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Grievances, Coverage Determinations, & Appeals

You can appoint a representative to act on your behalf for filing a coverage determination or appeal by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website at www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp. Please note by clicking on this link, you will be leaving the EnvisionRx Plus website.

GRIEVANCES
It is the policy of EnvisionRx Plus to provide meaningful procedures for timely hearing and resolution of grievances. This policy enables us to use listening and problem-solving skills to resolve the issue presented. The policy also provides a protocol for escalation of grievances when warranted or requested.

What is a grievance?
A grievance is different from an appeal because usually it will not involve coverage or payment for prescription drugs included in Medicare prescription drug coverage benefits. Instead, the following types of problems might lead to you filing a grievance:

Quality of your medical care

  • Are you unhappy with the quality of the care you have received?

Respecting your privacy

  • Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?

Disrespect, poor customer service, or other negative behaviors

  • Has someone been rude or disrespectful to you?
  • Are you unhappy with how our Member Services has treated you?
  • Do you feel you are being encouraged to leave the plan?

Waiting times

  • Have you been kept waiting too long by pharmacists? Or by our Member Services or other staff at the plan?
    • Examples include waiting too long on the phone or when getting a prescription at the pharmacy.

Cleanliness

  • Are you unhappy with the cleanliness or condition of a pharmacy?

Information you get from us

  • Do you believe we have not given you a notice that we are required to give?
  • Do you think written information we have given you is hard to understand?

Complaints related to the timeliness of our actions related to coverage decisions and appeals

The process of asking for a coverage decision and making appeals is explained below. If you are asking for a decision or making an appeal, you use this process, not the complaint process.

However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a complaint about our slowness. Here are examples:

  • If you have asked us to give you a “fast coverage decision” or a “fast appeal,” and we have said we will not, you can make a complaint.
  • If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint.
  • When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint.
  • When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint.

How do I file a grievance?
If you would like to file a grievance, you may do so by contacting Member Services at 1-866-250-2005 (TTY/TTD users should call 711), 24 hours a day, 7 days a week, or by writing to us at:

EnvisionRx Plus
Attn: Grievance Department
2181 E. Aurora Rd., Suite 201
Twinsburg OH, 44087
Fax: 1-866-250-5178

The complaint must be made within 60 calendar days after the situation occurred.

COVERAGE DETERMINATIONS
As a member of EnvisionRx Plus, you have the right to request a coverage determination with regard to the prescription drug coverage that you are entitled to receive under your plan, including:

  • Asking us to cover a Part D drug that is not on the plan’s formulary
  • Asking us to waive a restriction on the plan’s coverage for a drug (such as prior authorization, step therapy, or quantity limit restrictions)
  • Asking to pay a lower cost-share for a medication listed in one of the non-preferred tiers (i.e. Tier 2 or Tier 4)

What is a coverage determination?

A coverage determination is any determination made by EnvisionRx Plus with respect to the following:

  • A decision about whether to provide or pay for Part D drug (including a decision not to pay because the drug is not on the plan’s formulary, because the drug is determined not to be medically necessary, because the drug is furnished by an out of network pharmacy or because the Part D plan sponsor determines that the drug is otherwise excluded under section 1862(a) of the Act if applied to Medicare Part D) that the enrollee believes may be covered by the plan.

Prior Authorization or Other Utilization Management Requirements

  • A decision whether a member has, or has not, satisfied a prior authorization or other utilization management (such as step therapy or quantity limits) requirement.

Exception Requests

  • A decision concerning a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Drug tier (tier 5).
  • A decision concerning an exception request involving a non formulary drug.
  • A decision concerning an exception to a prior authorization or other utilization management requirement.

Reimbursement Requests

  • A decision concerning reimbursement for prescription drugs that you have already purchased

How long is the coverage determination process?

EnvisionRx Plus has both a standard and a fast (sometimes called expedited) procedure in place for making coverage determinations. When requesting a coverage determination, you, your doctor, or appointed representative should let us know which of the two decision timeframes you need.

Standard Decision. A decision about whether we will cover a Medicare prescription drug (Medicare Part D) can be a "standard decision" that is made within the standard time frame (typically within 72 hours).

Fast Decision. A decision about whether we will cover a Medicare prescription drug (Medicare Part D) can be a "fast decision" that is made more quickly (typically within 24 hours). A fast decision is sometimes called an "expedited coverage determination."

You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for Medicare prescription drugs (Medicare Part D) that you have not received yet. You cannot get a fast decision if you are requesting payment for a Medicare prescription drug (Medicare Part D) that you already received.

How do I request a coverage determination?

You, your doctor, or your appointed representative can request a coverage determination (standard or fast) by one of the following three ways:

  1. Click on the following link to start the EnvisionRx Plus coverage determination process on-line:
    On-Line Coverage Determination
    Please note by clicking on this link, you will be leaving the EnvisionRx Plus website.

