Authorization for Part D Drugs Process

Please reference your plan's formulary for a list of drugs that require prior authorization.

  • For more information on Keystone 65 Focus Rx HMO's prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 99 in your EOC or view Keystone 65 Focus Rx HMO Prior Authorization.
  • For more information on Keystone 65 Select Rx HMO's prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 99 in your EOC or view Keystone 65 Select Rx HMO Prior Authorization.
  • For more information on Keystone 65 Preferred Rx HMO's prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 101 in your EOC or view Keystone 65 Preferred Rx HMO Prior Authorization.

For Personal Choice 65SM PPO members, the plan requires prior authorization (approval in advance) of certain covered and prescription drugs that have been approved by the FDA for specific medical conditions.

Please reference your plan's formulary for a list of drugs that require prior authorization. For more information on Personal Choice 65SM Rx PPO's prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 103 in your EOC or view Personal Choice 65 Rx PPO Prior Authorization.



Part D Appeals

If you, your doctor, or your representative do not agree with the outcome of the initial coverage determination, appeal the decision by requesting a redetermination.

If you are a Keystone 65 HMO member, you can file a standard or expedited Part D appeal by using one of the methods below.

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited Part D appeal by using one of the methods below.

If our answer is yes to part or all of what you requested:

  • If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
  • If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.

If our answer is no to part or all of what you requested:

  • We will send you a written statement that explains why we said no and how to appeal our decision.

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

2017 Part D Appeals Process



Part D Grievances

You may file a grievance if you have a complaint other than one that involves a coverage determination (see Part D Appeals above). You would file a grievance for any type of problem you might have with us or one of our network pharmacies.

If you are a Keystone 65 HMO Member, you can file a standard or expedited Part D grievance by using one of the methods below.

  • Call 1-800-645-3965.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you are a Personal Choice 65SM PPO Member, you can file a standard or expedited Part D grievance by using one of the methods below.

  • Call 1-888-718-3333.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

2017 Part D Grievances Process



Appointment of a Representative

If you have someone appealing our decision for you other than your physician, your appeal must include an Appointment of Representative form. Click here for more information.

For Claims and Reimbursement

Keystone 65 HMO, Personal Choice 65 PPO and Select Option PDP:

FutureScripts Secure
PO Box 968021
Schaumburg, IL 60196-8021

Contact Information

Members and providers who have questions about the exceptions and appeals processes, would like to inquire about the status of a coverage determination or appeal request please contact the Member Help Team.

To obtain an aggregate number of grievances, appeals, and exceptions filed with Independence Blue Cross, please mail a written request to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652

Website Last Updated: 1/1/2017
Y0041_HM_17_43499f Approved 1/6/2017