ERS Retirees – Appeals and Grievances
Employees Retirement System of Texas
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Appeals and Grievances Process
HealthSelectSM Medicare Rx for Groups (PDP)



Appeals

An appeal is a type of complaint you make if you disagree with a coverage determination the plan has made about a prescription drug service or payment. For example, if we decide not to pay for a drug, item or service you think we should cover, or if we will not pay as much for a drug or service as you think we should.

Filing an appeal with our plan.
A standard appeal may be filed by you, your representative, your doctor or other prescriber.

  1. Write a letter describing your appeal, and include copies of any paperwork that may help us understand your case. Provide your name, member ID number, date of birth, and the name of the drug in question.
  2. Send the letter to:
    Part D Appeals and Grievance Department
    P.O. Box 6106, M/S CA 124-0197
    Cypress, CA 90630-9948

You must mail your letter within 60 calendar days from the date of the notice of our coverage determination, or within 60 days of learning that a payment was not made. If you miss the 60-day deadline, you may still file your appeal if you have a valid reason for missing the deadline.

You may call Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in your plan membership materials for more information or to get the fax number for Appeals and Grievances.

Fast (expedited) appeals:

  • If you are appealing a coverage determination our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a fast appeal. (You cannot get a fast appeal if you are asking us to pay you back for a drug you have already bought.) A request for a fast appeal can be made by calling (888) 867-5575, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.
  • You can get a fast appeal only if using the standard deadlines could seriously harm your health or hurt your ability to function.

UnitedHealthcare processes all requests for appeals according to the following time frames:

  • Standard appeal: The enrollee will be provided written notification of the appeal outcome within seven (7) calendar days from the receipt of the request for standard appeal.
  • Expedited appeal: Will be communicated verbally to the enrollee within seventy-two (72) hours and followed by written notification within three (3) calendar days of the verbal notification.

Requests for payment. The claim will be paid within thirty (30) calendar days from the date of receipt for standard appeal.


Grievances

A grievance is a type of complaint you make about us or one of our network pharmacies, including a complaint about the quality of your care. For example, you would file a grievance if you were unhappy with wait times on the phone or at a network pharmacy, staff behavior at a network pharmacy, or about not being able to reach someone by phone or get the information you need. Grievances do not involve coverage or payment disputes.

Filing a grievance with our plan.
You or someone you name as your representative may file a grievance. If you have a grievance, you or your representative may call Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in your plan membership materials. We will try to resolve your grievance over the phone. If you ask for a written response, file a written grievance, or if your complaint is about quality of care, we will respond in writing.

You must make your grievance within 60 calendar days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your grievance.

If you disagree with our decision not to expedite your request for a coverage determination or redetermination, you may request an expedited or "fast" grievance by calling Customer Service. If you disagree with our decision to process your grievance within the standard time frame, you may file a fast grievance.


Coverage determinations (including exceptions)

Your Part D plan's coverage determination is the starting point for most appeals and grievances you may make to the plan about your Part D coverage. The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.

What is an exception?
An exception is a type of coverage determination. You, your doctor or other prescriber may ask us to make an exception to our Part D coverage rules in a number of situations. For example, you can ask us to waive coverage restrictions or limits on your drug or you can ask us to provide a higher level of coverage (pay more) for your drug.

There are two time frames for coverage determinations:

  • A standard coverage determination is made within 72 hours of the request. A request for standard coverage determinations, including exceptions, can be made by calling (888) 867-5575, TTY 711, 8 a.m. to 8 p.m. local time, Monday through Friday, or by faxing a written request to (866) 308-6294.
  • An expedited (or "fast") request decision is made within 24 hours because your health requires it. You and your doctor or other prescriber should decide if you need to file a fast request. A request for a fast coverage determination, including exceptions, can be made by calling (888) 867-5575, TTY 711, 8 a.m. to 8 p.m. local time, Monday through Friday, or by faxing a written request to (866) 308-6296.

If you wish to send a written request by mail, the address for both standard and fast coverage determinations is listed in the Appeals section below.

Download these forms to request an exception:


Utilization management programs

Some covered prescription drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. In addition, some drugs may require a coverage determination to verify if they’re covered by your Part D plan. Utilization management programs allow these coverage determinations to be made for each plan member.

Drugs are considered "limited access" if:

  • The FDA says the drug can be dispensed only by certain facilities or doctors OR
  • Extra handling, provider coordination or patient education is needed to be able to dispense the drug and can’t be done at a network pharmacy.

Find out if your drug has any additional requirements or limits by looking for the following utilization management program abbreviations next to the drug names in your plan’s drug list. These requirements and limits apply to retail and mail service pharmacies and may include:

Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

Quantity Limits (QL)
The plan will only cover a certain amount of this drug for one copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug.

If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.


For more information

Details regarding exceptions and the appeal and grievance processes, including time frames, can be found in the plan's Evidence of Coverage.

If you have questions, please call Customer Service at (888) 867-5575, TTY 711, 8 a.m.–8 p.m. local time, Monday through Friday.

A UnitedHealthcare® Medicare Solution. Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare-approved Part D sponsor.

Request for Medicare Prescription Drug Coverage Determination »

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