  2. Mail or fax us your coverage determination request to:

    EnvisionRx Plus
    Attn: Appeals/Coverage Determinations(Clinical Services)
    2181 E. Aurora Rx, Suite 201
    Twinsburg, OH 44087
    Fax: 1-877-503-7231

    You may use our prior authorization form, exception request form, or coverage determination form for you convenience. Links to the forms are located below.

  3. Call us at 1-866-250-2005 (TTY/TDD users should call 711)

Prior Authorization and Coverage Determination Forms
Use the following links to download forms to complete a request for prior authorization, coverage determination or exception. You should mail your completed form to EnvisionRx Plus, Attn: Appeals/Coverage Determinations (Clinical Services), 2181 E. Aurora Rd., Suite 201, Twinsburg OH, 44087 or fax it to 1-877-503-7231

An adverse coverage determination constitutes any unfavorable decision made by or on behalf of EnvisionRx Plus regarding coverage or payment for prescription drug benefits you believe you are entitled to receive. The following actions are considered adverse coverage determinations:

  • A decision not to provide or pay for a prescription drug (which includes a decision not to pay because the drug is not on the plan's formulary, determined to be not medically necessary, the drug is furnished by an out of network pharmacy or EnvisionRx Plus determines the drug is otherwise excluded under section 1862 (a) of the Act) that you believe should be covered by the plan.)
  • The failure to provide a coverage determination in a timely manner when a delay would adversely affect your health.

What happens after I request a standard decision?
After receipt of a standard request for coverage determination, EnvisionRx Plus will review the coverage determination request and notify you of the decision, using the following time frames:

EnvisionRx Plus will notify you or your authorized representative, and your prescribing physician as appropriate of our decision regarding your standard request for coverage determination regarding covered drug benefits as expeditiously as your health condition requires, but no later than 72 hours from the receipt of the request, or for an exception request, receipt of the physician's supporting statement. EnvisionRx Plus will notify you or your authorized representative of our decision regarding your coverage determination request regarding a request for payment no later than 72 hours from receipt of the request.

If EnvisionRx Plus decides the coverage determination fully in your favor, we will: 1) attempt to contact you by phone; 2) send a written approval notification to you and your prescribing physician; and 3) process the coverage determination, which will allow the pharmacy to issue your prescription.

For denials related to drug coverage in whole or in part, EnvisionRx Plus will send a written notice of the determination to you as well as an oral attempt of notification, and the prescribing physician involved will receive written notification, if your physician provided a supporting statement. The denial notice will state the specific reason for the denial and contain all of the applicable Medicare appeals language. For denials related to payment, EnvisionRx Plus will also send a written notice containing all of the applicable Medicare appeal language.

If EnvisionRx Plus fails to make a coverage determination within the 72 hour timeframe, it constitutes an adverse coverage determination. EnvisionRx Plus will send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of adjudication timeframe and the IRE will issue a determination. You will be notified in writing by EnvisionRx Plus that your request was sent to the IRE.

What happens after I request a fast (expedited) decision?
If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision. If you ask for a fast initial decision without support from a doctor, we will decide if your medical condition requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast initial decision, we will send you a letter informing you that if you get a doctor’s support for a "fast" review, we will automatically give you a fast decision. You have the right to resubmit your request for an expedited coverage determination with your prescribing physician's support. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast initial decision, we will instead give you a standard decision (within 72 hours).

EnvisionRx Plus will notify you or your authorized representative, and your prescribing physician as appropriate of our decision regarding your fast request for coverage determination (and effectuate the change if favorable) as expeditiously as your health condition requires, but no later than 24 hours from the receipt of the request, or receipt of the physician's supporting statement, if provided. You will receive written notification and an attempt of oral notification and your prescribing physician will receive written notification, if your physician provided a supporting statement.

If EnvisionRx Plus fails to make a decision regarding a fast coverage determination within the 24 hour timeframe, this constitutes an adverse coverage determination. EnvisionRx Plus, will send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of the adjudication timeframe and the IRE will issue a determination. You will be notified in writing by EnvisionRx Plus that your request was sent to the IRE.

APPEALS
As a member of EnvisionRx Plus, you have the right to request an appeal to review an adverse coverage determination made by the EnvisionRx Plus on the benefits that you believe you are entitled to receive.

What is an appeal?
An "appeal" is the type of complaint you make when you want us to reconsider an adverse coverage determination we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. This includes a delay in providing or approving drug coverage (when the delay will affect your health), or on any amounts you must pay for drug coverage. There are several levels of appeals that you can exercise (request for redetermination, independent review entity, Administrative Law Judge (ALJ) hearing, and review by the Medicare Appeals Council). The first level of appeals is an appeal submitted to EnvisionRx Plus and is sometimes called a "request for redetermination." The appeal information below explains how long it takes for a first level appeal and how to request an appeal.

How long is the appeal process?
EnvisionRx Plus has both standard and fast (sometimes called expedited) appeal procedures. When requesting an appeal, you, your doctor, or appointed representative should let us know which of the two decision timeframes you need.

