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Coverage determinations
When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. (Please, also see the description of the exceptions process.) You must contact us if you would like to request a Blue Medicare HMO℠, Blue Medicare PPO℠, or Blue Medicare Rx℠ coverage determination, including an exception. You cannot request an appeal if we have not issued a coverage determination.
The following are examples of when you may ask Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx for a coverage determination:
- If you are not getting a prescription drug that you believe Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx covers.
- If you received a Part D prescription drug that you believe Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx covered while you were a member, but the plan refused to pay for the drug.
- If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped and that you believe you have extenuating circumstances that should exclude you from the reduction / non-coverage.
- If there is a limit on the quantity (or dose) of the drug, and you disagree with the requirement or dosage limitation.
- If you bought a drug at a pharmacy that is not in the network and you want to request reimbursement for the expense.
To ask for a standard decision, you or your appointed representative may call the customer service number for your plan, deliver a written request, or send a fax or email.
By phone:
Blue Medicare HMO
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO
877-494-7647 (TTY 888-451-9957 / 711)
Blue Medicare Rx (PDP)
888-247-4142 (TTY 888-247-4145 / 711)
7 days a week, 8 AM to 8 PM
By fax:
You may fax your request to 888-446-8535.
By email:
An email request for coverage determination or Part D exception must include the member's:
- Full name
- Member ID number (see your member ID card)
- Date of birth
- Phone number
- The name of the drug for which the coverage determination or Part D exception is being requested
- The name and telephone number of the person who prescribed the drug
To request for a Prescription Drug Coverage Determination requiring authorization, such as non-formulary, prior authorization, quantity limits, tier exceptions, or step therapy, please send your email to: PartDExceptions@bcbsnc.com
Forms may be submitted to this email address or mailed to the address located on the form.
To request reimbursement of a prescription drug for purchases you have already made, please send your email to: PartDClaims@bcbsnc.com
Forms may be submitted to this email address or mailed to the address located on the form.
To ask for a fast decision, you, your physician, or your appointed representative may contact us using the above information. After regular business hours, you should consult with a network pharmacy regarding your need for an emergency or temporary supply of medication until you can contact the Plan the next business day. Be sure to ask for a "fast," "expedited," or "24-hour" review. NOTE: You cannot ask for a fast decision on a request for coverage of a drug already purchased.
Generally, we must make our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. If your request involves a request for an exception (including a formulary exception or an exception from utilization management rules, such as dosage or quantity limits), we must make our decision no later than 72 hours after we have received your doctor's "supporting statement," which explains why the drug you are asking for is medically necessary.
If you are requesting an exception, you should submit your prescribing doctor's supporting statement with the request, if possible. We will give you a decision in writing about the prescription drug you have requested. You will get this notification when we make our decision under the time frame explained above. If we do not approve your request, we must explain why and tell you of your right to appeal our decision.
If you get a fast review, we will give you our decision within 24 hours after you or your doctor ask for a fast review, or sooner if your health requires. If your request involves a request for an exception, we must make our decision no later than 24 hours after we get your doctor's "supporting statement." Requests for reimbursement of prescriptions you have already purchased are responded to within 14 days after we have received the request.
Exceptions are part of the coverage determination process. You, your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that:
- Is not on the formulary
- Requires prior authorization
- Has quantity limitations
Example of an exception request:
If the Plan's formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal.
You or your prescribing physician may request an exception to the coverage rules for your Medicare prescription drug plan via phone or mail.
Phone:
Blue Medicare HMO
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO
877-494-7647 (TTY 888-451-9957 / 711)
Blue Medicare Rx (PDP)
888-247-4142 (TTY 888-247-4145 / 711)
7 days a week, 8 AM to 8 PM
Providers should call:
Mail:
Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx
c/o Blue Cross NC
Attn: Rx Coverage Determination
P.O. Box 2251
Durham, NC 27702-2251
A specific form is not required for you to make an exception request, although there are Blue Cross NC forms available to you and your physician to request an exception or prior approval for a drug. The request must include your prescribing physician's statement that they have determined that the preferred drug either would not be as effective for you and / or would have adverse effects for you.
We will review the exception request and notify both you and your prescribing physician of our decision as soon as your health requires, but no later than 72 hours from the time we receive your physician's supporting statement. Faster exception decisions are available if this 72-hour time frame could seriously harm your health or ability to function.
If the decision is not in your favor, the notice will be given by phone followed by a written notice within three (3) business days. The notice will tell you how to pursue your appeal rights if you are dissatisfied with our decision.
Appeals
An appeal is your opportunity to request a redetermination of an adverse coverage determination, which includes denied exception requests. For example, if we deny your request for an exception to cover a non-formulary drug, then you may file an appeal of the denial. An appeal can only be filed after an exception has been requested and denied by the Plan.
If you receive a coverage determination denial, you, your appointed representative, or your prescriber may file an appeal. An appeal must be filed within 60 calendar days of the date of the denial notice. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.
