2016 Coverage Determination, Appeals, and Grievances

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 65^SM 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.
  Y0041_HM_15_32556
• 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.

Coverage Determination Process

Download 2016 Coverage Determination Process

For more information on Keystone 65 Focus Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 153 in your EOC or click on the link below.

Keystone 65 Focus Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Select Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 157 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Preferred Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 153 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_16_31491 accepted 08/28/2015

For more information on Personal Choice 65^SM Rx PPO’s coverage determination process, please reference Chapter 9, Section 6 on page 165 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Coverage Determination Instructions
Y0041_H3909_PC_16_32919 accepted 08/28/2015

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.

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 91 in your EOC or click on the link below.

Keystone 65 Focus Rx HMO Prior Authorization
Y0041_H3952_KS_16_31546 accepted 08/28/2015

Please reference your plan's formulary for a list of drugs that require 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 95 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Prior Authorization
Y0041_H3952_KS_16_31546 accepted 08/28/2015

Please reference your plan's formulary for a list of drugs that require 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 88 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Prior Authorization
Y0041_H3952_KS_16_31491 accepted 08/28/2015

For Personal Choice 65^SM 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 65^SM Rx PPO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 100 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Prior Authorization
Y0041_H3909_PC_16_32919 accepted 08/28/2015

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.

• Call 1-800-645-3965 (TTY/TTD 711)
  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.
• Complete the Coverage Redetermination Request Online Submission Form
• Complete the Keystone 65 HMO Coverage Redetermination Request Form
  Y0041_HNS_14_10886 accepted 10/8/2013 and send to the plan either by fax or mail:

• Fax 1-888-289-3008.
• Mail to:
  Medicare Member Appeals Unit
  PO Box 13652
  Philadelphia, PA 19101-3652

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

• Call 1-888-718-3333 (TTY/TTD 711)
  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.
• Complete the Coverage Redetermination Request Online Submission Form
• Complete the Personal Choice 65^SM PPO Coverage Redetermination Request<
  Y0041_HNS_14_10886 accepted 10/8/2013 and send to the plan either by fax or mail:

• Fax 1-888-289-3008.
• Mail to:
  Medicare Member Appeals Unit
  PO Box 13652
  Philadelphia, PA 19101-3652

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.

Download 2016 Part D Appeals Information

For more information on Keystone 65 Focus Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 153 in your EOC or click on the link below.

Keystone 65 Focus Rx HMO Part D Appeals
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Select Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 157 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Part D Appeals
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Preferred Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 153 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Part D Appeals
Y0041_H3952_KS_16_31491 accepted 08/28/2015

For more information on Personal Choice 65^SM Rx PPO Part D Appeals, please reference Chapter 9, Section 6 on page 165 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Part D Appeals
Y0041_H3909_PC_16_32919 accepted 08/28/2015

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 65^SM 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

Download 2016 Part D Grievances Information

For more information on Keystone 65 Focus Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 179 in your EOC or click on the link below.

Keystone 65 Focus Rx HMO Part D Grievances
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Select Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 182 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Part D Grievances
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Preferred Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 180 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Part D Grievances
Y0041_H3952_KS_16_31491 accepted 08/28/2015

For more information on Personal Choice 65^SM Rx PPO Part D Grievances, please reference Chapter 9, Section 10 on page 190 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Part D Grievances
Y0041_H3909_PC_16_32919 accepted 08/28/2015

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.