Standard Appeal When we review a standard appeal, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for a “fast” appeal.

Fast Appeal When we review a fast appeal, we must give you our answer within 72 hours after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so.

You can ask for a fast appeal only if you or your doctor believe that waiting for a standard appeal could seriously harm your health or your ability to function. Fast appeals apply only to requests for Medicare prescription drugs (Medicare Part D) that you have not received yet. You cannot get a fast appeal if you are requesting payment for a Medicare prescription drug (Medicare Part D) that you already received.

How do I request an appeal?
You, your doctor or your appointed representative must request an appeal (request for redetermination) within 60 days from the date of the notice of the adverse coverage determination (date printed or written on the notice). There are three ways you may request your standard or fast appeal.

  1. Click on one of the following to start the EnvisionRx Plus appeal process on-line.

  2. Standard Appeal
    Fast Appeal

  3. Mail or fax us your appeal request to:

  4. EnvisionRx Plus
    Attn: Appeals/Coverage Determinations (Clinical Services)
    2181 E. Aurora Rd., Suite 201
    Twinsburg OH, 44087
    Fax: 1-877-503-7231

    The form below can be used to request an appeal

    Download Request for Redetermination

  5. Call us at 1-866-250-2005(TTY/TDD users should call 711)

What happens after I request a standard appeal?
EnvisionRx Plus will review the standard appeal (request for redetermination) and will provide you notice of our decision in writing (and process the change if favorable) as expeditiously as your health condition requires but no later than 7 calendar days of receipt of the appeal request. If EnvisionRx Plus decides that the time frame for the standard appeals process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.

What happens after I request a fast (expedited) appeal?
If EnvisionRx Plus decides that the time frame for the standard appeals process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited. A request made or supported by your prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function. When an appeal request meets criteria for expedited processing, EnvisionRx Plus must provide you and your prescribing physician notice of its decision (and effectuate the change if favorable) as expeditiously as your health condition requires, but no later than 72 hours after receiving the request.

If additional medical information is required to process the request, EnvisionRx Plus must request it within 24 hours of receiving the fast appeal request. Even if additional information is required, EnvisionRx Plus must still issue notice of the decision within the 72 hour timeframe.

If EnvisionRx Plus determines that your request is not time-sensitive, where your health is not seriously jeopardized, EnvisionRx Plus will notify you verbally and in writing and will automatically begin processing your request under the standard appeals process. If you disagree and believe the review should be expedited, you may file an expedited grievance with EnvisionRx Plus The written notice will include instructions on how to file an expedited grievance. You have the right to resubmit your request for an expedited appeal with your prescribing physicians support.

Failure to meet the timeframes noted constitutes an adverse determination and EnvisionRx Plus must forward your request to the Independent Review Entity (IRE) within 24 hours of the expiration of the adjudication timeframe for the IRE to issue the appeal (redetermination) decision. This applies to both standard and expedited appeal requests. You will be notified in writing by EnvisionRx Plus if your request is sent to the IRE.

You can appoint a representative to act on your behalf for filing a coverage determination or appeal by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website at www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp. Please note by clicking on this link, you will be leaving the EnvisionRx Plus website.

Further Appeals
If you disagree with a decision EnvisionRx Plus made regarding your appeal (request for redetermination), you may file an appeal with an outside entity. For further information regarding appeals, refer to Chapter 7 of your Evidence of Coverage or call Member Services at 1-866-250-2005 (TTY/TDD users may call 711). Member Services is open 24 hours a day, 7 days a week.

REQUESTS FOR INFORMATION
You may request aggregate numbers of grievances, appeals, and exceptions filed with EnvisionRx Plus, or specific information regarding the status of grievances or appeals you have filed, by calling Member Services at 1-866-250-2005 (TTY/TDD users may call 711). Member Services is open 24 hours a day, 7 days a week.

Or visit the CMS Medicare website at www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp. Please note by clicking on this link, you will be leaving the EnvisionRx Plus website

For more information regarding grievances, coverage determination requests, or appeals, refer to Chapter 7 of your Evidence of Coverage.

EnvisionRx Plus understands that there are times when members have questions or concerns about their prescription drug coverage. In order for us to resolve your concerns quickly, please call EnvisionRx Plus directly at 1-866-250-2005 (TTY/TDD users call 711) 24 hours a day, 7 days a week. Our staff will immediately respond and direct the issue to the appropriate department for a timely resolution.

If we cannot help with your issue and you wish to file a formal complaint, you may contact Medicare at www.medicare.gov/MedicareComplaintForm/home.aspx. Please note that by clicking on this link you will be leaving the EnvisionRx Plus website.

This information is available for free in other languages. Please contact our customer service number at 1-866-250-2005 for additional information.

Esta información está disponible de forma gratuita en otros idiomas. Por favor de contactar nuestro número de servicio al cliente al 1-866-250-2005 para obtener información adicional.

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