A specific form is not required for you to file an appeal; however, a form is available for your use by clicking on the link below. Completion of this form may help you with your review request and assist us in the review process.
A Medicare beneficiary may appoint an individual to act as their representative in filing an appeal. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file an appeal. An appeal by a representative is not valid until the Appointment of Representative (AOR) form (PDF) is completed and submitted, or other equivalent form, legal papers, or authority are submitted.
You or your appointed representative may file an appeal by phone, mail, fax, email, or in-person. You can also file a complaint with Medicare here: Medicare Complaint Form
By phone:
Blue Medicare HMO
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO
877-494-7647 (TTY 888-451-9957 / 711)
Blue Medicare Rx (PDP)
888-247-4142 (TTY 888-247-4145 / 711)
7 days a week, 8 AM to 8 PM
By mail:
Blue Cross and Blue Shield of North Carolina
Medicare Provider Appeal Department
P.O. Box 1291
Durham, NC 27702-1291
By fax:
888-375-8836
By email:
Send Part D appeal emails to: PartDAppeals@bcbsnc.com
A Part D appeal by email must include the member's:
- Full name
- Member ID number (see your member ID card)
- Date of birth
- Phone number
- The name of the drug for which the appeal is being requested
- The name and telephone number of the person who prescribed the drug
- The reason you think the drug should be covered
Standard appeals
We will perform a standard review of your appeal as soon as your health requires but no later than 7 calendar days after we receive your appeal. You will receive a written response to your appeal.
Expedited or fast appeals
We will review requests for an expedited or fast appeal as soon as possible, but no later than 72 hours following our receipt of the request. The decision on an expedited appeal will be provided by phone followed by the written notice.
An individual who was not involved with your original coverage determination will make a decision on your appeal.
If our decision is to deny the appeal, the notice will advise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructions on how to do so.
If we miss our time frames for claims adjudication or review of the appeal, we will automatically forward the appeal to the IRE for a decision.
There may be additional levels of appeal available to you. We will inform you of your additional rights in the notice, or you may refer to your Evidence of Coverage for further details.
Grievances
A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a plan or its delegated entity in the provision of health care or prescription drug services or benefits, regardless of whether remedial action is requested.
Please see your Evidence of Coverage for a detailed explanation of the grievance procedures and time frames for a response.
The grievance must be filed within 60 days after the event or incident that caused you to be dissatisfied. A specific form is not required for you to file a grievance. You may file a grievance by phone, mail, fax, or in-person. You can also file a complaint with Medicare.
A Medicare beneficiary may appoint an individual to act as their representative in filing a grievance. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file a grievance. A grievance by a representative is not valid until the Appointment of Representative (AOR) form (PDF) is completed and submitted, or other equivalent form, legal papers, or authority are submitted.
By phone:
Blue Medicare HMO
888-310-4110 (TTY 888-451-9957 / 711)
Blue Medicare PPO
877-494-7647 (TTY 888-451-9957 / 711)
Blue Medicare Rx (PDP)
888-247-4142 (TTY 888-247-4145 / 711)
7 days a week, 8 AM to 8 PM
By mail:
Blue Cross and Blue Shield of North Carolina
Medicare Provider Appeal Department
P.O. Box 1291
Durham, NC 27702-1291
By fax:
888-375-8836
Via Acentra Health
If you are dissatisfied with the quality of care you have received, you may also file your grievance with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The Beneficiary and Family Centered Care Quality Improvement Organization for North Carolina is Acentra Health.
By phone:
888-317-0751 or for the hearing and speech impaired call 855-843-4776 (TTY / TDD)
By mail:
5201 W. Kennedy Blvd.
Suite 900
Tampa, FL 33609
By fax:
844-878-7921
Online: www.acentraqio.com
The resolution of a grievance will be made as quickly as your concern requires, but no more than 30 calendar days after we receive the grievance. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If you request a written response to an oral grievance, one will be provided within 30 days after we receive the grievance. A written response will be provided for all written grievances. Our decision on a grievance is final and is not subject to an appeal.
You have the right to an expedited review of a grievance concerning our refusal to grant an expedited coverage determination or expedited appeal. This type of grievance will be responded to within 24 hours after we receive the grievance.
Disclosures:
Blue Cross and Blue Shield of North Carolina is an HMO, HMO-POS, PPO and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal.
Blue Cross and Blue Shield of North Carolina Senior Health DBA Blue Cross and Blue Shield of North Carolina is an HMO-POS D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.
Blue Medicare Supplement plans offered: [Plan A: BMS A, 1/24, Plan G: BMS G, 1/24, Plan HI DED G: BMS HDG, 1/24, Plan K: BMS K, 1/24, Plan N: BMS N, 1/24.]
Blue Medicare Supplement is not endorsed by or affiliated with the United States Government or the federal Medicare program.
Blue Cross and Blue Shield of North Carolina does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, sexual orientation or source of payment. All Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.
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Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
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Current as of 07/12/2024 | Y0079_12318_M CMS Accepted 08282024 | U36079, 6/24
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